Health service
Underfunding, inequitable services and dysfunctional economic incentives are cited as contributing factors to Ireland's chaotic healthcare system. A new report from Irish Congress of Trade Unions, written by economist and journalist Maev-Ann Wren and American health policy expert Dale Tussing, exposes Government failures and warns against privatisation. By Sara Burke
There were 36 more people on trolleys in Accident and Emergency (A&E) units in hospitals in Dublin in the second last week of November in 2005 than there were for the same week in 2004, according to new figures released by the Irish Nurses Organisation.
In 2004, for the week of 22 to 26 November, there were 583 people on trolleys in A&E. In the equivalent week in 2005, 21 to 25 November, there were 619 people waiting on trolleys.
On 25 January 2005, the Minister for Health Mary Harney said that she expected “real and measurable improvements to take place in the coming months in the delivery of A&E services. A&E is a litmus test for me, for the Government and for the people of our country.”
These figures are evidence that things are getting worse, and that the Minister has failed to introduce real and measurable improvements in the very area she identified as her own litmus test. These figures come the week that the Irish Congress of Trade Unions published a report that reveals the extent of chaos and mismanagement of the health services, and makes radical recommmendations for healthcare reform in Ireland.
FEWER BEDS:
> There are fewer acute beds available in hospitals now than there were at the publication of the health strategy in November 2001
In 2005, Ireland has 2.96 acute hospital in-patient beds per 1,000 of the population compared to an EU average of four beds per 1,000. In 2001, Ireland had 3.13 such beds per 1,000. At that time, the health strategy identified a need for 3,000 more beds. In fact there has been an increase of only 535 in-patient beds in hospitals since 2001.
In 2001 the health strategy identified a need for 3,000 more beds. Since then there has been an increase of just 535 in-patient beds in hospitals according to the Department of Health definition of acute beds. The fall in the ratio of acute beds to population is explained by growth in population and the redefinition of some hospital beds as non-acute since the establishment of the HSE's National Hospitals Office in 2005.
The Government claims a much faster growth in acute beds than this because it includes both in-patient and day beds in its count. According to this new research, the number of day beds has increased by 475 since 2001, but most of the increase can be explained by a redefinition of a day bed to include trolleys, recliners and couches rather than the provision of extra treatment places.
HEALTH SPENDING TOO LOW, NOT TOO HIGH
› State spending on health is significantly less than the European average on healthcare.
According to the OECD, Ireland's public current spending on health was 94.4 per cent of the EU 15 per capita average in 2003 (actually it is now established that the OECD figures overstate health funding here and the real amount spent on health was less than 90 per cent of EU 15 average in 2003
Estimates of public current healthcare spending remain below the EU average.
The most recent data available shows Ireland's capital health expenditure to be the highest in the EU but the research highlights that this needs to be seen in the context of decades of low investment and neglect. From 1970 to 1996, Ireland invested on average each year 63 per cent of EU per capita capital spend on health. In 1990, health capital spend in Ireland was 38 per cent of the EU average.
The proportion of national spending on health has increased and the most recent OECD data show Ireland spending 8.9 per cent of its national income on health, just below the EU average of nine per cent. The authors of the report suggest this is an overstatement due to inadequacies in the Irish data. This increase in health spend reflects a pattern seen in most developed countries. The OECD average rose from 7.7 per cent of national income in 1997 to 8.8 per cent in 2003. This is due to increasing costs in healthcare provision, ageing populations and advances in technology which are often expensive.
IMPRESSIVE PROMISES BUT NO ACTION
› The Government has failed to implement its own policies outlined in Quality and Fairness – a health system for you (2001), the Hanly Report (2003), and the Primary Care Strategy (2004)
› Promises to increase the number of hospital beds available, to develop primary, continuing and community care services and increase healthcare staffing have all been broken
Not alone has the Government not met its promises, but in fact it is acting in contradiction to those policies.
SUBDISING PRIVATE HOSPITALS
› The Government pays €40 million for every €22 million invested in private hospitals through the tax incentive scheme for private hospitals
The report analyses the extent of public subsidies to private healthcare, eg tax payers, in the bottom half of the income distribution contribute to the private healthcare of those in the top half because hospitals' charges for private care do not include the true cost. It shows that the Government actually pays €40 million for every €22 million invested in private hospitals through the tax incentive scheme for private hospitals introduced by Charlie McCreevy as Minister for Finance.
And despite the high exchequer cost of investment in private healthcare, the Government has no share of the profits of private hospitals, nor does it control the type or quality of care they offer. Private healthcare providers are known to “cherry pick”, ie they select healthier and “easier” patients who often are treated more easily and need less ongoing care. Research shows that people who use private healthcare are younger, richer and healthier than public patients.
Stopping the current plan underway to build private hospitals on public grounds is recommended in the report. According to David Begg, general secretary of ICTU, “one of the most disturbing trends uncovered by the report is that of privatisation of our health services, a privatisation that is occurring by stealth. This insidious trend is built on a myth – that it will cost the taxpayer nothing and will deliver extra capacity for the health service. This study comprehensibly demolishes that myth. If this trend is allowed to continue unchecked, it will irreparably damage our health service.”
INADEQUATE PUBLIC HEALTHCARE FUNDING
› If ten per cent of current public spending was invested in health, the Government could fully implement the health strategy
Some current Government policy – including the building of private hospitals on the land of public hospitals, continuing to subsidise private healthcare, the contracts given to consultants and GPs – are condemned as crucial incentives which favour private practice and patients and mitigate against a healthcare service provided on the basis of need. The authors recommend Ireland progress towards a universal provision of care on the basis of need in a planned way.
DIFFERENTIAL PAY SCHEMES FOR PUBLIC AND PRIVATE PATIENTS
› Hospitals, hospital consultants and general practitioners get paid differently for treating public and private patients
The ICTU report also advocates a new way of paying consultants and general practitioners through a combined flat fee and fee for service mechanism and moving towards a one-patient system, no matter what type of patient is being treated. Currently, hospitals, hospital consultants and general practitioners get paid differently for public and private patients. This is identified as another incentive that works in favour of the unfair, two-tier health system.
A&E CRISIS TIP OF ICEBERG
› The crisis in A&E is just the tip of the Irish health service crisis
Cutbacks in community and public long-stay care, decades of low capital investment in health and social services, failure to provide a primary care service and to address critical issues such as the long-stay care of the elderly – hospital medical staffing, internal hospital management and integration between different parts of the health service – have all significantly contributed to the A&E crisis. Priority should be given to developing primary care and long care to address A&E crisis.
PROMISES ON COMMUNITY CARE NOT DELIVERED
› The health strategy promised 5,600 community nursing and care units over seven years. None of these has been acted upon, while at least 65 public long stay places were closed during 2005. Apart from ten pilot area projects, the primary care strategy has not happened
The ICTU research endorses the Hanly report, which proposed a radical reconfiguration of acute hospitals, where hospitals would be organised in networks with major hospitals staffed on a 24-hour, seven-day consultant coverage and full emergency services serving catchment areas of 350,000 to 500,000 while more local hospitals would have more limited services. The authors also endorse the Hanly recommendation of moving to consultant-provided rather than consultant-led care. Currently, private patients are more likely to get consultant-provided care while public patients will be looked after by non-consultant hospital doctors. The ICTU research recommends significant increases in consultant numbers in order to allow consultant provided services for all.
The report will inform ICTU's negotiations with the Government on healthcare reform.
* ‘The Health Report: An Agenda for Irish Health Care Reform' by Maev-Ann Wren and Dale Tussing, published by Irish Congress of Trade Unions ∏More www.ictu.ie