Trust is key if reforms in healthcare will succeed

The impact of austerity cuts and the State’s contractually driven approach to the healthcare professions must change if hoped-for improvements are to be realised, writes Ray Kinsella

Trust is key if reforms in healthcare will succeed

A central pillar of the 2011 Joint Programme for Government was the unequivocal commitment to introduce universal health insurance.

“A system of universal health insurance (UHI) will be introduced by 2016, with the legislative and organisational groundwork for the system complete within this Government’s term of office,” it said.

Speaking about the Government’s achievements in recent years at the MacGill Summer School, Health Minister Leo Varadkar acknowledged that UHI wouldn’t happen by 2016. That was clear two years ago. In fairness, one of the minister’s first actions on taking over the post was to row back on this commitment.

The focus of policy is now on introducing universal primary care. The commitment here was also unequivocal: “Universal Primary Care will remove fees for GP care and will be introduced within this Government’s term of office.”

UPC will not be fully implemented by 2016 either. The plan now is to roll it out fully in the ‘next term of government’. The first step began earlier this month with children under six, with over-70s to follow.

In effect, the Government’s approach has shifted from explaining why its original commitment to introduce UHI is not going to happen by 2016, towards an essentially political narrative of saying that both UHI and a full UPC scheme would be delivered in the ‘next term of office’.

It would be prudent to reflect on the sustainability of even the scaled-back objective of ‘free’ UPC. It is under pressure from a chronic shortage of GPs, inadequate funding, and low morale across the professions. These have been magnified by the on-going legacy effects of austerity — which is not mentioned once in the MacGill address.

G.P. SERVICES FOR THE UNDER SIX The immediate point to note is that it is that‘free’ primary care is to be delivered through the country’s GP network. It is an important point. Were the Government to attempt to itself deliver primary care — through the HSE, for example — it would be very much more expensive, as well as taking very much longer. The country’s GP capability is, therefore, central to delivering on the promise of universal primary care.

The first challenge facing the next minister for health relates to the ongoing impact of austerity policies on Ireland’s health service. In his speech, the Minister does not once use the word ‘austerity’.

The reality is that the short-term, counterproductive cuts in staffing and services have had a devastating impact — as it has had in other countries — both on the experience of service users in the last five years , and on the capacity of the system to respond to future pressures.

There is an enormous amount of ‘catch-up’ from the austerity to be delivered, before factoring in the challenge of accommodating ‘free’ UPC. The under-six cohort will increase the number of patients entitled to ‘free’ care from 180,000 to some 420,000. That is a huge increase. Importantly, it will lead to a significant rise in the average number of consultations and in the average time spent on consultations. An increase in out-of-hours consultations can be anticipated. In addition, the provision of team-based GP services, encompassing more practice nurses and other allied health service professionals, will make increased managerial, organisational, and regulatory demands on GPs. And that’s before very significant new GP service commitments in ‘wellness assessments’ and asthma, to take just two examples. Increased societal pressures relating, for example, to increased prevalence of addiction and family-related strains will be transmitted to GP consulting rooms.By their nature, GPs hold a unique position of trust with individuals and families with practices delivering continuity of care often across three generations. They are also ‘gate-keepers’ to the acute system. Austerity ‘cuts’ ran deep at every level. They took no account of the strategic importance of the services provided by GPs. Government had little regard to uncertainty arising from the effects of the cuts on existing as well as prospective GPs regarding the personal, and financial, costs of committing to the profession.

Austerity contributed to the twin pressures on the supply side of the profession; emigration of graduates and also early retirement. The latter alone will have a seriously negative effect on the supply of GPs available over the next five years. In Ireland, specialist training takes four years — it is hard to turn supply around in the short term. run Bear in mind that, in 2014, for the first time, there were unfilled places in a number of GP training centres. This tells its own story about the morale and the erosion of trust.

This cannot easily be ‘airbrushed’ away. Mr Varadkar was at pains to emphasise the recruitment that is now going on; a whole cohort of nursing staff that were ‘cut’ are now being incentivised to return. In fact, within a year or two of the cuts, recruitment agencies were in Britain seeking Irish nurses to come back. Government observed up close the impact of counterproductive cuts in consultant staff and were compelled to reverse policy. The effects of austerity on healthcare are toxic — the IMF, especially, knows that well enough. Many highly (and expensively) trained graduates and experienced consultants who were effectively pushed out by the nihilism of austerity are now settled in the healthcare systems in Australia, Britain, and elsewhere. Good for such countries – bad for Ireland. Dysfunctional policy making in medical manpower is a chronic condition in Irish healthcare system. Austerity made it a whole lot worse.

Looking to the medium-term, the country needs well in excess of 1,000 thousand, probably going on for 1,500,fifteen hundred more doctors. It will be difficult, and it will take time, to turn the shortage of GPs around. It seems inescapable therefore that the ‘GP deficit’ will require recruitment recruitingof many from abroad.

These supply-side factors are playing out against the background of increased demand. On top of a planned transition to UHI, there are demographic pressures relating to both a rise in the population and also the impact of aging. These are long-term issues but, then again, medical graduates considering a commitmentcommitting to an additional four years of training and starting in GP practice do take a long-term view. They have options.There has been real pressure on GPs to finalise a GP Contract for the under sixes – especially in some parts of the country. And yet getting sustainable, and fair, contractual structures and incentives right from the outset is vital.

Looking ahead, different demographics have different needs and make different demands on GP services. Future contractual arrangements need to be aligned both to the urgency of increasing the supply of GPs into the future and, at the same time, making it worthwhile for existing GPs and new graduates to commit to the profession.

Trust is key. The Government’s relationship with the medical, nursing and midwifery professions has long been adversarial. This has been exacerbated by the legacy of austerity which has a deeply perverse impact on health status, outcomes and services.

In Ireland, the Government pushed through cuts in the teeth of evidenced-based warnings from the professions and representative bodies about the consequences. These entirely predictable consequences cannot now be brushed to one side.

The State gets a rare degree of commitment from the medical and nursing professions, yet they engage negatively with the professions, pushing a contractual agenda and expecting a vocationally-driven response.

The funding for implementing the extension of universal GP care to children under six is almost certainly inadequate — it is a demand-led scheme. If so, this will lead to a continuation of the nonsense of annual ‘overspends’, which has bedevilled service planning in recent years.

Realistic and sustainable policy objectives directed towards universal GP care — objectives that are widely shared by all stakeholders, not least by the profession — are vulnerable, once again, to being underestimated. And that is only part of the healthcare equation facing into 2016.

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