Hospital overcrowding: Integrated Care the sustainable solution

The financing of care has to change, writes Dr Tom O’Connor

This week saw the numbers of patients on hospital trolleys exceeding 612 for the first time ever. The crisis has now reached breaking-point. The blame game continues between the health minister and the HSE.

At 2.6 beds for 1,000 of the population, Ireland has the second lowest number of hospital beds in the OECD after Sweden. Germany, and Austria are highest with eight. Within the EU 27, the average is about five, so Ireland is half this figure. Even allowing for designated rehabilitation beds somewhat inflating the figures in other countries, Ireland still has a low number of hospital beds internationally.

So, in the very short term, new beds are required and there have been immediate moves yesterday to bring 120 beds on stream immediately. More than 1,600 hospital beds have been removed from Irish hospitals since 2004.

This is despite Census 2016 showing the population of Ireland has risen to 4.75m, from 4.24m in Census 2006. So we have 500,000 more people now with 1,600 fewer beds. Even in the short term, just to clear the hump of the current crisis, at least a further 500 hospital beds are required.

However, the gold standard for a sustainable public health solution is to configure services in such a way that far fewer people need to go to an emergency department (ED) in the first instance.

The HSE’s Tony O’Brien pointed to a key aspect of the way forward yesterday on this newspaper, saying he welcomed the call from the Irish Medical Organisation and the National Association of General Practitioners to develop “a fundamental shift to GP-led primary care”.

Primary care is care delivered at the closest proximity to the patient, without having to go to hospitals, in secondary or tertiary care. Primary care is about keeping people healthy, health promotion and also preventing people from getting diseases where possible, through using flu jabs and other vaccines.

It is also about preventing patients with chronic illness such as COPD, heart problems, asthma, or diabetes from getting sick, requiring them to have to go to an ED.

In Ireland, the OECD evidence suggests that we don’t have a problem with people going to an ED instead of their GP when they are sick. However, having seen their GP, many patients with chronic illnesses do need to go to an ED.

This is because there are not sufficiently resourced diagnostic and other test services available at the local GP clinic. This is made clear in a HSE report last year which stated that 86% of GPs believed improved access to diagnostics would reduce their referrals to emergency departments and outpatient departments.

The same report said that one in five GPs do not have direct access to abdominal or pelvic ultrasound in the public system. Some 70%-80% of GPs have no direct access to CT scans. A quarter of GPs do not have direct access to Dexa scans in the public system.

The lack of care in the community is another reason why old patients find themselves on trolleys in an ED. There have been cuts of two million hours to home helps in recent years. Though there has been an increase in home care packages, there is significant unmet need care need at present regarding old people who cannot afford to purchase home care from private providers. The failure to adequately fund mental health in the community is also driving hospital admissions.

Consequently, there needs to be a dramatic impetus towards significantly enhanced primary care, community care, health promotion, and disease prevention. In fact, all these elements need to be urgently linked up and integrated into a seamless service delivered in the community. This model is known as integrated care.

Integrated care is now the international gold standard for health and social care delivery. Sweden, though having the lowest number of hospital beds in the OECD, has a very good health system, simply because it has a strong integrated care system at the levels of primary and community care which requires for fewer hospital admissions.

The HSE has been pushing Integrated Care in its policy documents for the last 10 years. In the last two years, greater urgency has developed. The first HSE integrated care conference was held in 2015. This had hundreds of working examples of best practice on show from health and social care staff all over Ireland, and was replicated again at the end of 2016. In May, the HSE will host the biggest integrated care conference in Europe.

The financing of care has to change. A universal social insurance funded model of care has to happen. The USC charge of 6% should be dedicated as a universal social insurance for health insurance purchase for all citizens, as happens in Germany and France and tax revenue to replace it found elsewhere.

In the meantime, the rolling out of integrated care, which started only last year, with the creation of primary care networks within community health organisations needs to be hugely prioritised.

This requires incentivised payments system for GPs. In addition, the development of primary care centres has been too slow, and is less than a third of the 300 needed. Real planning, without political interference, needs to happen.

Right now, direct provision of or grants to GPs to provide diagnostic services is needed to prevent unnecessary referrals to EDs. Cutbacks to GPs need to be reduced and increased capitation fees under the PCRS are needed. It is ludicrous that a GP only gets €55 per annum for a person aged 16 to 45, irrespective of the number of visits. GPs will be the lynchpin of the integrated care preventing people from going to an ED, along with social care workers and social workers in the community.

Immediately also, we need a significant increase in nurse-led community intervention teams for discharge planning. We further need the rolling out of more falls-clinics in communities, to prevent old people from breaking hips and bones and finishing up in an ED. There is also a greater need for more urgent care centres in communities to prevent ED admissions.

All these are integrated care solutions. Integrated care is the sustainable solution.

Dr Tom O’Connor Lectures in Health, Economics and Social Care at CIT. His book, Integrated Care for Ireland, was published in 2013.