Special Report - Day 2: How sick is our health service?
The Covid-19 pandemic precipitated significant and rapid changes in the health service, the speed and scale of which illustrated the capacity and flexibility within the service for a new way of doing things. Picture: Denis Minihane
Covid-19 precipitated significant and rapid changes in the health service when the pandemic struck in March.
While some of these changes, such as the takeover of private hospitals, were temporary in nature, the speed and scale of change illustrated the capacity and flexibility within the health service for a new way of doing things.
In some quarters, it raised hopes that Sláintecare — a 10-year plan to transform the health service — could be fast-tracked to deliver universal healthcare and end the two-tier public-private system.
- - A number of “quick wins” built into the Sláintecare blueprint have not been taken up by the Government but could immediately improve access to healthcare, according to Professor Steve Thomas
- - Professor Anthony Staines argues that the current Irish health service model is upside down, with too much emphasis on acute hospital care and not enough investment in primary care
- - The Covid-19 pandemic has led to improved co-operation across the health service but there is a long way to go to address cost and access issues for public patients, says co-leader of the Social Democrats Roisin Shortall
- - Sláintecare is a vision rather than a clearly mapped out plan, according to the Irish Hospital Consultants Association president Professor Alan Irvine
- - Sláintecare is “aspirational” without funding and increased manpower and capacity across the health service, according to IMO president Dr Padraig McGarry
- - Workforce planning and the recruitment and retention of nurses in the health service will be key if more care in the community is to be delivered, according to INMO secretary-general Phil Ní Sheaghdha
- - Little progress has been made on patient safety despite several high-profile cases and inquiries, according to the Irish Patients Association (IPA).
- - Time is precious for terminally ill patients, who must continue to justify their illness in order to qualify for a medical card in the last years of their lives, says patient advocate John Wall
On taking up his post last June, Stephen Donnelly, the health minister, said Sláintecare should be accelerated in light of the pandemic, which had created a “perfect storm” and compounded challenges already within the health service.
“The mission is universal healthcare,” Mr Donnelly said.
“That does exist for some people in Ireland right now but for an awful lot of men, women and children in this country — who are waiting months or years to see a doctor, for a scan, for treatment, for surgery — we don’t have it. So the mission is universal healthcare and the route to that is Sláintecare,” he added.
Since then we’ve had record funding of €22bn announced for the health service this year and a €600m winter plan that is placing greater emphasis on providing more care in the community instead of in hospitals.
After the budget announcement, the executive director of the Sláintecare programme, Laura Magahy, told an Oireachtas committee she would like to see the 10-year strategy delivered in half the time or less.
“I want to see it done in five years. In fact, I want to see it done in four or three years. We are only two years into it,” Ms Magahy said.
The Department of Health said that “considerable progress” had been made on Sláintecare, despite the pandemic.
Among the initiatives progressed were telehealth medicine and e-health solutions, the integration of services across acute and community services, and managing more care in the community.
One example is the use of video-conferencing tools for outpatient appointments, which has allowed 30% of all appointments to be delivered remotely.
The establishment of 96 community health areas to serve local populations of 50,000 is one of the first steps being taken to restructure how services are delivered.
These community healthcare networks are being funded under Budget 2021 and will recruit more than 2,000 staff, including nurses and community therapists, to support independent living and deliver more care in the community.
The broad outline of six new regional health areas, with devolved budgets, has also been agreed, although the pandemic has delayed the completion of business plans to roll them out.
The changes delivered through the Covid-19 response, the department said, illustrated what is possible and presented “opportunities for implementing Sláintecare at pace” with the support of record funding of more than €1.35bn to “enhance the permanent capacity” of the service.
This year, close to €900m will be spent on providing extra acute, critical care, and community beds as well as initiatives to support more people and provide more care in the community.
Over the next three years, the department intends to focus on three key initiatives — providing more care and support in the community; reducing waiting lists and commissioning new elective hospitals in Dublin, Cork and Galway; and progressing universal access to healthcare through a ‘citizen care masterplan’.
The goal of Sláintecare, the agreed Oireachtas all-party 10-year plan published in 2017, is to enable the delivery of the ‘right care in the right place at the right time by the right team’, at low or no cost.
For the moment the healthcare system operates on a two-tier public-private basis.
While many people have private health insurance, a medical card, or free GP card, a large cohort of the population falls between these options and must pay for care whenever they attend their GP or hospital.
Sláintecare hopes to untangle the existing two-tier system to offer timely universal care to all citizens, regardless of means.
Between 85% and 95% of inpatient/daycase patients are seen in less than 15 months. Around 75,000 patients were on inpatient/daycase waiting lists in October 2020 — over one fifth for more than a year.
No one should wait more than 12 weeks for an inpatient procedure, according to the Sláintecare vision.
There is a long way to go to achieving that goal, however.
At the moment, 80% of patients should get an outpatient appointment in less than 52 weeks — 600,000 patients were waiting on an outpatient appointment in October 2020 — but this is to be reduced to 10 weeks under Sláintecare.
Currently, 99% of patients should be seen or discharged from an emergency department within nine hours. Even though Covid-19 has reduced emergency department attendances, overcrowding is still an issue.
Hundreds of patients continue to spend hours on trolleys and the full capacity protocol was triggered over 1,900 times this year.
Under Sláintecare, maximum waiting times in emergency departments should be reduced to a four-hour target.
Public and private services operate side by side in the public health system. Around 16% of inpatients and 13% of daycases were private patients in November 2019.
Around 800,000 people with health private insurance receive all their care in public hospitals. Under Sláintecare, there will be a phased elimination of private care from public hospitals.
- Covid-19 fallout: The impact of the pandemic on health services will impact on the scale and pace of changes possible in the next year and beyond:
- Targeted funding and investment: Significant funding is needed to address ongoing capacity deficits in beds and staffing at acute and community care level:
- Recruitment challenges: The health service, similar to many others around the world, are competing for staff in the wake of the pandemic and other factors, such as pay and conditions for doctors, nurses, and public health specialists among others, remains an issue:
- Untangling the two-tier system: Untangling the public and private healthcare systems will be one of the biggest challenges to rolling out universal healthcare. It is not yet clear how public and private hospitals will operate in the future or how universal GP care will be provided.
- Public-only consultant contract: Plans to remove private care from public hospitals and offer public-only hospital consultant posts will present challenges. The Department of Health said it is progressing legislation to facilitate the new public-only contract as a “priority”.
A number of “quick wins” built into the Sláintecare blueprint to transform our health service have not been taken up by the Government but could immediately improve access to healthcare and help get patients through the doors during the pandemic.
That’s according to Professor Steve Thomas, a health economist at Trinity College Dublin, who supported the Oireachtas committee on the future of healthcare in 2016 and 2017 to develop the Sláintecare report.
Dr Thomas said the “slow” progress on Sláintecare before the Covid-19 pandemic was “disappointing”, but accepted that it took some time to translate the report into actions for implementation.
While some progress was made on reforming health regions and integrating care, some “quick wins” that could improve access to care had not been progressed by the Government, such as reducing prescription charges and the drugs payment threshold for single households.
He said some of these quick wins could be rolled out temporarily during the Covid period to get patients through the doors and accessing care. “If we want to encourage people to access healthcare services then we should think about dropping some of those access charges,” he said, citing hospital inpatient charges as an example.
The Covid-19 pandemic had created an environment in which change happened quickly and was now considered possible, Prof Thomas said, pointing to GPs turning to telemedicine and the temporary takeover of private hospitals.
The shift, Prof Thomas said, was reflected in the winter plan. “It’s not a normal winter plan. It’s about advancing some of the infrastructure and getting it in place for Sláintecare. It’s the old adage of never waste a good crisis.”
The current Irish health service model is upside down, with too much emphasis on acute hospital care and not enough investment in primary care, according to DCU Professor of Health Systems Anthony Staines.
Progress on Sláintecare was “extraordinarily slow” but he agreed that the strategy could and should be delivered in 30 months, as recently alluded to by HSE boss Paul Reid.
“It should be done much faster and the benefits of that would be considerable,” the DCU Professor said.
It is still unclear how public and private hospitals will operate under any future universal healthcare model, he said, suggesting that a new model of care could see services provided by public and private facilities operating under the same tariff or cost basis.
“There would be one queue with everyone treated the same,” he said.
Polyclinics, which operate in other EU countries, could also be part of a new model of care, carrying out certain procedures that would otherwise be carried out in hospitals, while the remit of GPs could be expanded to enable them to carry out minor procedures.
GPs, however, were barely mentioned in Sláintecare but should be at the core of any new shift to deliver more care in the community.
“We are the only place on Earth where you pay to see a GP but can access free hospital care,” he said.
The reconfiguration of the HSE to deliver care through six new regional areas with devolved budgets has potential but also has risks.
There is a danger, Professor Staines said, that budgets for primary care, mental health and other community services could be “eaten up” by acute hospitals unless separate budgets are made available.
He added that in the UK GPs were given budgets to manage and could decide how government funding was spent at primary care level.
“It’s an option. It would mean giving power to GPs and changing the way GPs work as well,” he said, adding there could be a shift towards larger group practices in the future.
GP practices could also take on pharmacists and psychologists as members of their team. All of this would require greater investment in primary care.
“General practice should be the heart and core of community care but it’s hardly mentioned in the Sláintecare document,” he added.
The Covid-19 pandemic has led to improved co-operation across the health service but there is a long way to go to address cost and access issues for public patients, co-leader of the Social Democrats Roisin Shortall said.
Ms Shortall, who chaired the Oireachtas Committee on the Future of Healthcare, said elements of Sláintecare had been accelerated by the pandemic but that little progress has been made on fundamental issues such as removing costs as a barrier to care.
Costs such as GP fees presented a barrier for a sizeable proportion of the population, she said, adding that Ireland is an outlier in Europe in how primary care services are delivered.
“There is a need to recognise that a lot of people can’t get healthcare because they can’t afford it. That’s the reality,” Ms Shortall said.
“The public healthcare system has long waiting lists and it has user charges as well. It’s not free care,” she said.
Health funding, she said, was being spent in the wrong places.
“We’re spending as much if not more than other European countries. So we’re doing something fundamentally wrong and that’s really what Sláintecare identified, the need for complete reform of how we provide services,” Ms Shortall said.
On waiting lists, she said using private hospitals to clear backlogs under the National Treatment Purchase Fund (NTPF) was not the right approach.
She said: “That compounds the two-tier nature of the health service. It incentivises the division of private and public care.
"Instead, we should be filling consultant posts and ensuring adequate staffing levels in public hospitals.”
Ms Shortall said reconfiguring the HSE into six new devolved regional health areas, which has paused due to the pandemic, was an essential step in reforming how services are delivered and need to start moving again.
“That restructuring is essential to achieve the integration of services, better value for money, and local accountability,” she said.
Sláintecare is a vision rather than a clearly mapped out plan, according to the Irish Hospital Consultants Association, which said there is no sign that the blueprint to transform the health service is being accelerated by the Covid-19 pandemic.
Its president, Professor Alan Irvine, said Sláintecare — the 10-year proposal to transform healthcare and social services in Ireland — represents an idea rather than a clear strategy to deliver a new model of care for the country.
“I don’t think there is any clear acceleration for Sláintecare.
"We have seen an increase in budgets for health services and that is welcome and we’d like to see that spent wisely and in a scalable way,” he said, adding that frontline staff should have a role in how funds are spent.
The additional €4bn in funding in the budget will only serve to keep the health service “alive” rather than transforming it, Prof Irvine said.
He questioned if ambitions to deliver free universal healthcare were grounded in reality as there was no clear plan for delivery.
“Can the public system build four new elective hospitals in the next seven years,” he asked, pointing to the length of time to progress the national children’s hospital, first mooted 14 years ago.
Prof Irvine said it was also unclear at this stage how the Government proposed rolling out universal healthcare, a central tenet of Sláintecare.
Given the slow progress in implementing Sláintecare three years on from its publication, Prof Irvine said he remains sceptical about its delivery.
Prof Irvine does welcome plans to move towards regionally controlled health areas.
“That would provide local empowerment and decision-making in terms of how budgets are spent and staff are recruited," he said.
In the short-term, Prof Irvine said, doctors want and need capacity and colleagues to enable them to provide an adequate level of service instead of working in the red zone “all of the time”, describing the day-to-day challenges of dealing with overcrowding and inadequate capacity as extremely challenging.
Sláintecare is “aspirational” without funding and increased manpower and capacity across the health service, according to Dr Padraig McGarry, president of the Irish Medical Organisation (IMO).
The Longford GP said the new blueprint for the health service would not happen overnight and could not be fast-tracked by Covid-19 without matched funding, staff and additional capacity.
On the prospect of Sláintecare being accelerated, Dr McGarry said: “There is a lot of talk about it but, when you look at the funding applied, it doesn’t appear to match it. If you don’t have matched funding, it will remain aspirational.”
The need for 2,000 additional consultants and an extra 1,260 GPs to deliver universal healthcare, as well as 5,000 hospital beds to cope with predicted demand was not matched by government proposals, he said.
On a positive note, the new GP contract negotiated last year is beginning to reverse the damage wreaked by Fempi (Financial Emergency Measures in the Public Interest) cuts in recent years, which “practically broke the model of general practice”, he said.
The recent changes and investment in general practice, such as the roll out of chronic disease management programmes over the past year, may attract doctors working abroad to return home.
“Hopefully this will bring about a reversal of fortunes and, to some extent, we are beginning to see that with more people seeking to get on schemes this year," he said.
Recent GP training figures showing record levels of applicants for training programmes may also reflect a shift and renewed interest in general practice.
A shortage of GPs across the country combined with expected retirements, however, will continue to present challenges and may lead to a shift from single-handed practices towards group practices.
On Brexit, Dr McGarry said cross-border co-operation functioned well and should continue into the future.
Workforce planning and the recruitment and retention of nurses in the Irish health service will be key if more care in the community is to be delivered under a new model of healthcare in the future, according to secretary-general of the Irish Nurses and Midwives Organisation Phil Ní Sheaghdha.
Ms Ní Sheaghdha said that recruitment issues presented one of the biggest challenges for the health service.
"We have to become more self-reliant so that nurses are staying and joining the workforce, because up until now we’ve been very reliant on overseas recruitment, which has reduced globally because of the pandemic," Ms Ni Sheaghdha said.
In the wake of the Covid-19 pandemic, the number of nurses and midwives had only increased by around 230 since last year, she said, adding that a commitment to offer nursing graduates jobs must be honoured.
The pandemic, she said, also highlighted the need to bring care-of-the-older-person services, including private nursing homes, into the public system.
A 2018 capacity report suggests that the number of general practice nurses should increase by 89% and public health nurses by 67% by 2031.
Any shift towards more care in the community under Sláintecare will see nurses of all grades — including more advanced nurse practitioners and clinical nurse specialists — playing a key role, she said.
“If it’s designed properly, nurses should play a more central role,” she said, adding that nurses led clinics for chronic diseases in the community in the UK and other countries.
“What would make a difference to the patient would be to see a model of care that is delivered closer to where they live than the current system,” she added.
Little progress has been made on patient safety despite several high-profile cases and inquiries leaving the health system open to repeating the mistakes of the past, according to the Irish Patients Association (IPA).
“We are not learning from mistakes. They come back and are repeated in certain ways,” IPA director Stephen McMahon said.
The open disclosure of medical errors has yet to be rolled out, he said, and the Patient Safety Bill, as drafted, does not go far enough.
There should also be open disclosure for health service management failures, Mr McMahon said, suggesting that an independent regulator could be established for senior healthcare managers: “Open disclosure is also an issue for management when they make bad decisions that impact on patients.
"It’s not about a witch-hunt it’s about accountability and to have the individual and organisation accountable for what they do,” he said.
The National Patient Safety Office, which is part of the Department of Health, falls short of what was originally intended, an independent patient safety authority, he said.
The Minister for Health, he said, should make a performance statement every year on their stewardship of patient safety and progress made.
“There’s no measurable or quantifiable statement on patient safety performance,” he said, estimating that preventable deaths could exceed 2,000 per year when ED overcrowding, preventable errors, healthcare-associated infections, and the impact of delayed diagnosis are taken into account.
Time is precious for terminally ill patients, who must continue to justify their illness in order to qualify for a medical card in the last years of their lives.
That’s according to patient advocate John Wall, who has spent the past two years campaigning for easier access to medical cards for anyone with a terminal illness diagnosis.
Mr Wall, who was himself diagnosed with a terminal cancer, has been pushing for the current terminal illness exemption for medical cards to be extended from 12 months to 24 months to ease the burden on patients. The change would eliminate the need for patients to be means-tested and have their medical card reviewed every six months.
On foot of a recent clinical advisory group report, which suggested that legislative changes will be required, any hopes of a breakthrough were dashed.
On the back of that report, Health Minister Stephen Donnelly has sought a range of legislative options by February 10, which will likely take further time to consider and for the Government to deliver on its commitment.
While the work being carried out was laudable and extended beyond the medical card issue, Mr Wall said he could not endorse the “extraordinarily slow” process.
“I am still confident that we will get it across the line but it is taking a lot longer than anticipated."
The medical card application process in itself was “daunting”, overly bureaucratic, and puts many people off, Mr Wall said.
While he has been granted a medical card, Mr Wall and other patients with a prognosis beyond one year face the burden of their card being reviewed on an ongoing basis, including a means-test of their financial circumstances.
“If you’re not dying quick enough you won’t get a terminal illness medical card,” he said.
“Most people that I am advocating for already have a medical card, but at the moment it means that it’s reviewed and you have to go through that protracted process every six months of justifying your illness,” Mr Wall said, adding that the cost to the exchequer of extending the exemption would be “minuscule”.
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