Health cutbacks are killing hope of reform

THE health and social care systems right now are in crisis, despite the fact there are clear plans available that can make a huge difference.

The necessity to keep people from being admitted to A&E, hospitals, nursing homes and residential care is a matter of extreme necessity. Austerity cannot be used as an excuse to deny the implementation of sweeping changes in the health and social care system for which clear blueprints exist.

As of Jul 1 2013, on the back of a 96% rise in hospital waiting lists, the total number reached 48,279, with 3,062 waiting between nine and 12 months and 653 more than a year.

Unless more care is delivered with improved infrastructure in primary care — with GPs with social workers, mental health, physiotherapy and other professionals linking in with community care teams in mental health, elder care, disability, children’s health, older care — these lists will grow larger and become an impossible challenge.

Ireland also has the fourth lowest number of hospital beds per 100,000 of 28 Eurostat surveyed countries at 313.9, with an average of 538 beds across the 28 countries. Germany has 825; France 642 and Portugal 347 (all figures for 2010 the most recent). As recently as 2004, Ireland had 564 hospital beds per 100,000.

More than 90% of all health care is delivered at the primary care level by GPs, nurses and associated health and social care practitioners. In 2011 we had 532,000 people over 65 years. In 2031, we will have more than one million. There will also be an increase of 370,000 people aged 45-64, according to Census 2011 Population Projections.

In response, government policy has been moving to reform the health system towards more primary and community care to reduce the growing pressure on the hospital system. The vehicle for this has been to plan for ‘Integrated Care’.

The HSE and Department of Health have been working on developing integrated health and social care since the DOH Primary Care Strategy of 2001 and various HSE programmes, including the HSE Integrated Service document (2008) and subsequent National and Regional Service Plans.

The Department of Health policy ‘Vision for Change’ (2006) is also about integrating health and social care in the community for mental health service users. Likewise, the HSE has been planning to discharge disabled people from residential settings into the community as per its ‘Time to Move on from Congregated Settings’ Report of (2011). It has arrived at a four-tier integrated services model which spans primary care, social care, secondary hospital and tertiary hospital care.

Indeed, the HSE is implementing polices whereby smaller county and general hospitals will cease to perform complex health procedures and will be ‘re-configured’ as day hospitals/urgent care centres or clinics. All of these are planned to be linked to primary and community care, with the aim of reducing the necessity for people to stay in acute hospitals or even need hospital care in the first instance.

Other interventions such as Falls Clinics in the community for older people and enhanced geriatric community care, all liaising between primary care teams and health and social networks, are designed to keep people from being fully admitted to hospital or having to enter nursing homes. Community mental health teams are planned to liaise with primary care teams to fulfil the gold standard of keeping mentally ill patients at home and utilising the same objective for the general population, the disabled and others with chronic or acute conditions, such as diabetes, asthma and other illnesses.

With people living longer, population ageing becoming acute, a growing population, a low number of hospital beds, increased rates of suicide and poor mental health, there is a huge urgency to implement ‘integrated’ health and social care in primary/community care. Older people and their families cannot afford €1,000-€1,200 per week for nursing homes and older people neither desire nor need nursing homes, if integrated care is available in the community. In addition, the ‘Fair Deal’ scheme is over-subscribed, whereby older people pay a proportion of their estate on death to pay nursing home bills.

The Department of Health and HSE have a very useful four-tier model of integrated care to deal with these issues. The lynchpins are primary care teams in primary centres working alongside teams (elder care, mental health, disability etc) in the community health and social care network.

Yet the progress to achieving the required number of primary care centres has been very slow, which to a large extent is not a fault of the HSE, given the cutbacks in health budgets. Yet, austerity is killing people, as verified in a recent book by the eminent public health specialists Stuckler & Basu (2013).

To highlight these issues an event has been planned for the Royal Irish Academy on Nov 12 from 6-8pm. Representatives from groups representing older people, mental health service users, GPs and academics will meet. They will be addressed by Prof Des O’Neill, who authored the seminal report on the Leas Cross Nursing Home. HIQA will also be represented. The HSE’s Angela Fitzgerald, HSE regional director for performance and integration for Dublin North East will also address the meeting.

* Dr Tom O’Connor is college lecturer on economics and social policy/ social care at Cork Institute of Technology. The book Integrated Care for Ireland (edited by Tom O’Connor) will be launched on Nov 12, at 6pm Royal Irish Academy

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