The Health service: a catalogue of crises and failures


1. The two-tier health system

Suzie Long's early and unnecessary death put a public face on Ireland's unequal two-tier health system. Public patients wait significantly longer to access essential medical services than people who can afford to pay privately.
The 2001 health strategy promised “equitable services on the basis of need”. Six years on, there has been no change in how public patients access services – access is still determined by ability to pay, not need.

Public patients are discriminated against in a number of ways; they have to wait significantly longer get a diagnosis; they then have to wait longer for treatment once they get a diagnosis; they are less likely to be treated by a consultant; they are accommodated in over-crowded wards where the risk of infection is higher.

The government actively incentivises private health insurance which in turn props up the two-tier health system; there is tax relief for 52 per cent of the population who have private health insurance; and private patients (or their insurers) do not pay the full cost of their private care in public hospitals, despite promises since 1999 to end this privilege for the rich.

Technically, only 20 per cent of beds in public hospitals should be used for private care. At the end of 2006, the HSE warned Tallaght Hospital that the number of private patients they were treating was at 40 per cent, twice the recommended level. Consultants speak publicly about how half of their workload is private practice – not surprising as the 80/20 rule is not regulated and over half the population have private health insurance.

Orla Hardiman, consultant neurologist and spokesperson for Doctors Alliance said, “its not a figment of imagination, there are 100s and 1000s of Susie Longs”. This will continue to be the case until there is a one-tier health system, provided on the basis of need.

2. Abuse of older people in nursing homes

In May 2005, the abuse of older people resident in Leas Cross nursing home was exposed by RTÉ's Primetime programme.

In November 2007, a report written by Des O'Neill detailed the institutional abuse that was taking place in Leas Cross and the failure of the health board management to prevent or stop the abuse. O'Neill's report recommended independent inspections of all nursing homes and adequate funding of residential care for older people. Mary Harney promised independent inspections would be in place by 2007.

Two and half years after Leas Cross, no nursing home is independently inspected. All private nursing homes are inspected by the HSE, while public nursing homes are still not inspected. The HSE inspections, published on the HSE website, show many of the problems of Leas Cross are still taking place. These include poor staffing levels,

inadequate or no medical records, failure to report deaths, inappropriate use of restraints and incompetent management of prescribed drugs.

Michelle Clarke, Chief Inspector of the Social Services Inspectorate (the body charged to carry out independent inspections), said it would be late summer 2008 before residential centres for older people are independently inspected.

The Leas Cross report also highlighted the rates paid for beds in nursing homes as “worryingly low”. Recent research published by Age Action shows that weekly fees for nursing home beds are up to €400 short of the actual cost of appropriate levels of care.

Tadhg Daly, who represents private nursing homes, says the current situation is a “recipe for disaster, with the HSE travelling the country hunting for the cheapest bargains for private nursing homes, while at the same time they expect higher standards of care”.

Unless all homes are independently inspected and care for older people is sufficiently funded, more Leas Crosses are possible.

3. Illegally charging older people for care

The Government illegaly charged older people for nursing home care from 1970 to 2005. Under the 1970 Health Act, everybody is entitled to free health care (apart from a fee of €60 per night for a maximum of 10 nights). This entitlement includes long term residential care for older people.

The illegal charges were highlighted as far back as 2001 by the then Ombudsman Kevin Murphy and acknowledged as needing reform in the Government's Health Strategy published in December 2001.

Yet, it was not until 2005 that a Supreme Court ruling put a stop to the practice. The Government then moved swiftly to set up a compensation scheme for those illegally charged and simultaneously rushed though legislation to legalise charges.

So now people are still entitled to ‘free' nursing home care. However, due to the shortage of public nursing home places and the cost of private nursing home care, not everyone who is entitled to this care gets it.

Two thirds of all nursing home beds are in private homes. Some people pay all the costs of nursing home care themselves, others get subventions from the HSE, while some people get their care completely paid for by the HSE.

From 1 January 2008, the ‘Fair Deal' for older people will be introduced. The ‘Fair Deal' will mean that those in need of nursing home care will pay 80 per cent of their income towards their nursing home costs (as is the current practice) but they will also be charged up to 15 per cent of the value of their home and other assets after their death.

The Fair Deal discriminates against older people as it introduces a new form of payments that will only be imposed on older people.  

4. The Health Service Executive (HSE)

In January 2005, the HSE was established. It replaced eleven existing health boards and other health agencies were subsumed into the HSE with the primary aims of providing more integrated and accountable health and social services.

It had great difficulty attracting a CEO, and eighteen months after its establishment Brendan Drumm took up the post.  
Ten years ago, 68,000 people were employed in the health system; when the audit of structures was carried out at the end of 2002, 96,000 were. Not one person lost a job when the eleven boards and other health agencies were amalgamated. In fact, the numbers employed by the HSE have increased consistently. Since December 2005, there has been a 37 per cent increase in senior administrators (grade VIII). Brendan Drumm told the Oireachtas (in a closed session) on 8 November that 130,000 people work for the HSE.

Frontline staff talk about increased bureaucracy, confusion over who is responsible for what, and more centralised decision-making and control since the establishment of the HSE.

Since the coming into being of the HSE, there has been industrial action by nurses, consultants, junior hospital doctors, pharmacists and electricians.

5. Accountability in the health sector

There is considerable confusion about who is accountable for what in the health sector. For example who is now responsible for health policy – the HSE or the Department of Health?

In the area of cancer services, the development of ‘centres of excellence' is being driven by the HSE. Yet in relation to the plan to co-locate private hospitals on the grounds of public hospitals, it is being driven by the Department of Health.

Interestingly, the 41-page document circulated to members of the Oireachtas on 8 November by Brendan Drumm, there was not one mention of the co-location plan (see privatising the health service).  

The budget for the HSE in 2007 is €13.4 billion. Before the HSE was established, Brian Cowen expressed very serious concern over HSE's capability to manage such a large budget. The Comptroller and Auditor General has repeatedly expressed concern over the HSE's ability to manage specific aspects of its budget.

On the 4 September 2007, cost cutting initiatives were introduced by the HSE over-night due to budgetary overruns. Both Mary Harney and Brendan Drum say the cuts do not impact on patient care. Doctors, nurses and patients all around the country are speaking out about the detrimental impacts these cuts are having on patient care. Meanwhile Brendan Drumm and his senior advisors were allocated large bonuses (Drumm's is said to be €80,000), while Bertie Ahern has accepted a pay hike of €38,000, higher than the average wage of a nurse.

Before the HSE was set up, the vast majority of Dáil Questions on health were responded to by the Department of Health, now over two thirds of these are referred to the HSE. In 2006, 95 per cent of Dáil Questions referred to the HSE remained unanswered. The HSE now has a target of responding within 20 days and says 75 per cent of responses are now within that time. As of January 2008, the response time target will be 15 days.

6. Privatising health services

The mainstay of the reform agenda in the health service since 2002 has been privatisation.

In 2002, tax relief was introduced for developers to build private hospitals and nursing homes. For every €100 million spent on construction, the State gives the investor €40 million in tax breaks. These tax breaks have resulted in a proliferation of for-profit health care providers. While there has always been a dependency in Ireland on the provision of health and social services outside of the State system, up until 2002 these were predominantly voluntary, Church-run or not-for-profit.

In 2002, the National Treatment Purchase Fund (NTPF) was set up to reduce waiting times for some treatments. The NTPF buys private care for public patients. Much of this care takes place in public hospitals, which is subsidised by public money (see two-tier health system).

The NTPF has reduced waiting times for some patients for some treatments. Yet, in July 2007 there were 14,738 adults awaiting surgical procedures, and 62 per cent of these were waiting over three months, despite commitments in 2002 to reduce all waiting times to below three months.

While the NTPF reduces some of the immediate pressures on the hospital system, it does not address the causes of the delays for treatment in the first place and it diverts money from the public health system into private care.
In June 2005, Mary Harney heralded the co-location initiative as an innovative and fast solution to address the shortage of beds in the public hospital system. The plan to build private hospitals on the grounds of public hospitals in order to “free up 1,000 more bed for public patients” – beds currently being used by private patients in public hospitals.

The 2001 Health Strategy had promised 2,800 new inpatient public beds. By the date of the announcement of the co-located plan, just 400 new public inpatient beds were provided.

The co-location plan copper fastens the unfair and unnecessary two-tier health system. It will result in increased separation of public and private health systems moving Ireland's health care firmly into a Boston model of healthcare.

7. PPARS Financial Fiasco

PPARS – an integrated computerised payroll and human resources system, originally intended to serve 17 health agencies – was expected to cost €9 million. By late 2005, PPARS had cost €130 million, at which point it was operating in just three health service regions and in one hospital.

The Report from the Comptroller and Auditor General (C&AG) published in 2007, notes that significant spending by the HSE on PPARS in 2005 remains unsanctioned by the Department of Finance. Yet in December 2006, the Department of Finance sanctioned a further spend of €1.5 million by the HSE on the “ICT consultancy for PPARS”. Since then the HSE has formally decided against introducing it across the country.

Not only was PPARS the wrong system which cost 15 times its original estimate, there were also technical problems with the system, for example one employee in the northwest was paid €1 million in error.

The most recent annual report from John Purcell, the C&AG ,said that the report provided by the HSE to the Department of Health in relation to its spending on information technology in 2006 said, “it appears that the inconsistencies of treatment of expenditure and the level of error were so significant as to greatly limit the value of the return for control purposes”.

8. Misdiagnosis of breast cancers

On 31 August 2007, the HSE told patients using the breast cancer diagnosis services at Portlaoise Hospital there was “no need for concern” after a consultant radiologist was sent on leave and a review of radiology practice set up. Two weeks previously the director of nursing raised concerns about high numbers of ‘false positives', that is women who were told they had breast cancer, who went on for further tests which showed they did not have breast cancer.

The HSE organised a review checking 3,000 mammograms – all breast radiology work carried out in the hospital since November 2003.

To date, nine women who were originally given the all clear for breast cancer, have been told they have cancer and are undergoing treatment.

On Thursday 22 November, it emerged at the Oireachtas Health Committee, that a further 97 women who underwent ultrasound scans were being recalled for examination amid fears that they were wrongly given the all clear. Some of these women had their fears confirmed of a positive breast cancer diagnosis when assessed on 24 November.

Mary Harney and Brendan Drumm say they did not know about the review of 568 ultrasounds by Dr Peter Naughten until hours before the Oireachtas Committee meeting. However, Dr Naughten had told the HSE months ago, that some of the women needed to meet cancer surgeons.

In 2000, Niall O'Higgins' report on national breast cancer services suggested the centre for the midlands be situated in Tullamore. In 2001, the then Midland Health Board located the breast cancer services in Portlaoise. In 2005, a surgeon in the hospital wrote to Mary Harney describing the services in the hospitals as a “shambles”. Mary Harney passed the letter to the HSE. In 2006, hospital staff expressed concerns to the HSE about the old age of the radiology equipment. Portlaoise Hospital is no longer taking any new cancer patients.

In May 2007, Rebecca O'Malley, a 41 year old Tipperary woman went public about her misdiagnosis in Limerick Regional Hospital, which has resulted in a 14 month delay in her cancer treatment. In August, another Tipperary woman was misdiagnosed. She was a patient in Barrington's private hospital in Limerick and her cancer treatment was delayed by 18 months.

On 17 November, Mary Hynes, assistant director of the HSE's National Hospital Office said the health service is “failing miserably” to meet assessment times for breast cancer diagnosis.

9. Accident & Emergency

When Mary Harney took up the position as minister for health, she said that improvements in A&E would be a litmus test of her role in health. Overcrowding and long waiting times for patients in hospitals A&E departments resulted in protests from patients and their families. Jeanette Byrne became the public face of trolley waits and set up an organisation called Patients Together campaigning for better public health services. Days after actor Brendan Gleeson raged against the health system and his parents' experience in A&E on the Late Late Show, Brendan Drumm set up an A&E task force.

When Brendan Drumm took up his post in late summer 2005, he said it would take two years to sort the problems of A&E. The task force report recognises that a shortage of hospital beds and services in the community result in over crowding in A&E. It set a target of a six-hour maximum wait time. On 6 November, according to HSE figures, 109 people were waiting for admission to hospital around the country and 64 per cent of these were waiting for more than the 6-hour target.

10. Infections in hospitals

“The key issue here is not funding: it is really about pride, standards and management,” said Mary Harney weeks after taking up office as minister for health in 2004. Ireland has one of the highest rates of MRSA and although C Diff is not a notifiable condition, it is on the increase.

There have been a myriad of initiatives to address hospital acquired infections, focussing on cleanliness and hygiene and the appointment of infection control managers. Last year, 557 cases of MRSA were recorded in Irish hospitals.
Recent research carried out by the Health Information Quality Authority gave none of the State's 51 hospitals a top score for hygiene. Nine hospitals were rated as ‘poor', 35 as ‘fair' and just seven rated ‘good'.

International research shows MRSA is closely linked to hospital occupancy rates of over 85 per cent. Most Irish hospitals have occupancy rates of over 95 per cent and some are over 100 per cent.

The failure to provide the 2,800 additional beds promised in the health is a significant contributing factor to high rates of infections in Irish hospitals.

11. Mental health Ignored

Funding of mental health services has decreased year on year over the past decade.

In 2001, 8.1 per cent of the health budget was spent on mental health services, in 2006, 7.1 per cent was spent. In Northern Ireland and England, at least ten per cent of the health budget is spent on mental health.

In January 2006, the government adopted the new mental health strategy ‘A Vision for Change' as government policy and promised it would be implemented in full over the next seven to ten years. NGOs working in mental health say the €150 million budget for implementation is totally inadequate and not much progress has been made in first two years of its timeframe.

The promised National Mental Health Directorate to drive mental health services in the HSE has not happened. The recent ban on recruitment is having a significant impact on the setting up of the promised multi-disciplinary teams, one third of mental health teams have less than half the staff they need. There is no capital programme for investment in mental health services.

The plan is to shut down all mental health institutions but if the community services are not in place, this will result in more people with mental illness on the streets. Dr Edmund O'Dea, chairman of the Mental Health Commission, is critical of the absence of funding. “You can't close down one section of the service and automatically start another.. There is a need for parallel funding on both sides until thenew model is ready. At the moment, that's not identified in HSE plans,” says O'Dea.