Dr Rhona Mahony, Master, National Maternity Hospital, Holles Street
If a remedy is something that cures a disease, we must first make the correct diagnosis if we are to treat the condition successfully and avoid the potential of making things worse.
There are truly lots of good about our health service. We have a highly skilled and committed workforce and every day triumph over disease but there are real challenges too. This is the story of an accidental out dated infrastructure, growing bureaucracy and chronic underinvestment in people. In the last decades we have lurched from one political healthcare reform to another without any clear diagnosis or treatment plan, with high expectation, some success and promises that cannot or have not been be kept. At times, both patients and frontline healthcare staff alike have borne the brunt of political medicine treating somatic disease.
NO PARTICULAR STRATEGIC PLAN
The antecedents of our present day difficulties in delivering efficient healthcare lie in the history of the development of our health care system – an accident of benevolence, infectious disease, catholic emancipation, and the infamous sweepstake bonanza.
The parliamentary grants of the 1700’s began the voluntary hospital system, followed by other benevolent contributions including the Dublin Industry Hospitals, cholera hospitals, the workhouses of the famine and the religious voluntary hospitals founded after Catholic emancipation. In time the workhouses became county hospitals, TB sanatoria were planned or built, and numerous nursing homes were opened. And by the time the Free State emerged in 1922, our predilection for incarcerating individuals deemed insane and unmarried pregnant women was well under way. The result was a myriad of small hospitals developed without any particular strategic plan.
The 1953 Health Care Act and the arrival of the VHI in 1955 provided much greater cover for inpatient hospital care and much less support for community care, thus driving care delivery into hospitals and away from the community.
By 1965 Ireland had 169 hospitals with only three having over 300 beds providing 7.3 beds /1000 population compared with 4.3/1000 in UK. Today, we have 2.4 acute beds/1000 population and 49 acute hospitals. In the 1970s efforts were made to rationalise the number of Hospitals but these efforts were generally met with stiff local and political resistance.
VOLUNTARY HOSPITALS GUARD THEIR AUTONOMY JEALOUSLY
Today our hospital system remains a hybrid system of Voluntary hospitals, who are charitable institutions, providing services to the state under service arrangements, and HSE Hospitals who are funded and managed by the HSE. There are over 17 Voluntary hospitals with independent governance structures reporting to Boards and it is these hospitals that provide the majority of our tertiary services. In business terms, the state purchases services not available in HSE hospitals. This arrangement is often portrayed as state donation to charity with no regard for the services obtained and value for taxpayer’s money. Voluntary hospitals guard their autonomy jealously, recognising that this autonomy is at the root of innovation, strategic development and responsive decision-making close to patients. It is certainly worth noting the proportion of advanced and tertiary service that is delivered within the voluntary system. However, this autonomy at times comes into conflict with the implementation of national strategy, and it is likely that the forthcoming voluntary hospital review will explore this issue. Nonetheless, if any serious hospital review is to take place it should surely include a review of hospitals managed by the HSE and the referral patterns of patients between the two systems.
On this background, Ireland faces increasing healthcare demands following a period of acutely reduced resources during the recent economic recession. The years between 2012 and 2016 saw an average annual deficit of 210 million euro in the acute hospital sector. Unrealistic and late annual allocation has led to hospital rationing and impaired service innovation. The blunt moratorium on staff recruitment was deeply damaging and to this day it remains extremely difficult to gain approval for medical consultant appointments and other front line staff. Curiously the opposite appears to be the case in the series of management administrations above the hospital. The traditional late December cash injection into hospitals does little more than apparently address deficits but does not facilitate coherent budgetary planning.
Over the last decades, population increase and demographic changes in Ireland have increased demand for health services. Irish fertility rates remain at the higher end of European norms at 14 births/1,000 population and our population has increased by 12% in the last decade to 4.7 million. During the same period there has been a 35% increase in people over 65 years. This cohort now accounts for 13% of our total population with a further projected rise of 17% over the next 5 years. Patients over 65years are more likely to suffer from chronic disease and account for over 50% of total in-hospital patient beds and over a quarter of all Emergency Department (ED) attendance.
So how does Ireland address the current challenges?
In good health, a healthcare system will strive to:
P: prevent disease
A: provide timely access to care in an appropriate setting
C: provide competent care
E: Strive to consistently enhance experience and outcome
Let us consider these elements in turn.
LITTLE REAL INVESTMENT IN PREVENTION OF DISEASE
The prevention of disease often gets relatively little attention with a predominant focus on treatment of disease. Modern healthcare all over the world has shifted from acute episodic care to the treatment of chronic disease. People live longer with more morbidity and this morbidity is hugely influenced by lifestyle. But first you must be born and prenatal care must be prioritised. Following birth, one of the biggest determinants of good health is education. Research has shown that well-informed educated people make better decisions about lifestyle and are economically better off, so they can afford better decisions. This is a major societal issue and social disadvantage begins in utero.
It is worth considering the precursors of the majority of our chronic diseases: smoking, drinking alcohol to excess, drug addiction, malnutrition, obesity, lack of exercise and psychological stress. These life style factors are all modifiable but we make very little real investment in disease prevention as a country and this must be a key pillar of future health strategy in Ireland.
ACCESS TO CARE IN AN APPROPRIATE SETTING
Patients should access healthcare on the basis of medical need and not economic means. This is an unassailable aspiration. But how does the issue of access to healthcare stand today? 40% of Irish patients have full eligibility for healthcare and 45% of the population have PHI (private health Insurance). There may be some overlap in these figures but there is clearly a vulnerable group in between and it is clear that people defer accessing appropriate care due to financial constraints.
There is no doubt that patients with PHI have faster access to a wide range of medical, surgical and diagnostic services. There is a wide range of approaches to this inequity internationally with mixed success, but Ireland will have to find a solution based on its own unique demographic and infrastructural situation. Current healthcare statistics in our acute hospitals demonstrate clearly the difficulties and delays in accessing public healthcare. It is impossible to provide a comprehensive list but the following statistics are worth highlighting:
Elective Surgery cases have reduced by 54% since 2012 (187,000 to 86,000 cases) and Inpatient/Day case waiting lists have increased by 12% over the past year (86,000). Outpatient waiting lists have increased by 15% over the past year (484,000) and the number of patients treated on trolleys is up 58% since 2012 (93,621). We have 2.9 doctors/1,000 population (OECD average 3.3) and 2.4/1000 acute hospital beds (OECD average 3.6). 600 patients with documented delayed discharge (range 450 to 800 over past 3 years). The IHCA estimate that we are short 290 ICU beds and 4,000 acute hospital beds.
A mere 6% of Healthcare budget is spent on Mental Health Services and WTE employment in Mental Health Services is 23% below recommended levels.
LONG WAITS IN EMERGENCY DEPARTMENTS
Paradoxically, Ireland has 49 acute Hospitals for a population of 4.7 million. This might seem generous by any standard but some of these hospitals are relatively small and despite the number of hospitals, the number of acute beds in our hospital system is significantly lower than the OECD average. In addition, most of our acute adult hospitals are effectively four hospitals in one; an acute adult centre for medical and emergency presentation, a general practice facility, an elective procedure hospital and a hospital for care of the elderly. These four groups have very different requirements. Over 600 beds in Ireland are occupied by long stay patients who need rehabilitative and enabling care, and not acute care. Therefore any estimation of acute bed number does not provide a true reflection of capacity.
This contributes to the long waits in EDs throughout the country and is exacerbated by the difficulties in the provision of community care, which is particularly problematic in rural areas. From the outset, the lack of focus on community services has left a difficult legacy that will require strategic focus and investment. Much of the care has been provided through individual general practitioners with additional services provided by private practitioners in a way that favours market forces in urban areas but leaves rural areas poorly served.
PRIVATE INSTITUTIONS CAN CHERRY PICK
The result of our haphazard accidental infrastructure is the dilution of clinical staff across multiple sites that are expensive to run and maintain. As auxiliary infrastructure improves we need to focus on getting patients to hospital rather than getting hospitals to patients. The large territories of Australia and Canada and their transport systems provide plenty of examples of how this can be achieved.
Against these figures, it is easy to understand why a private healthcare system has developed in Ireland. People choose private healthcare for a range of reasons, including access, choice in regard to treating physician and accommodation. In turn private institutions can cherry pick low risk high volume procedures that maximise income while expensive and highly specialised treatments like intensive care are discharged within the public system. Indeed the 1970 Healthcare act and the 2008 consultant contract recognises the reality and necessity for private healthcare to provide additional capacity within the system. Every year almost 700 million euro is generated in income from private patients in public hospitals and in a highly expensive mechanism, the National Treatment Purchase Fund provides private care to public patients to relieve waiting lists. One third of the income at NMH is generated by the treatment of private patients, and this income funds care for all patients whether private or public. The hospital would not function without this income.
69% of funding for public healthcare is raised through taxation, 13% through PHI and 15% through OOPP (Out of Pocket Payments). This suggests that the cost of private healthcare provision in private hospitals is in the order of several billion. Should we succeed in the aspiration to create a one tier system it is envisaged that many people will no longer access PHI or care in private hospitals and this must be factored into any cost analysis in relation to a one tier system.
Irish universities and postgraduate training schemes do not produce sufficient numbers to sustain hospital and community requirements. This position is further exacerbated by the loss of graduates due to terms and conditions pertaining in Ireland. While a great deal of attention is given to remuneration, much less is paid to working conditions in Ireland, and to the low morale of staff on the frontline. Long hours, inadequate staffing, poor working environment, unattainable expectation, personalised and sensationalised media reporting and a spiralling and highly adversarial medical negligence system are just some of the problems. The SCA report that the liability for clinical claims was 1.6 billion by the end of 2016, a 23% rise on the previous year with 65% accounted for by maternity care, despite improving outcomes. The current trajectory of rising legal costs is unsustainable.
The growing difficulty of attracting nurses, midwives and doctors is a critical issue with enormous long-term implication for service provision. The IHCA estimates that over 400 permanent consultant posts are not filled on a permanent basis with all the attendant clinical risk, expense of locum appointments and impaired service development. Insufficient attention is paid to the growing crisis of low morale and impaired recruitment and retention of frontline clinical staff. It is impossible to deliver healthcare without the appropriate number of skilled staff.
Low pay for nurses and a flat career structure despite clinical advancement exacerbates the current staffing deficit in nursing and midwifery. This is a particular problem for certain nursing disciplines and for hospitals in urban areas where the cost of living is prohibitive.
Patients coming to hospital or community practice want to be seen by trained doctors, not doctors in training. The ratio between consultants and doctors in training in Ireland is too low and this impacts on care delivered to patients and training for doctors, students and other healthcare staff.
Patients get sick seven days a week and hospitals and community care facilities are expensive assets, which should be utilised more efficiently. Increasing the working week will allow existing facilities deliver more and have a major impact on waiting lists. This is not an easy transition and the recent heated debates in the UK are instructive.
EXCELLENT EXPERIENCE AND OUTCOME
Comprehensive outcome data is critical if we are to understand how we perform. The annual reports of the three Dublin maternity hospitals are testament to the great benefit of detailed outcome data. It is deeply inappropriate to provide care without knowledge and monitoring of clinical outcome. Such reporting should be the norm throughout our system and should be the subject of detailed analysis of trends to direct healthcare strategy.
A major barrier to this data collection at present is lack of standardised data collection and a universal IT system. The MNCMS (Maternity Neonatal Clinical Management System) currently being implemented in the maternity hospitals is a step forward and will revolutionise data collection, but we need a national infrastructure or all of the dysfunction in information retrieval and dissemination between the various healthcare entities will persist despite costly investment.
COHERENT MANAGEMENT OF IRISH HEALTHCARE
At hospital level, management structures are clear and accountability is defined and understood. Above the hospitals, the myriad of reporting relationships makes accountability difficult to define and communication suffers. In recent years we have increased the number and complexity of healthcare administrations with a large increase in senior administrators above the level of the hospitals. Currently there is the group structure that exists but has not yet achieved legal status and certainly hasn’t achieved the intended delegated autonomy and transfer of decision making. With this structural development one can expect a realignment of HSE functions and staffing reductions. The opposite has been the case so far. It is difficult to understand a 13% increase alone in Corporate HSE while the frontline struggles to respond to rising activity levels. Newspaper reports allude to a 40% increase in senior management staff in the management structures that sit above the hospitals. There has been surprisingly little analysis of these trends, which are reflected in confused lines of accountability and authority. The number and complexity of administrative functions above the hospitals has inhibited the devolution of decision making to the group and hospitals and further away from the patient. Throughout the structures, the incidence of acting positions and rotation at senior level is a barrier to performance and creates significant clinical risk through delayed or absent response. It is also a major cost in a service that is deeply affected by frontline deficit. Clearer lines of responsibility and accountability are required.
The current healthcare problems stem from inadequate capacity, a dysfunctional infrastructure, disordered administration and funding, and chronic underinvestment in people. These issues must all be addressed but the solution will not be found in short-term political cycle nor in popular promises easily made and impossible to implement.
The ultimate goal of a one-tier system based on clinical need rather than financial means is an unassailable aspiration, but a wide range of complex expensive steps must be taken and politicians, clinicians and society alike need to buy into the reality of the challenges faced and actions needed. There have been many attempts to reform healthcare and this paper does not provide the blueprint but I believe the following issues need to be addressed.
The remedy required is complex, and will require a long-term perspective but the priorities must include the provision of adequate service capacity through appropriate staffing and capital development. The efficient delivery of services requires corporate organisational reform and we must understand our clinical outcomes if we are to plan strategically, and we must. This cannot be achieved without adequate financial investment but, given the long term horizon, the cost of reform is difficult if not impossible to accurately estimate. Nonetheless, we cannot afford not to reform our current health system if good health is a national priority. To carry on as we are is simply not sustainable.