A History of where healthcare policy went wrong and could go right

November/December 2020 15

Chay Bowes has alleged she said O’Brien

and Sullivan were advisors to her.

The WhatsApp exchanges between Ó’Tuathail

and Bowes [above centre] demonstrate

Ó’Tuathail warned Bowes there was a “link”

between Sullivan and McDonnell, a link which

seems to be conﬁrmed by Sullivan’s covert mes

sage attempting to recruit a helpful Ó’Tuathail

into VHSI’s clutches. Why was Sullivan doing

this?

Bowes alleges when he proposed the idea of

a not-for-proﬁt Community-based ‘hospital’ to

the former head of the HSE, Tony O’Brien, that

O’Brien suggested he meet Dean Sullivan, cur

rent Head of Strategy for the HSE. When he met

her McDonnell employed him on the spot but

they fell out when he raised questions about

the roles of O’Brien and Sullivan and the speed

with which she was proceeding.

Having government pay this private company

for healthcare procedures on behalf of patients

is central to VHSI’s business model. DCU profes

sor, Fine Gael member and former Seanad can-

didate Anthony Staines, who has been advising

McDonnell on the future of the health service,

conﬁrmed the importance of government con

tracts to VHSI’s Swords hospital. McDonnell

has long based VHSI’s operations in Staines’s

DCU’s Invent campus.

“The objective - and this depends on agree

ments from the government, from the health

service, is [the hospital] would be open to all

comers. But there has to be a deal put in place

that would cover that, because we have a large

number of private hospitals in the country,

which are expensive and not necessarily

working brilliantly”, said Staines.

Though Staines now maintains his rela

tionship with VHSI is an informal one, in

March 2018 he tweeted a picture of McDon

nell signing a memorandum of understand-

ing with the NHS, writing that the organisa-

tion “will work with us to deliver innovative

healthcare in Ireland [emphasis added]”.

Staines took part in the ocial photocall an

nouncing the partnership in November 2018,

when the NHS said the partnership would al

low the two parties “to share expertise and

experience on providing high quality inte

grated health and social care”. The partner-

ship however came to nothing, allegedly due

to funding issues on VHSI’s side.

“We had some initial discussions and

they were really keen to form a partnership

with us, but really they weren’t in a position

to move forward. We haven’t done anything

with them, if I’m honest, since then. There

were initial discussions regarding what they

wanted to do re health services, but really

nothing’s happened. We haven’t had any

contact with them for quite some time now.

I think they needed funding”, said an NHS

spokesperson.

Before founding VHSI, McDonnell worked

for Passage Healthcare as the company’s

chief operations ocer in Ireland. It was to

end in acrimony in just under half a year, ac

cording to the company’s executive vice pres-

ident, Ronan Collins, who said the company

“lost a lot of money” trying to expand into

Northern Ireland during McDonnell’s tenure.

“I can’t really talk about it, but she wasn’t

suitable. She was let go before her six months

ﬁnished. It was a bit of Northern Ireland, bit

of everything, clash of personalities, clash

of how she wanted to structure the business

and various elements. We parted ways”, said

Collins.

Collins doesn’t, however, seem to hold

animosity towards McDonnell and wished

her well with her ‘private hospital’ in Dublin.

“Now we’ve come back full circle and we’re

kind of back on good terms. She’s doing

a fantastic project in Dublin now. I believe

she’s building some kind of private hospital.

And it looks like an amazing project and no

doubt it’ll be a roaring success”, he said.

It won’t be for want of political nous.

At subsequent meetings she would

hold her phone so she could show

that Sullivan was on the phone to

her. She also said Tony O’Brien was

an advisor. She said Bowes’ plan

would not work and he should be a

big boy about it.

A History

of where

healthcare

policy went

wrong and

could go right

Community Hospital

Ireland could have

been a viable answer

to our hospital-

capacity crisis

When did it go wrong?

In the second half of the 1940s, after it was in-

stigated in the UK, a National Health Service

was promoted by Fianna Fáil and even made it

as far as a White Paper. But Ireland never got

a single-tier health service, at ﬁrst because of

medical-profession lobbying supported by the

Fine Gael Opposition, then because of-church

opposition, and then because of medical-

profession lobbying and revised Fianna Fáil

ideology.

Donogh O’Malley, hero of free secondary

education was against “socialised medicine’

when Minister for Health (1965-6): “those who

could pay should pay”.

The two-tier, medical-card, system of ac

cess to hospital care is a construct of Fianna

Fáil governments, albeit never seriously chal

lenged by any other party in government.

With no vision for the health system, Fi

anna Fáil threw money at health care in the

late 1970s only to cut back savagely in the late

1980s. Between 1986 and 1993 over a third

(5500) of beds were cut nationally.

The health budget quadrupled from under

by Chay Bowes

Audrey McDonnell with Vrdkr nd Reilly

16 November/December 2020

€4 bn in 1998 to over €15bn in 2008, largely

playing catchup after Haughey-era cuts; and

to €17.8bn in 2020.

2000 beds were cut in 2009 under Fian

na Fáil/Greens/PDs but Fine Gael put back

around 900 between 2011 and the start of Co

vid.

Because of the shortage of hospital beds,

the average hospital stay in Ireland at 6.2

days is much shorter than the OECD average

of 8.2 days; and Ireland hospitalises far fewer

patients, at 139 per 1,000 of population annu

ally, compared with an OECD average of 169.

Fianna Fáil, under Finance Minister Char

lie McCreevy (1997-2004), gave generous tax

breaks to developers to build private nursing

homes and hospitals: although it was govern

ment policy to have fewer, bigger, safer acute

hospitals, another arm of government was giv

ing away public money to build small, proﬁt-

able, unregulated hospitals anywhere they

decided, totally contradicting the policy.

In 2001 it gave and in 2008 it took away,

un-means-tested medical cards for over-70-

year-olds, recently reinstated by Fine Gael, the

government then had to negotiate a very bad

deal with GPs who (led by James Reilly who

later ﬁnished up as a bad Minister for Health)

squeezed the pips. As a result, GPs were paid

three times the rate for looking after richer

over-70s than those who already had medical

cards. This skewed GP services so that doctors

were paid more to provide care to those who

needed it least.

The establishment of the HSE is the biggest

public-sector reform in Irish history. Prepared

by Micheál Martin but executed by Mary Har

ney it was badly planned, leaderless for its

ﬁrst seven months, without structures, a clear

plan for redeployment of sta who’d been or

ganised on a county level, or a vision speciﬁ-

cally to provide universal, quality care.

There have been numerous attempts to re

form but without any real transformation. The

renegotiation of the consultants’ contract a

decade ago was a lost and expensive oppor

tunity at enormous expense to reform the Irish

health system but it is only very recent and

exorbitant proposals to pay €250,000 – twice

what Britain’s NHS pays - to consultants to

practise only publicly are something of a start.

A White Paper on Universal Health Insur

ance was published in 2014 with a report on

the potential costs of the model published in

November 2015. The debate was always too

much about the cost of this rather than on

how a focus on insurance might actually serve

the presumed goal of universal healthcare.

In the end Leo Varadkar suspended it, liken

ing universal health insurance to Irish Water.

He claimed it would have been impossible

to impose the extra fees without a backlash

from struggling families. While denying the

Coalition had performed a U-turn on its cen

tral health policy, he was unable to give any

speciﬁc year as to when a new version will be

introduced. He also appeared to criticise his

predecessor James Reilly by alleging there had

been an “obsession” with the Dutch form of

UHI. Varadkar insisted he remained commit

ted to introducing the policy at some unspeci-

ﬁed stage in the future. In fact the role of insur-

ance has been eliminated in Sláintecare.

Then Minister for Health Leo Varadkar

pledged at the 2011 election to bring an end to

the hospital trolley crisis.

The 2011 Programme for Government

pledged:

“This Government is the ﬁrst to commit to

developing a universal, single-tier health ser

vice, which guarantees access to medical care

based on need, not income. By reforming our

model of delivering healthcare, so that more

care is delivered in the community, and intro

ducing Universal Health Insurance, the aim is

to reduce the cost of achieving the best health

outcomes and end the unfair, unequal and in

ecient two-tier health system…

A system of Universal Health Insurance

(UHI) will be introduced by 2016…

Universal Primary Care will remove fees for

GP care and will be introduced within this Gov

ernment’s term of oce under a Universal Pri-

mary Care Act”.

It was all meaningless.

Cancer care is an illustration of where

genuine progress has been made. A series of

healthcare scandals propelled it to the top of

the agenda. Cancer-care was moved from 30

to nine, safer, hospitals.

The National Treatment Purchase Fund

(NTPF) also provides funding to private-sector

hospitals for public patients who are long

waiters and for private long-term care facili

ties.

Additional funding of €25 million has been

committed to the National Treatment Purchase

Fund, bringing the total funding to €100 mil

lion in 2020. This fund will be used to improve

access to hospital services and reduce waiting

times for patients, a key Sláintecare goal.

The Programme for Government states: “

Expanding primary and Community Care is at

the heart of Sláintecare – making the vast ma

jority of healthcare services available in the

home or close to home, rather than in our hos

pitals”. Over the lifetime of the Government,

it states the Government “will seek to expand

universal access to health care in a manner

that fair and aordable”. The Government

will ﬁnalise the new Sláintecare consultant

contract and legislate for public-only work in

public hospitals

The National Treatment Purchase Fund

(NTPF) is an Irish government body which was

established to decrease waiting lists in the

Irish public healthcare system. The NTPF ap

parently reduced waiting times for procedures

from between two andfive years in 2002 to

an average of 2.4 months in 2009. NTPF pa

tients also ensure business for consultants

who work in hospitals that are part of the NTPF

scheme. The summer months can often be a

quiet time for consultants and a guaranteed

stream of business from the NTPF is most wel

come. One consultant in the Blackrock Clinic

was reported saying the NTPF took slots on

consultants’ private lists that might not be full

otherwise.

According to the most recent data, health

expenditure in Ireland was €20.3bn in 2016.

By comparison, total revenue-take in taxes for

the previous year on personal income, prof

its and gains came to €19.2bn. In addition

to these taxes, the public paid almost €6bn

in out of pocket health expenses, health in

surance and other voluntary care payment

schemes. Of all OECD countries, only the Unit

ed States and Switzerland have a greater level

of health spending than Ireland as a propor

tion of real Gross National Income.

Despite our relatively high level of health

spending, Ireland is ranked amongst the

worst countries in Europe for access to

November/December 2020 17

health services, emergency department (ED)

waiting times, hospital admission delays

and post discharge patient support. Ireland’s

acute hospitals have occupancy levels far in

excess of international norms and it is widely

acknowledged that these occupancy levels

compromise patient safety, contribute to

the spread of infections, impede eective

management of resources and reduce surge

capacity needed during the clinical winter

or times of emergency. The OECD’s 2017 re

port, ‘Tackling Wasteful Spending on Health’,

places Ireland as having a signiﬁcantly higher

level than the OECD average of postoperative

sepsis in abdominal surgeries and illustrates

a chronic use of highly addictive benzodiaz

epines in people over the age of 65. This is

not good for our health.

The Outlook

Over the past 10 years in Ireland the number

of people 65 years and over has increased by

34%. According to the Department of Health’s

ﬁgures, 38% of Irish people over the age of 50

have a chronic disease. The Irish longitudinal

study on ageing, TILDA, reports that 64.8% of

people in Ireland over the age of 65 age live

with two or more chronic conditions.

As the population ages, the proportion with

chronic disease increases along with numbers

of patients with multiple chronic diseases. We

are already seeing the eect of these increas

es in the occupancy issues for our acute hos-

pitals mentioned above. Demand for health

services is set to increase signiﬁcantly due to

current and foreseeable demographic chang

es, epidemiological trends, growing public ex-

pectations and innovations in technology and

medicine.

From 2016 to 2031 there will be a 10% in

crease in overall population, a further 59% in-

crease in population over 65 years of age and

an almost doubling of the population over 85.

The CSO forecasts nearly a fourfold increase

in people over 80 years of age in the next 30

years.

In their report, Projections of Demand for

Healthcare in Ireland, by Wren et al (2017), the

ESRI forecasts a 37% increase in demand for

hospital beds from 2015 to 2030.

The Government recognises that, as a con

sequence of these demographic trends and

without reform of our health system we would

need an additional 7,150 hospital beds to ad

dress occupancy issues and meet demand.

By comparison Tallaght University Hospital

has 562 beds and the two largest hospitals in

the State, St James’s Hospital and Cork Univer

sity Hospital have 1,010 and 800 beds respec-

tively.

The average cost of creation of each

new hospital bed reported from the HSE is

€1,000,000 per bed.

The planning challenges and delays in build

ing new hospital facilities in Ireland are well

recognised and evidenced by the planning

challenges to the New Children’s Hospital.

Additionally, each new hospital bed has an

annual running cost, reported by the HSE, of

€306,000.

Government Plans to Address

the Problem

We have an excessive orientation towards

hospitals to deliver our health services in Ire

land. Dating back as far as the 1930s and the

early formation of the State this bias toward

hospitals has been to the detriment of advanc

ing community based and primary care health

services. The result is a health system which

has become overly centralised and hierarchi

cally structured. It has become increasingly

deﬁned by its institutions and from a clinical

or bio-medical perspective rather than from

the community it serves.

Today, over three quarters of hospital beds

are used for treating patients with chronic

illness. and over half of the national acute

hospital budget is attributable to treatment

of patients with chronic diseases. This is un

necessary. Extensive proof exists both interna-

tionally and in Ireland that community based

clinical care provides a better experience for

patients and results in equivalent or better

medical outcomes as well as helping to main

tain independent living, eliminating the risk

of hospital acquired infections and reducing

other treatment risk factors such as falls. This

view has been adopted in the unique cross-

party healthcare policy vision developed by

the Oireachtas Committee on the Future of

Healthcare. The Committee’s Sláintecare re

port recommends the development of a more

integrated health service, centred on a com

munity based care model and this provides

the policy within which our health services will

develop over the coming decade.

The Government is committed to this di

rection of reform and in addition recognises

a need to build additional physical capac

ity in the health system. Capital spending

of €10.9bn is planned to 2027 to renew and

The broad agreement in the direction of health

reform, combined with ﬁnancial and physical

constraints, provides an opportunity to develop a

new community-based and community-directed

health-delivery service.

develop health infrastructure. However, this

spending will not be used to simply expand

the current unsustainable system of care.

To support the transition to a future proofed

model of care the Department of Health will tie

capital investment in new hospital facilities

to reform. Hospitals wishing to receive invest

ment in bed capacity must be able to demon-

strate planned reform of services.

The Department of Health has announced,

in its recently published Sláintecare Imple

mentation Strategy, that it intends to fund

community health service reform through an

Integration Fund. This fund will be open to in

dependent third parties who can demonstrate

value in driving innovation in reform of health

service delivery. There is no central plan for

implementing service reform and there is ac

ceptance that for system change to occur it

must be supported by outside innovation.

The broad agreement in the direc

tion of health reform, combined with ﬁ-

nancial and physical constraints, pro-

vides an opportunity to develop a new

community-based and community-directed

health-delivery service.

Sláintecare aspirationally agrees, but it

remains to be seen if the political will re

ally exists to grasp the nettle of change.

My position, and CHI

My position, derived from years analysing

the sector, was that Community Health Ireland

was a big part of the solution to many of these

problems.

It is frustration at the diculties I encoun

tered trying to put the idea in to action that led

in the end to this Village magazine feature.

Chay Bowes is a healthcare patient focused

entrepreneur trying to promote community-

based health services.