Are We Getting Value for our Healthcare Buck?
Susan Mitchell, Health Editor, The Sunday Business Post
I wish to thank Joe Mulholland for his invitation to address the MacGill Summer School. It is a privilege to be here with such a distinguished panel.
This year each of us will spend an average of about US$5,000 on healthcare. That’s a considerable amount of money. Are we getting bang for our healthcare buck?
My proposition here today is not that we as a nation are over-spending on healthcare, but that it is mal-funded and, all too often, malfunctioning. For despite having one of the highest proportionate spends on healthcare in the EU, we have a public health system that is blighted by poor access and outcomes that are often inferior to those achieved elsewhere.
I readily acknowledge that there are some very excellent things happening in our health service. However, tonight’s theme invites one to outline what is not working as well as it should and offer some reasons as to why.
I will also attempt to dispel the pervasive myth that health systems elsewhere are grappling with problems of the same magnitude. They certainly face many of the same challenges – such as the advent of expensive new medicines and technology – though many other countries have managed those challenges considerably better than we have.
Let me first address the issue of health spending.
The failure of successive governments to remedy our troubled health system can no longer be attributed to a lack of investment in healthcare, given what we now know to have been the scale of the spend in recent years. Nor can any paucity of data on the distribution of the health spend across the various delivery arms of the health service, nor any lack of data on performance indicators and health outcomes be offered in mitigation.
Last December (2015) the Central Statistics Office (CSO) released data on Ireland’s health expenditure. Many commentators and interest groups were surprised to see just how much money was actually being spent on healthcare in Ireland. The figure (for 2013) came to €18.8 billion (current not capital) – a figure that captures government spend as well as private health insurance and out-of-pocket payments made by individuals.
According to OECD figures (Figure 1), that meant that we, as a nation, spent US$4,980 per capita on healthcare. We spent more than the vast majority of countries in the OECD, a grouping of developed countries. Within the EU, only two countries, Sweden ($,5,003) and The Netherlands ($5,240), spent more than we did per capita (The figures are expressed in terms of USD purchasing power parities, or PPP, which means the common currency used is US dollars and differences in purchasing power have been taken into account).
We also emerged as relatively high spenders when our healthcare ‘spend’ was measured against Gross Domestic Product (GDP) and especially against Gross National Income (GNI). According to the OECD, our spending as a proportion of GDP (at 10.5 per cent that year, i.e., 2013) was only exceeded by five other countries (Sweden, The Netherlands, Germany, Denmark and France). At 12.3 per cent, Ireland had the highest spend on healthcare as a percentage of GNI of all EU countries. Figures for 2014 tell a similar story (Figures 2, 3 & 4).
These data are hugely significant. For the best part of a decade the consensus had been that Ireland was spending in or around the OECD average on healthcare. Every vested interest group in health had repeated this ad nauseam in an effort to compel successive governments to provide more money for the public health service.
It is important to clarify that the reason our ‘spend’ had been underestimated was because we were slow to adopt the agreed detailed System of Health Accounts (2011) reporting. This system had already been embraced by many advanced countries.
Among the stated aims and objectives of this system is to better capture the ‘spend’ on healthcare irrespective of where that spend emanates from. It also aims to eliminate anomalies that previously existed. For example, in the past, many countries did not fully capture their spending on long-term residential care, which skewed international comparisons.
The adoption of this accounting system by the CSO has resulted in higher estimates for expenditure on health care than previously captured. Other countries have had the same experience. Importantly, the new system has facilitated better comparisons with these countries than ever before.
For those charged with health policy and the running of the health service, these data – and most especially the international comparisons they facilitate – can make for uncomfortable reading. Perhaps they should. I say this because despite spending considerably more money than the majority of our European neighbours, we have a lot less to show for it.
Access to Health Services
Access to the public health service in Ireland is poor by any standard. Our health outcomes, though they are improving, are, in the main, quite mediocre.
Let me focus first on access to the system. The health service covers a vast spectrum. We have mental health care, acute/hospital care, disability care, primary care – and a lot more besides. We enjoy good and ready access to GP care in this country. This is laudable, but it is just one facet of primary care, albeit a very important one.
Primary care encompasses all the health or social care that you can find outside of the hospital setting. Think physiotherapy, occupational therapy and home care – to name but a few. It is difficult to retrieve meaningful waiting time data for patients trying to access these services, but we know there is huge pent up demand.
In early June, a collaborative report on home care services was published. Called Meeting Older People’s Preference for Care: Policy, But What About Practice, it was produced by the Irish Association of Social Workers, Age Action, the Alzheimer Society of Ireland and the School of Social Policy, Social Work and Social Justice in UCD. It depicted home care in Ireland as a service in crisis, with growing waiting lists for home helps and home care packages.
Social workers estimated that more than half of the older people they work with could be at home instead of in long-term residential care, if the appropriate services were available. Many of the elderly in this situation are not even on a waiting list. This is a real scandal.
The trolley ‘crisis’ is rarely out of the news. Long waits, as measured by the number of patients on trolleys, have become a persistent problem – not least for politicians. Remember when former health minister, Mary Harney, declared it a “national emergency” that 495 patients were on trolleys on a given day in 2006? It must be one of the longest running national emergencies we have ever had.
By 2007, Taoiseach Enda Kenny was on election posters promising to “end the scandal” of patients on trolleys. He didn’t. In fact, by 2015 Irish hospitals had the highest ever level of hospital overcrowding recorded (It should be appreciated that the number of patients on trolleys on wards was only recently included in the statistics. This has inflated the numbers).
Hospital waiting lists tell another grim story. They are disimproving. Most people going on to a waiting list today will wait longer for that treatment than they would have had to wait in previous years. Recent figures, published by the National Treatment Purchase Fund (NTPF), showed there were 33,000 patients waiting longer than 6 months for elective care (daycase and in-patient procedures) at the end of June 2016. In 2011, just before the Fine Gael and Labour coalition took office, there were 9,000 patients waiting longer than 6 months. The figure has more than trebled in five years. Such waiting lists are not the norm internationally.
Out of the 33,000 patients waiting longer than 6 months, some 12,600 patients were waiting longer than one year for their care (June 2016).
Across the water, the NHS (National Health Service) collates similar data. It makes for a very interesting comparison. In April, just 870 patients were waiting longer than one year for treatment in England. England has a population of 53 million. The Republic of Ireland has a population of 4.7 million. We have a fraction of their population and yet, somehow, we have almost 13,000 patients waiting longer than 12 months for treatment compared to their 870.
In its Health At A Glance (2015) report, the OECD provides a snapshot of median waiting times for various planned (elective) procedures. They include cataract surgery, as well as waiting times for hip and knee replacements. The average and median waiting times for these procedures were less than four months in many countries. It is very clear that Ireland is an outlier, unless of course, you are fortunate enough to have a decent level of private health insurance cover.
Outcomes and Quality of Care
Let me briefly address patient outcomes and the quality of care.
Life expectancy in Ireland has improved and this is obviously a very welcome development. Our health outcomes are also improving. Survival rates following hospital admission are getting better all the time. But we still have some way to go in order to catch up with our European neighbours (Table 1).
Take cancer. Successive governments and the health service, to their credit, invested a great deal of money and effort in an attempt to improve cancer care in Ireland. And, it has improved. Nevertheless, in spite of the additional cash, the detailed plans and new screening programmes, we still lag behind very many comparable European countries.
A large international cancer survival study called CONCORD-2 was published at the end of 2014 in the medical journal The Lancet. It compiled data from cancer registries in 67 countries, including Ireland. Ireland’s National Cancer Registry described it as “the most comprehensive international comparison of cancer survival to date.”
The authors examined five-year survival rates for a range of cancers, including ovarian, breast, rectum, stomach, colon, lung, liver, prostate, and childhood leukaemia for patients diagnosed between 2005 and 2009. The data show that survival rates recorded in other western European countries were higher – and at times considerably higher – than they were in Ireland. I looked at the figures for sixteen western European countries. Ireland had the worst survival rates of all sixteen countries for cervical, ovarian, breast, and rectal cancer.
About 3,000 new diagnoses of cervical cancer are made every year in Ireland. Only 56 per cent of women diagnosed with cervical cancer survived longer than five years in the late 2000s. In Iceland, 73 per cent survived – an improvement of 30 per cent on the Irish figure.
Our survival rates for stomach, lung and colon cancer were significantly lower than they were in many of the other countries. The chances of surviving some common cancers – including breast cancer – also trailed at least ten years behind the profile of many comparable European countries.
I asked Dr Harry Comber, director of the National Cancer Registry, to explain why Ireland was lagging behind. His response [quote] “The short answer is we have no coherent theory [that explains our poor ranking]. Lots of people have looked at it, but nobody has been able to pick it apart,” Dr Comber said.
The picture for heart attacks and strokes is more encouraging. Better access to high quality care, including faster transportation of patients, evidence-based medical interventions and high-quality facilities, have contributed to a significant reduction in our mortality rates from heart attacks and strokes.
Between 2006 and 2015, there has been a 36 per cent reduction in in-hospital mortality rates within 30 days of admission following a heart attack (acute myocardial infarction). Moreover, the death rate for haemorrhagic stroke fell by 25 per cent over the same ten-year period. This is clearly very good news for such patients.
The 30-day case fatality rate after patients are admitted to hospital having suffered a heart attack or a stroke are regarded as good indicators of acute care quality. Today, the mortality rate in Ireland from heart attacks is actually lower than it is in most other OECD countries. But that is not the case for stroke, where our fatality rate is higher than average.
As a nation, we are investing a considerable amount of money in health and yet, as I have illustrated, we still do not have an accessible health service or enviable outcomes for many common diseases. Why is this so? To answer takes me to the key issues of planning, work practices and capital spending.
While our current health expenditure soared from €6.4 million in 2000 to €19.1 billion in 2014, capital expenditure has lagged far behind. As CSO figures show, capital expenditure only climbed from €522 million to €894 million over the same period. Many of our healthcare facilities are extremely old and no longer fit for purpose. That adds cost. We do not have electronic health records, meaning there is huge duplication of medical tests and diagnostics. There is an urgent need to ramp up capital investment, but it is important to separate this from current expenditure.
Poor Policy, Bad Planning
I would also argue that many of our difficulties arise from substandard planning and erratic policy change, compounded by outdated and restrictive work practices.
Far too many reports gather dust. For example, a national suicide strategy called Reach Out was published by the government of the day back in 2005. It made 16 key recommendations, only 2 of which were ever fully implemented. Now, we have a new suicide strategy. Under the Vision for Change (2006) strategy we were promised a radical transformation of the mental health service, but the promised move to community based mental health services has not been delivered.
Moreover, policy is ever-changing and often unclear. In 2010, the Fianna Fáil led government was pursuing a policy of hospital co-location. There was a lengthy tender process and some consortia even went so far as to apply for planning permission. Then Fine Gael and Labour came to power. The co-location plan was axed. There followed the saga of the Fine Gael/Labour coalition promising to deliver universal health insurance to all by 2016; but they made the promise before doing their homework properly. Last year, the ESRI reported that a system of universal health insurance would come at an enormous additional cost. The plan for universal health insurance was dropped.
Now, hospital groups have been established as a precursor to the setting up of independent hospital trusts. Yet nobody appears to have decided how these hospital trusts will function or operate. What does an ‘independent’ trust actually mean? Is it administrative, budgetary or related to service? Will they be completely autonomous? I have asked these questions of the Department of Health. The response? Silence.
We appear to have started down a road without knowing where we actually want to go. In an interview that he gave me last year, Tony O’Brien, director general of the HSE, described the HSE as an “amorphous blob.” He said the setting up of the HSE was too hasty and ill-thought out. Are we on course to repeat the same mistake again?
Even when there is a clear aim or objective, it is often beset by poor planning. The last government constantly promoted “free GP care”, in other words, GP care that would be free at the point of access. It was recognised that this would require an increase in GP numbers. That government promised to increase training places for GPs. But, the number of training places did not increase during those years. It is but one of many examples that I could cite to illustrate the gulf between supposed policy and action, or delivery.
There has been much rhetoric about universal primary care and shifting chronic disease management out of hospitals. Everyone agrees that this makes sense. In fact, we have all been in agreement for quite some time. In 2001, Micheál Martin launched the then government’s primary care strategy, called A New Direction. Every Irish town was to have comprehensive primary care services by now. Yet, fifteen years on we are not even close to delivering universal primary care to all.
In order to shift chronic disease management out of the hospital setting, we need a new GP contract. Yet, negotiations on this have not even started. That does not suggest any real sense of urgency.
As I illustrated earlier, we have a desperate problem with waiting times. Recently, the health minister announced a significant pot of money for the National Treatment Purchase Fund (NTPF) to help address waiting list numbers. I am not in any way anti-private medicine, but this is the same band-aid solution we have been using for over a decade. It has never addressed the underlying problem.
In fact, efforts to address the underlying problem appear to be ignored. HIQA, the healthcare regulator, has made a number of recommendations aimed at improving waiting lists by providing referral thresholds for GPs. It has produced a series of 22 thresholds. It was asked to do this by the HSE. Not one has been implemented. I am at a loss to explain why.
Many of the problems of our health service are compounded by poor (e.g., short-term) politics and lax administration, but it would be remiss of me to omit any reference to the vested interests that are also stifling reform. It goes without saying that there are very many exemplary hard-working and dedicated staff working in the health service, but much more could be achieved if there was a serious root and branch reform of work practices.
The following will, perhaps, give you a flavour. There is a serious problem with demarcation of roles.
Up until very recently nurses in Ireland did not perform tasks regarded as core duties by nurses in other countries. They included taking blood and putting intravenous lines into patient’s veins. Some nurses did, but it was not uniform. Instead, this work was done by non-consultant hospital doctors (NCHDs). The INMO recently agreed to facilitate this task transfer, but only after securing additional remuneration.
If you walk into a public hospital to get a scan, three radiographers (who take scans) often preside over the scanning machine. This does not happen in private hospitals, where two are deemed sufficient. Doctors and managers have questioned the need for this and said it was exacerbating the existing shortage of radiographers.
There is much talk about difficulties in recruiting and retaining nurses. There is no doubt that this is an issue; yet the reality is that we have many more practising nurses per 1,000 population than other EU countries. I agree with Mary Brosnan, President of the Irish Association of Directors of Nursing And Midwifery (IADNM), who said “there has been an issue with skill mix” in the health service and pointed to the fact that grades such as operating theatre assistants and intensive care technicians were used in many other countries. Why are we not actively examining this?
Very many hospital consultants work extremely hard and well over the hours they are contracted to work in the public system. However, a significant cohort do not and this is because they are busy working in the private system where they are paid extra money. Clinical directors are being paid €50,000 over and above their consultants’ salaries to manage clinical care and doctors at their hospitals. Where are they? And why are hospital managers turning a blind eye?
Excellent things are happening at the coalface within our health service and we have made some considerable efficiency gains. There has been a 54 per cent increase in day case procedures (2006-2014) and a reduction in the so-called cost per weighted unit of care in hospitals (derived by dividing the cost of care by the number of cases). More patients than ever before are admitted on the same day for surgery. But these gains are being negated to a considerable extent by inefficiencies elsewhere.
Our health spend increased again in 2014, topping €19 billion (Figure 4). This is all the more remarkable given we have one of the youngest populations in the EU (Figure 5). And yet, the only mantra we hear from most of our elected representatives is about the need to invest more in our health service.
To conclude, it is my belief that many of the difficulties besetting our health service have their origins in an inadequate capital investment over decades, as well as short-term politics, inefficiencies at administrative level, and vested interests. Until we find a remedy for these, the health service is not going to prosper anytime soon. The recent establishment of a parliamentary Committee on the Future of Healthcare (aimed at achieving cross-party consensus on a long-term vision) is to be welcomed, as a first step. Perhaps they will surprise us.
Figure 1. Health expenditure across OECD countries per capita, 2013 (or nearest year). Note that some of the above data have been revised since first published by the OECD in 2015. These revisions are incorporated in the text, where appropriate
Table 1. Quality of care – international comparisons
Graphics: Thompson Reuters 25 April 2013