A CRITICAL CONDITION
Failure to tackle vested interests is turning a sick health service into a dangerous one.
This year over a billion pounds of our money will be spent on the health service, yet cutbacks are making the hospitals dangerous and public patients can't get urgent operations. One in twenty people in the Irish workforce works in the health system, yet wards full of geriatric patients are left unattended/
Fintan O'Toole, Mary Jane O'Brien and Mark Brennock find out why.
If I go out in a breeze it feels like I'm pushing up a hill." Marie Flannery is a young woman in her early thirties, living in a Corporation house in Ballyfcrmot , Dublin, with her four children. Early last year she hegan 10 get severe pains in her chest. She went to her doctor, Doctor Connolly in Cornmarkct. and was given a lettcr for the heart clinic in St James Hospital. That was in June 1984. At the clinic she was put on a treadmill. "I had to walk on it first then it speeded up and [ had to run." Soon she felt a tightening in her chest and she told the doctor. She was made to lie down for a while, then sent into another room, before she was told that she was suffering from angina, the hardening of arteries which can lead to heart failure. She was asked if there was a history of heart disease in her family and said that her father had died of a massive heart attack.
After her visit to St James, Marie Flannery was given tablets for angina. Doctor Connolly, her GP, was told that Mrs Flannery was to go into Baggot Street Hospital for heart surgery in September 1984. He told her that.he would try to get things speeded up but that there was a long waitting list. Since then, Marie Flannery has heard nothing. She is f, ightened bccuase of the way the doctor in the clinic spoke so seriously about her condition. She knows that one of her neighbours, Mrs Ursula Whelan, who was first told at the James Street clinic in 1978 that she would need heart surgery, had to wait for four years until she had her operaation. Marie Flannery is a public patient and she waits.
Brendan Casey, from Greystones in County Wicklow also discovered that he needed heart surgery when he was in the Bon Secour Hospital in Glasnevin for a routine checkkup. Two months later the operation was performed in the Mater Hospital. Mr Casey was a private patient. "It cost a few hundred quid over the VHI, but I was not going to quibble. I was back at work in less than three months. I think anybody who is offered an operation is lucky. It means they're curable." There are no reliable estimates of the number of public patients currently awaiting heart surrgery, but general practitioners, hospital doctors and nurses have confirmed to us that waiting lists of up to four years are common for public patients. Private patients can have surgery almost as soon as a diagnosis is made. Heart surgery, along with orthopaedic surgery and operations like hip joint replacements is one of the areas where cutbacks in health spending have hit hardest. "If I send a public patient in for hip joint replacement it will be between one and a half and three years before it is done," says one general practiitioner in the Eastern Health Board area. "If the patient can buy the operation, it will be done in a matter of weeks."
"Doctors filling in at night can no longer be responsible for any more mistakes," according to the Irish Medical Organisation. Until this year, most junior hospital doctors worked a rota known as a "one-in-three", working one shift and then sleeping. Now most work a "one-in-two", sleeping every second night. The shift runs from say 9am on Monnday through to 5pm on Tuesday, without a break. One doctor in an important area of surgery in a Dublin hospital has worked a "one-in-one", for the past two months, techhnically on call all the time. The doctors say that for much of the time they are unfit to work, making mistakes, failing to spot fractures, making incorrect diagnoses. They say that their working conditions are dangerous. "I average 110 hours to 120 hours a week," said one junior doctor in Crumlin Children's Hospital. "We are beginning to tolerate a lower level of patient care and the working conditions are seriously affecting our decision-making ability. As well as the overwork, the lab cutbacks and radiology cutbacks mean that doctors are taking decisions on less information than we might have done before."
The cost of insurance cover for hospital doctors to prootect them against claims from patients who have suffered from mistakes is set to rise substantially this year. The Medical Defence Union which insures doctors in both Briitain and Ireland is to increase its Irish premiums from £365 to £490 a year. According to Doctor Roger Doherty of the MDU, "the cost of meeting insurance cover is to rise as cases taken against doctors rise, because of the increase in the number of claims and the jury awards system." The Irish Medical Organisation attributes the increasing insurrance rates to the overwork of hospital doctors, especially those on night duty. Junior doctors are currently planning to strike from November 12.
For half an hour on Christmas Eve last, the thirty-six patients in Clifden District Hospital were left completely unattended. Thirty of the geriatric patients are classified as "high dependency", requiring a high level of care and attention, but from llam until 6pm, there are only two nurses on duty. After 6pm there is only one nurse on duty. These nurses also had, until this month, to answer ambuulance calls. For that half hour on Christmas Eve both nurses were on ambulance calls and the patients were left unatttended. The matron of the hospital has now been given perr. mission to call in another nurse to cover ambulance calls, but the same staffing arrangement prevails.
In Ennis General Hospital during the summer months this year there were one nurse and one attendant in charge of 110 patients all night. Twenty-four beds in the hospital have now been closed, making one nurse and one attenndant to eighty-six patients. The closure of the beds means that geriatric patients seeking admission to hospital are not getting in. The staffing level, claims John Pepper of the Irish Nurses Organisation "is dangerous to say the least." Last year the Irish Nurses Organisation in Stranorlar met with the North Western Health Board to express their "conncern about the inability of nurses to provide proper care," for the patients in Saint Joseph's Hospital because of low staffing levels, particularly at night. In one block of the Clonakilty Geriatric Hospital in County Cork, there is one nurse for ninety-eight patients at night. If a nurse in another block needs assistance - which happens frequently when patients fall out of bed - those ninety-eight patients can be left unattended. The dangers of fire and accident, apart from possible medical crises, are obvious.
Crudely applied health cutbacks have led to longer waitting lists for certain major operations, staff shortages which are in many cases dangerous, and the absence of essential services. In the entire South Eastern Health Board region, for instance, there is no full-time child psychiatrist in public service. In the counties of Wexford and Kilkenny, which each have around 1,500 births a year, there is no resident paediatrician. Yet even in crude economic terms, paediaatric services help to reduce future demands on the health services by cutting down the amount of physical handicap. "In purely economic terms," according to the National Planning Board, "avoidance of handicap by intervention in the early days of life of vulnerable babies (thus avoiding the need for the life-long support which many handicapped persons require) would not only be humane, but also costteffective in the long term."
Cutbacks in health expenditure were not meant to affect the quality of service to patien ts, yet they have clearly done so. In April oflast year, the National Planning Board, while recommending an annual reduction of 4% in real terms in health expenditure between 1985 and 1987 maintained that these savings could be achieved "by good management without any sacrifice of the standards of services." But, it warned, "There is a danger that this recommendation would be implemented so that the costs are borne primarily by patients and the public in general rather than through inncreased cost efficiency in the health system . . . Econoomies in health expenditure should as far as. possible be achieved by reducing the inputs to the health services (beds, drugs, payments to doctors, nurses, hospital buildings, administrators etc) rather than by reducing the quantity or quality of beneficial and necessary care to the public." .
ThoUghout the nineteen-sixties and seventies, health expenditure by Irish governments grew very rapidly. Public health expenditure as a percentage of Gross National Product nearly doubled between 1971 and 1980 (from 4.39% to 8.24%) (it has fallen since then to an average of around 7% per annum) with the most dramatic increase coming between 1977 and 1979 when the Fianna Fail government of Jack Lynch and Martin O'Donoghue was engaged in a policy of active job creation in the public sector. "We were just interested in giving out jobs then," says a former Department of Health official who worked in the personnel area at the time. "A hospital just phoned up and said 'Look we want five of this, or six of that' and we said, 'sure, fine'."
This injection of money into the health services, howwever, served largely to cover up the structural inadequacies in the system, inadequacies which amounted to anarchy in the planning of health expenditure. In most other European countries, the planning of national health services after the Second World War involved a period of conflict between government and the medical establishment. In Ireland, the injection of capital allowed such fundamental questions of policy to be ignored.
In the Dublin area, hospitals had been founded by reliigious orders and benevolent organisations, independent of the state which did not then see a role for itself in proviiding medical services for the poor. In the provinces, the hospitals developed from the poor law system. Only with the Health Act of 1970 did a coherent structure for the health services emerge. Even then, however, the private voluntary hospitals in the Dublin area, all of the major hospitals in the city, were allowed to remain as 'private institutions while being funded almost in their entirety by the state. Money was being poured into the health serrvices and it was allowed to run along the channels that had been established many years before. The 1970 Health Act did provide for Regional Hospital Boards, whose powers of control would have extended to all hospital services in their areas, including the private voluntary hospitals. These boards, however, never functioned as envisaged and have not met for many years.
The eight Health Boards established in 1970 operate only about half of the "acute" (short-term general hospiital) beds in the country. The rest are under the control of religious authorities, the consultants who work in them, and private individuals who serve on their boards. All indeependent studies agree that there is an over-provision of acute hospital beds in Ireland, yet the institutions which provide these beds are not under the control of Health Boards, even though they are publicly funded.
It has been the policy of every government since 1970 to shift the burden of health spending away from instiitutions such as hospitals, including the voluntary hospitals, and towards community and out-patient care. Yet no government since 1970, or before, has followed this ofttstated policy. The present Minister for Health Barry Dessmond has stated time and again his commitment to the development of community based health and social serrvices. The government's main policy document Building On Reality claims that "the emphasis on community/outtpatient care will continue to be a major element of health policy." In fact the current spate of cutbacks in the health services are not only not aimed at transferring resources to community health care, they are having the effect of reeducing the level of health care in the community.
Seventy per cent of the huge increase in health spendding that took place between 1977 and 1979 went into the General Hospitals Programme, in spite of stated policy to shift the emphasis away from hospital care and towards the community. The acute hospitals have continued to eat up roughly the same share of the health budget as they have always done, in spite of Barry Desmond's stated aims. In 1980 they took 56% of the non-capital health spending; in 1985 they will take 54.4%.
The National Planning Board, in recommending general cuts in health expenditure, was anxious to emphasise the benefits of increased spending on community care. Its recommendation that the number of hospital beds should be cut by five thousand by April 1986 was combined with a proviso that "alternative and suitable facilities are made available." The board maintained that "the elimination of unnecessary short-stay admissions to acute hospitals," could be effected by a strengthening of community serrvices. The evidence, however.' is that no such shift of emmphasis has taken place and that community services are suffering from the cutbacks in the same way as the instiitutional services.
The lack of finance for the community based home help service is a clear example. This service caters largely for the elderly and the disabled in their own homes, with the aim of keeping patients out of institutions. Local people are paid by the health boards to visit elderly or disabled neigh-. bours, lighting their fires, helping them to wash and dress, doing shopping and often housework. The state is spared the cost, an average of £300 a week, of keeping a person in an institution. Since 1980, however, the allocation of reesources to the home help service has been declining in real terms, from £6.3 million in 1980 to £5.2 million last year and around the same level this year. Home help workers are paid £1.25 per hour.
The role of public health nurses, another main plank of community care has also been adversely affected by the cutbacks. Because of ward closures, patients are being disscharged earlier from hospitals and others are being denied access to hospitals for longer periods. Public health nurses now say that their work is 90% curative and only 10% preventive, instead of vice versa as it is meant to be. The non-replacement of public health nurses on leave or absent also means that the service is being stretched, and the Irish Nurses Organisation claims that child welfare visits which normally take place within a few days of a new born baby being discharged from hospital are now being delayed for up to three or four months.
A shift of emphasis from the institutions to the commuunity could only take place if the Health Boards, who decide on the use of resources in their own areas had control over the running of the voluntary hospitals, as recommended by the Planning Board. Barry Desmond was unable to answer queries from Magill about efforts to bring the voluntary hospitals under Health Board control, because the issue is "under policy review."
Last year, a thousand hospital consultants, employed by the Department of Health under the terms of a Common Contract which allows them to do an unlimited amount of private practice and to use public hospital faciilities - laboratory tests, radiography, scanners, and the serrvices of nurses and junior doctors - earned £33.03 million from the state. The Department of Health decided in 1985 to attempt to recoup £1.4 million of this as a contribution from consultants towards the public services which they use. In June 1984 the consultants refused to agree to any contribution towards the use of public facilities in treating their private patients. In the absence of agreement the Department of Health set the target of £1.4 million and disstributed it among the health boards, reducing their 1985 allocations by the amount that each health board or volunntary hospital was expected to raise from the consultants. However, sources on the health boards have told Magill that they have found it so far not feasible to collect the money from the consultants. Consequently the cuts have been transferred to patients in a reduction of the level of services.
Furthermore, Magill has discovered that the differentiaation between private and public work by consultants is not always clearcut and that there is scope for serious abuse. Everybody in the country of whatever level of income is entitled to all in-patient hospital services free of charge in public wards and at outpatient clinics. The only restriction is that people who earn in excess of £13,500 a year have to pay hospital consultants' fees. Outpatient services are free of charge to all patients, regardless of income, and those who wish to make arrangements to see consultants privately are expected to pay the full cost.
The evidence suggests, however, that hospitals are chargging people whom they know to be members of the VRl for services already provided free of charge to everybody by the Department of Health. Consequently the voluntary hosspitals and some consultants are being paid twice for the same job. On being admitted to hospital, a patient should be asked what type of accommodation they want: private, semi-private or public. Instead, it is normal practice to ask patients if they are members of VHI. This question opens up a path for the consultant to be paid twice for treating the same patient, by the Department of Health and the VHI.
The problem lies in the fact that the distinction between private, semi-private and public care is often vague or nonnexistent. The abuse is illustrated by the case of a man who was admitted to Saint James Hospital in Dublin after a heart attack. He was asked whether he was insured by the VRl. He received care for over a week in a nine-bed public ward. On being discharged, he was sent a bill by Saint James. This patient had wished to be treated in a public ward and was angry at being charged for a service which is already paid for by the Department of Health. Other patients in his position would simply forward the bill to the VHI who in tum would pay the hospital. The hospital Ðand the consultant - would be paid twice for the patient's stay, once by the government and once by the VHI.
It is not possible to estimate the extent of the abuse of the health system in this way - or the loss to the Departtment of Health in paying fees which have already been paid - but the VRl has decided that from December of this year, they will only cover patients who have actually reeceived care in a ward of not more than six beds.
Other abuses of the health services also arise because of the lack of separation between public and private facilities. Everybody earning under £13,500 a year is entitled to free consultant's services while they are in hospital, but if they are also a member of the VHI and the hospital happens to find out, they could be charged for consultant's fees. Unnknowingly, the patient will forward the bill to the VHI who will then pay the consultant, who has already been paid by the Department of Health. Many consultants who are employed on whole-time contracts by the Department of Health with a salary of around £26,000 also receive up to £18,000 a year from the VHI, which has one million members. In Britain, a consultant employed by the National Health Service is not allowed to earn more than 10% of his or her salary by treating private patients.
There are even further possibilities for abuses of the health services and of public money when hospital outtpatient services are taken into consideration. A woman wishing to attend a public out-patients clinic in Saint James was given directions to a consultant's private rooms in the grounds of the hospital. She was shocked when she later received a bill for the consultation. In Britain there is a law prohibiting consultants from renting accommodation in National Health Service hospitals. The problem in Ireland arises because there is confusion about who is entitled to free out-patient services in hospitals. Even though everyone in the country is entitled to free hospital outpatient services, and nobody should receive a bill for a visit to an outtpatient unit unless they have made specific arrangements to visit a private consultant, the vm information office' confirmed to Magill that they do receive bills for outtpatient services and that they will pay them. "Everyone should be entitled to outpatient services free of charge. However, in some cases people are charged. I don't know under what circumstances people are charged, but if they are members of the VHI we will cover it."
The root of the problem of abuse of the health services lies in the lack of a clear distinction between private and public services. In July the British Minister for Health Kenneth Clarke issued a statement saying that the rules for private practice in National Health Service Hospitals were to be tightened. The British health service collected £56 million' from private practice last year. "The key point," according to Mr Clarke, "is that all private patients should be properly identified as such at all stages." In Ireland, where according to Department of Health figures, over half of the current membership of the VHI are people who would be entitled to totally free hospital care in public wards, the need for such a clear distinction seems all the stronger. The VHI itself costs the taxpayer an estimated £25 million a year because VHI subscriptions are tax deductible at the top rate of tax. If consultants are paid twice, by the Department of Health and by the VHI, then the taxpayer is paying twice.
In the light of this need for a clear distinction between private and public medicine, the case of Beaumont Hospiital, the major new hospital in the suburbs of Dublin, seems all the more surprising. In trying to reverse a deal struck under a Fianna Fail government in which consultants moving out to Beaumont from other hospitals were to be allowed to build a private hospital on the grounds of the public facility, Barry Desmond has offered the consultants 10% of the beds in the nO-bed hospital for their private patients. In doing so he has moved towards reducing the number of public beds available in the hospital, built enntirely with public money, and giving the consultants access as of right to public facilities for private patients.
This year the General Medical Services (GMS), the • ~cheme which pays for visits to general practitioners will cost at least £93 million. Last year out of an allocation of £86 million, £54.5 million, not including pharmacists' ,fees, went on drugs in the GMS alone. The cost of drugs to the taxpayer in the GMS is inextricably linked to the cost of doctors' fees and the way in which those fees are orgaanised. Doctors are not accountable for the decisions which they take about the use of expensive drugs by their patients ·and there are no procedures .at present to ensure cost-. effective prescribing or the curtailment of undue hospital referral. Doctors prescribe what they judge to be best for their patients. According to the Department of Health, they are "regularly encouraged to prescribe the cheapest version of the drugs required by their patients and in this regard are regularly circularised by the GMS PaymentsBoard with statements of the comparative cost of alternative versions of commonly prescribed drugs." The Department has already made savings of around £13 million last year by excluding non-prescription items from the drugs that are available under the GMS and by implementing a new agreeement with the Federation of Irish Chemical hidustries under which the prices of most drugs supplied to the health service are controlled by reference to the price charged in the UK.
Both Barry Desmond and independent experts agree, however, that "potentially more significant savings" could be effected in the GMS "if there were a reduction in the volume of prescribing both in terms of the number of prescriptions written and the number and quantity of drug items on each prescription," and if doctors would prescribe more generic drugs. Generic drugs are drugs which have exactly the same ingredients and effects as brand name drugs except that they are sold at a fraction of the cost. The Planning Board went so far as to recommend that a further reduction of 15% in drugs expenditure could be achieved by 1987 as well as the 15% which has already been cut since 1983. Barry Desmond accepts, however, that "such a reduction would entail a significant shift in the preevailing style of practice."
There are a number of obstacles to the greater use of generic drugs. In the first place the. drug companies have forged very strong links with the medical profession through sponsorship of seminars (often in exotic locations) and research projects and through saturation advertising. (James Raftery in a National Economic and Social Council report on Health Services last year recommended that "resstrictions of sales promotions by pharmaceutical firms," should be considered.) Also doctors feel safe in prescribing brand name drugs, since in the case of any action for damaages arising from harm done by a drug that they prescribe, they would have the weight of a multinational company behind them. In Britain last April generic drugs were introoduced with the backing of a statutory National Drugs Board, testing their safety and quality. In Ireland the equivalent body is a Drugs Advisory Board, which does not have the same force or standing. There are, furthermore, a number of drugs inntroduced in' recent years for which generic versions are not available at all in Ireland.
The cost of drugs in the GMS is linked to the other major cost in the system - the fact that doctors are paid a fee for every visit a patient makes to them, rather than being given a general capitation fee to cover every patient for a year, as is the case in most other countries. A system which provides a financial incentive for doctors to have patients in their surrgery as often as possible also encourrages them to over-prescribe drugs, since patients tend to expect a preescription at the end of a visit. The Annual Report of the GMS for 1984 reveals a clear tendency for doctors with small numbers of GMS patients to have a higher number of visits from those patients than doctors with large numbers of GMS patients have from theirs, thus allowing the former to maintain their income from the scheme. There is no effective control over this abuse by either the medical profession or the Department of Health.
The present system of payment for doctors in the GMS was the subject of a report by an inter-departmental Working Party, on which the medical profession was also represented, pubblished in August 1984. The working party concluded that "a change in the present method of payment was desirable in order to secure a more effective style of general practice and one which placed greater emphasis on prevention, patient education, the sysstematic management of chronic illness and a reduction in the extent of reeliance on in -patien t services." "It is widely acknowledged," Barry Desmond told Magill "that a fee per visit system gives greatest financial rewards to those who provide the greatest volume of services while such high volumes may not be synonymous with high quality of care."
The main stumbling block to a serious modification of the wasteful fee-per-visit system is the current innsistence of the Irish Medical Organisaation in negotiations with the Departtment of Health on a public sector pennsion arrangement. According to Barry Desmond, who has offered the IMO facilities for a self-employed superrannuation scheme, "Public sector pennsions are not available to those who are not employed on appropriate terms as officers of health boards or other public bodies. Doctors particiipating in the GMS are, of course, selffemployed contractors."
Health spending in Ireland contiinues to go in a direction which is against the stated aims of government policy. There is scope for major cutbacks in the fees of consultants, in the cost of drugs and in the GMS. But the vested interests are firmly enntrenched. The Health Boards which control the allocation of health spending outside of the voluntary hosspitals contain a heavy representation from the medical profession itself. Eithne Fitzgerald, a former labour member of the Eastern Health Board and an economist, found that because local authority membership of a Health Board is usually on the basis of political seniority - it offers the political perk of access to represenntations about medical cards and hosspital places - "the result can be a board with a relatively elderly memmbership and one which is less likely to question official policy and disturb the cosy relationship with the officials." While the cosy relationship continues, people like Marie Flannery will have to wait. •
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The Eastern Health Board's gift to a multi-millionaire
The most staggering example of profligacy in the health system at a time when cutbacks are biting into the services available to the poorest members of society, is the Eastern Health Board's generosity to the Institute of Clinical Pharrmacology. ICP is one of the biggest business successes of recent years in Ireland, paying dividends of £1 million to its shareholders in 1984. After a successful floation on the US Stock Exchange the company is now worth £4-5 million, with the personal share of its chief executive Dr Austin Darragh worth £27 million. ICP makes its profits from the testing of drugs for the international market and it was there that Niall Rush died last year.
ICP's headquarters is located on the grounds of St James Hospital in Dublin and the 12,500 square foot site is owned by the Eastern Health Board. According to ICP's prospecctus, issued for potential investors at the time of its American floation of shares, "ICP pays a nominal rent for this site." The EHB "has agreed to permit ICP to use the site on which its current headquarters is located," until April 1986 or the completion of ICP's new headquarters, which is on a one-acre site, also on the grounds of St James. This site too "is the subject of a renewable long term lease by the Eastern Health Board at a nominal rent to ICP." For a site half the size of the one it now occupies in Dublin, ICP pays rent of 58,500 dollars a year in New Jersey.
But what is most staggering is that when ICP gives up its present site and moves to the other "nominal rent" site on the grounds of St James, the Eastern Health Board will pay ICP "a payment estimated on December 31 1983 to be £273,000." For the amount of money it is giving free to ICP, a company worth £45 million, the Eastern Health Board could employ at least thirty extra nurses for a year.