Low staff vaccination rates and lack of single rooms in hospitals threaten patient safety, while the health sector’s view it has been starved of cash is wrong, writes Seán Barrett.
Reopening Ireland is a welcome first step on a road to reform. The Covid measures imposed large costs on the economy as a whole and on certain sectors in particular. Given the urgency with which the measures were introduced a considerable power was given to the medical sector to impose punitive costs on other sectors including some which prima facie do not appear to be a major cause of the spread of the virus.
For example, hardware shops, clothes shops and garden centres were closed to stop the spread of the virus. Each has suffered large loss of market share to department stores selling the same products. The case for shutting clothes shops was that a potential customer might leave the virus on a jacket when touching it. This would endanger other persons trying on the jacket.
One might contrast the assumed jacket danger in the shop with the high rate of virus infection in hospitals and nursing homes. There is a low take up of the flu vaccine among health staff, and particularly among nurses. The Journal on January 9, 2018 reported a flu vaccination rate for nurses of 32% and for all hospital healthcare workers of 37.9%. On October 10, 2019 the HSE’s flu vaccine head announced a 68.5% vaccine rate for the over 65 age group in the wider population. The vaccination rate for the population over 65 was thus 2.1 times the rate for nurses and 1.8 times the rate for healthcare workers in hospitals.
Back in 2017 Minister Simon Harris and Chief Medical Officer Tony Holohan expressed concern about the low vaccine uptake among patient facing staff. Staff who are not vaccinated represent a threat to patients as they can spread flu and tend to be absent from the workforce when they are most needed. By contrast, if two thirds of dentists opted out of dental medicine, public opinion would soon be aware and corrective measures would result.
In addition to the problem of unvaccinated staff, patients face a shortage of single rooms in hospitals with an increased risk of hospital acquired infections (HAI). The SARI Report (Strategy for the Control of Antimicrobial Resistance in Ireland) in 2008 found there were three hospitals without any single room and that the median share of single rooms in the remaining 63 Irish public and private hospitals was 6%. The overwhelming majority of studies of single and multiple occupancy hospital rooms show a much higher infection rate, often well more than double, in rooms with multiple occupancy.
The Health Protection Surveillance Centre report on Hospital-Acquired Infections (HAI) in 2019 found “at 24% the HAI prevalence in adult ICU (intensive care units) was higher than in the overall population (6.1%).” This grim picture is confirmed by the State Claims Agency, a division of the National Treasury Management Agency. The Report of the NTMA IN 2018 found the cost of clinical claims resolved in that year was €247m, an increase of 84% on €135m in 2017. There are 3,196 clinical claims pending with an estimated outstanding liability of €2.33 billion, an average of €729,000 per claim.
Clinical claims account for 74% of the estimated costs of total claims across all sectors now facing the State. General claims in all the other sectors account for €0.82 billion of estimated outstanding liability. There are 7,462 general claims with an average cost of €110,000. The average clinical claim at €729,000, costs 6.6 times the average for general claims in the wider economy and society.
The government’s publication Health in Ireland (2019) confirms Ireland has a high cost health service. Ireland spends 12% of GDP/GNI* on health. This is third in the world after the USA and Switzerland. Switzerland has 36% more of its population share than Ireland over 65. This age group spends more than double the average of the population as a whole. The age adjustment brings Ireland into second place on this ranking. Ireland spent $4,869.4 on health per head in 2018.
This was 46% more than Spain which had the longest life expectancy, 42% more than Italy, 15% more than in Finland and 20% more than in the United Kingdom. The 2017 data show that Ireland spent 13% more than Canada, 14% more than Belgium, and 20% more than Australia. In real terms health expenditure per head in Ireland increased by 22.8% between 2007 and 2017.
Health is the best sector in Ireland at lobbying for more. It promotes strongly the idea that it has been subject to cutbacks. It has used the Covid-19 crisis to further increase its budget and staffing so that the axe will fall elsewhere when the bill comes to be paid. The sector’s success in transferring public odium over the rapidly escalating cost of the National Childrens’ Hospital away from itself undermined the financial credibility of the 2011-2020 governments.
The Oireachtas Committee on the Future of Healthcare (2017) stated that “the expansion of the general government health budget in the last two years has been at a rate of 7% a year. The Committee recommends that this expansion should be continued at least over the next five year period.”
This amounts to a 61% increase over seven years. Inflation in Ireland in 2017 was 0.25%. Health spending was proposed to increase at 28 times the rate of price inflation in the general economy.
Some elders have disliked the advice to cocoon both because of the word itself and the condescending attitude implicit in it. The Health in Ireland Report, at Table 1.8, based on 2017 data, has good news for them. At age 65, life expectancy in Ireland is 21 years for females which is also the EU average. In terms of healthy life years the EU 28 females have 10 years ahead and Ireland has just under 14. Males in Ireland have life expectancy at 65 of 19 years compared to 18 in the EU 28.
A little over 12 healthy life years await the Irish male at 65 compared to 10 for males in the EU 28.
The Health in Ireland 2019 Report also shows the many problems face the unreformed Irish health service. There were 13,000 adults and over 2,000 children on the waiting list for inpatient and daycare elective procedures and over half a million people on the outpatient waiting list with over 150,000 waiting for 52 weeks in November 2019. Last December an average of 300 admitted patients were waiting on trolleys in emergency departments daily at 2pm.
With its own problems so pressing the health service will have to address health reform rather than target output and employment in sectors such as hardware and drapery shops, garden centres and hotels. The low staff vaccination rate and lack of single rooms in hospitals threaten patient safety and contribute to the huge legal costs of the sector. The tendency to pay way over the odds for buildings has attracted the adverse attention of the IMF and has yet to be corrected.
The large awards by courts against the health sector must be addressed. The health sector’s view that it has been starved of cash and staff by the Department of Finance and DPER is simply not supported by the high national output share spent on health in a country with a relatively young population. As Ireland faces huge job losses across the economy in the biggest economic crisis since the Great Depression of the 1930s special pleadings by the health lobby will be less convincing. Reform of the health service will be the key.
Seán Barrett, Department of Economics of Trinity College, Dublin