Health Report Card - Village Magazine

32 February 2016

2016 ELECTION

Health

Report Card

by Michel Smih

veryone who is ordinarily resident in

the country has access to public hos-

pital services, whether they have

health insurance, a medical card or

nothing at all.

The services may not be free and may be sub-

ject to waiting times depending on medical

condition.

Without a medical card patients are charged

€100 for all treatment received in a public hos-

pital accident and emergency room, though a

referral letter obviates the charge.

A White Paper on Universal Health Insurance

was published in 2014 with a report on the

potential costs of the White Paper model pub-

lished in November 2015. The debate was

always too much about the cost of this rather

than on how a focus on insurance might actu-

ally serve the presumed goal of universal

healthcare. In the end Leo Varadkar suspended

it, likening universal health insurance to Irish

Water. He claimed it would have been impossi-

ble to impose the extra fees without a backlash

from struggling families. While denying the

Coalition had performed a U-turn on its central

health policy, he was unable to give any speciﬁc

year as to when a new version will be intro-

duced. He also appeared to criticise his

predecessor James Reilly by alleging there had

been an “obsession” with the Dutch form of

UHI. Varadkar insists the Coalition remains

committed to introducing the policy at some

unspeciﬁed stage in the future.

The Irish health system ranks 21st in the 2015

Euro Health Consumer Index, up one place from

2014 but down from 14th in 2013. Lower-income

countries such as Macedonia, Croatia and Slo-

venia all rank ahead of Ireland in the index,

which is led by the Netherlands and Switzer-

land. And there has been a litany of speciﬁc

scandals and failures that have characterised

the media discourse on health. Or the consist-

ent overspends. Enda Kenny says his greatest

disappointment as Taoiseach is ongoing stories

of people’s negative experience with the health

services.

Most of the health issues in the general elec-

tion arise inevitably not from abstract policy but

from crises and failures to address long-stand-

ing problems. Unfortunately for the government

the public perception of the health service

remains that it is a sort of dysfunctional

“Angola”: Rebecca O’Malley, Susie Long, Leas

Cross, Áras Attracta, Savita Halappanavar and

‘Grace’, the woman with intellectual disabilities

who was tortured and sexually abused in a

foster home over thirteen years.

Worse still the proportion of the Irish popula-

tion that was over the age of 65 has been static

at 11% for years. But forecasts suggest that the

percentage of people over the age of 65 will rise

to 26% by 2026. About 20,000 additional

people turn 65 each year and the actual number

of people over that age will double in the next

few decades. Within that the number of “older

old”, people over the age of 80, will double.

Minister for Health Leo Varadkar no longer

repeats the 2011 election pledge to bring an end

to the hospital trolley crisis. The Government

should move towards a similar system to that

of the UK where trolley counts are not relied

upon to examine waiting times.

Meanwhile, though there has been some

marginal improvement since last year, over

crowded Emergency Departments (EDs),

famously described by actor Brendan Gleeson

in 2004 on the Late Late Show as “unspeaka-

ble… like a military ﬁeld hospital… a disgrace…

a war crime continue to make it difﬁcult for staff

to fully examine and adequately treat patients,

risking cross-infection and patient safety. There

have been improvements in the number of

emergency consultants (though problems sub-

sist at weekends and nights) and the

out-of-hours availability of GPs but the biggest

problems are the maintenance of too many EDs

(30 countrywide) and the under-resourcing of

alternative primary care. Furthermore there

has been for example no systematic introduc-

tion of minor-injury clinics, or deployment of

techniques like acute medical assessment and

early-discharge planning, no improvement in

GPs’ access to diagnostics to enable them to

avoid sending patients to hospitals, or improve-

ment in hospital IT.

"D"

"a poor vision

that failed"

February 2016 33

Overview

"This Government is the ﬁrst to commit to developing

a universal, single-tier health service, which guaran-

tees access to medical care based on need, not

income. By reforming our model of delivering health-

care, so that more care is delivered in the community,

and introducing Universal Health Insurance, the aim is

to reduce the cost of achieving the best health out-

comes and end the unfair, unequal and inefﬁcient

two-tier health system".

That’s the theory in the 2011 Programme for government.

But both of the key elements have failed.

End to two-tier system:

Universal Health Insurance

"A system of Universal Health Insurance (UHI) will be

introduced by 2016".

"The Universal Health Insurance system will be

designed according to the European principle of social

solidarity: access will be according to need and pay-

ment according to ability to pay".

"UHI will provide guaranteed access to care for all in

public and private hospitals on the same basis as the

privately-insured have now".

"Insurance with a public or private insurer will be com-

pulsory with insurance payments related to ability to

pay. The State will pay insurance premia for people on

low incomes and subsidise premia for people on

middle incomes".

As of now Universal Health Insurance is in disarray - suspended.

The idea was no discrimination between patients on the grounds of income or insurance status. The

two-tier system of unequal access to hospital care would end, even if a vision centred on private insur-

ance might be deemed a jolt towards privatisation and proﬁt-taking. Currently health funding is 80%

government, 9% insurance (half the population has insurance) and 9% out-of-pocket consumer pay-

ments. The shift would have been radical.

The ESRI reports underpinning the initial costing exercise for UHI were published in November and

concluded that more research is needed in this area before deﬁnitive conclusions can be drawn about

the best type of model to implement universal health care.

Primary Care

"Universal Primary Care will remove fees for GP care

and will be introduced within this Government’s term

of ofﬁce under a Universal Primary Care Act".

Leo Varadkar conﬁrmed before the election was called that Fine Gael could not commit to the introduc-

tion of universal care in the next Dáil term due to a shortage of GPs.

Free GP care for children under 6 was introduced in 2015 and by late December over 219,000 children

and 93% of GPs had signed up. GP care without fees for persons aged 70 and over was also imple-

mented in July and over 50,500 people have signed up to this GP service. Of course, these changes

prejudice needy patients and anecdote suggests there has been a big increase in visits to GPs by

under-sixes. These steps to wider non-needs-based healthcare mean, for the ﬁrst time, some 800,000

of the eldest and youngest in our society are now able to access GP care without being charged, a small

fraction, of course, of the 4.5m people envisaged. Budget 2016 announced the plan to extend universal

GP care without fees further to include all children aged 11 years and under, subject to the negotiation

of a comprehensive new GP contract with the Irish Medical Organisation.

But Fine Gael has abandoned plans to introduce free GP care for all citizens over the lifetime of the next

government. Leo Varadkar said extending free GP care to “everyone for everything” would overwhelm

the primary care system: “We set out to be very honest and what we believe to be achievable reforms

in health over the next couple of years and we do not think it is achievable to extend free GP care to

everyone in the country, to all adults and children in the space of ﬁve years because we are already

short on GPs”.

Prescription charges, which former Minister James Reilly promised to eliminate, in fact rose from €.50

to €2.50.

Cost Reductions

"This Government will act speedily to reduce costs in

the delivery of both public and private health care and

in the administration of the health care system".

"Action will be taken to reduce the cost of procure-

ment for medical equipments and construction of

facilities".

The Health (Pricing and Supply of Medical Goods) Act 2013 provides for cheaper generic drugs and

reference pricing.

The Department of Public Expenditure and Reform says Irish hospital costs were an extraordinary 80%

higher than the European average in 2014.

Scandalously the health budgets have had to be supplemented by an unanticipated €2.4bn since 2011.

€5bn and 1,250 beds (of which 300 have been reinstated by the coalition) have been taken out of the

Health Service. Ireland spends 8.1% of GDP on health compared with an OECD average of 8.9%, though

we have an unusually young demographic and GNP is a more appropriate measure. The HSE had a

budget (capital and current) of €14.5bn in 2015. €13.5bn is current expenditure, of which more than half

goes on stafﬁng. €4.8bn goes on hospitals, €2.6bn on publicly-funded GP care, €1.3bn on nursing

homes, and support services for older people, €1.56bn on disability services. Legal claims are high at

€70m up from €21.7m six years earlier. The HSE says salaries for doctors, managers and other health-

care professionals are too low and generating a brain drain. But there is no consenus on this issue

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"a poor vision

that failed"

34 February 2016

2016 ELECTION

Cost Reductions (cont.)

The 2016 Fine Gael manifesto instead commits to introducing free GP care for children up to 18.

Minister Leo Varadkar said the shortage of GPs meant the system could not cope with additional

demands.

The Labour Party is still committed to its introduction but it is now highly unlikely free GP care will be

included even in the next Programme for Government.

"Under the new GP contract the rate of remuneration

of GPs will be reduced. Under a new consultant’s con-

tract hospital consultants’ remuneration will be

reduced".

According to an OECD report GPs earned an average of €115,940 in 2013, down from €118,677 the year

before.

The OECD said that hospital consultants earned €164,494 on average in 2014, not including private

income, down from €173,646 the previous year.

The OECD ﬁgures are inevitably disputed by medical organisations.

Up to 2000 consultants could be set to receive millions of Euro compensation, after a recent Employ-

ment Appeals Tribunal decision, because the HSE is not paying higher salaries agreed in 2008 to

incentivise them to treat more public patients but eliminated when public-service salaries were

reduced by 15%.

"Reference pricing and greater use of generics will be

introduced to reduce the State’s large drugs bill and

the cost to individuals of their medications".

A deal agreed with Ireland's employment-heavy pharmaceutical industry in 2012 reduced the cost of

the State’s bill on existing medicines by a meagre €400m over 3 years.

Waiting Lists

"A Special Delivery Unit will be established in the

Department of Health to assist the Minister in reducing

waiting lists and introducing a major upgrade in the IT

capabilities of the health system".

The SDU was established by James Reilly to reduce the numbers of patients on hospital trolleys and on

waiting lists with a former CEO of St James’s hospital as Director.

Waiting times for emergency treatment in Irish hospitals are the worst in Europe, according to the Euro

Health Consumer Index.

It also found waiting times for minor operations and CT scans were among the longest of 35 countries

surveyed.

Damningly, Ireland with a population of 4.5 million has 7800 on waiting lists for more than a year.

92,000 people were treated on trolleys in 2015. England has a population of 53 million but only 800

people on waiting lists for medical treatment more than a year. The Department is missing its unambi-

tious target of guaranteeing all outpatients will be seen within 15 months. The policy of no-one being

on a trolley for more than nine hours is a chimera.

Patient Safety Authority

A Patient Safety Authority, incorporating HIQA, will be

established.

In May 2012, James Reilly described the proposed patient safety authority as “a key component” of

his health reform programme but in 2014 it was one of the new organisations criticised by the Depart-

ment of Public Expenditure and Reform as representing “a proliferation of quangos”. He said a patient

advocacy agency would be established, initially within the structures of the Health Service Executive.

HSE

"The Health Service Executive will cease to exist over

time. Its functions will return to the Minister for Health

and the Department of Health and Children; or be

taken over by the Universal Health Insurance system.

Staff will be deployed accordingly".

The HSE is as unloved as the UK's NHS is adored. The HSE’s spokesperson recently said it was set up

as a “punchbag”, and its CEO says it concessions were made to unions when it was instigated that

meant it was never going to yield any real beneﬁt. Its board has been abolished and replaced by a

Directorate which is more accountable to the Minister for Health

The Vote of the HSE has been disestablished and funding of health services is now provided through

the Vote of the Ofﬁce of the Minister for Health. But the HSE remains, and will be around for another

three or four years though its CEO, Tony O’Brien, notes there is “no timeline” nor even future annual

budgets (the NHS has ﬁve-year budgets) has said that it has been starved of funding to deliver major

change, that we had “messed about with the structures” with no coherent vision. He believes the

debate on free GP care suggests that some don’t want a change to the two-tier health system, though

it may be that some just don’t see the initial changes being made as being progressive.

GPs

"During the term of this Government, GP training

places will be increased. GPs will be encouraged to

defer retirement and will be recruited from abroad,

and the number of practice nurses will be increased so

that GPs can delegate care when appropriate to

nurses".

As of late 2014, just 25% of GP trainees plan to stay in Ireland after graduation, almost 17 per cent of

GP graduates are already working overseas and fewer than one in ﬁve of this group plans to return to

Ireland.

The HSE says the number of contracts the HSE has with GPs has increased by 400 in the last six years.

A Memorandum of Understanding has been signed with the IMO to develop a new contractual frame-

work focused strongly on strengthening GP services in primary care

A wider range of registered medical practitioners can now provide services under GMS scheme as a

result of the Health (Provision of General Practitioner Services) Act 2012

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Health Report Card

February 2016 35

Hospitals

"Under UHI public hospitals will no longer be managed

by the HSE. They will be independent, not-for-proﬁt

trusts with managers accountable to their boards".

"The existing policy of co-location of private hospitals

on public hospital lands will cease".

"Public hospitals will be given autonomy from the

HSE".

"Boards will include representatives of local communi-

ties and staff".

"Smaller hospitals may combine in a local hospital

network with a shared management and board".

"Hospitals will be paid according to the care they

deliver and will be incentivised to deliver more care in

a “money follows the patient” system".

Seven new Hospital Groups have been established as a ﬁrst step to independent Hospital Trusts

established in line with the Government’s programme, initially on a non-statutory administrative

basis, pending the establishment of Hospital Trusts with the focus now turning to the development of

Hospital Group Strategic Plan. In 2015, the Activity-based Funding Implementation Plan 2015-2017 was

published which provides a road map and list of thirty-four actions to ensure this new method of fund-

ing becomes fully embedded in the acute hospital system over the coming years. Activity-based

funding budgets for inpatient and day-care services are being introduced for the 38 largest public

hospitals. Developing ABF budgeting for other areas like outpatients will continue in 2016.

Care of Older People and

Community Care

"Investment in the supply of more and better care for

older people in the community and in residential set-

tings will be a priority of this Government".

"Additional funding will be provided each year for the

care of older people".

"This funding will go to more residential places, more

home care packages and the delivery of more home

help and other professional community care services".

"The Fair Deal system of ﬁnancing nursing home care

will be reviewed with a view to developing a secure

and equitable system of ﬁnancing for community and

long-term care which supports older people to stay in

their own homes".

There is a direct link between increased waiting times and longer queues for approval under the Fair

Deal scheme. Last year a further €44m was allocated to provide 1,600 extra nursing home places

under the Fair Deal scheme. This investment has reduced the waiting times for the Fair Deal scheme.

As it stands, the ﬁrst €36,000 euro of assets (€72,000 for a couple) is not counted in the means test

for the scheme.

The Government has invested more than €70 million in additional funding to address delayed dis-

charges from hospitals of patients who have completed acute treatment; the resulting speedier access

to the Fair Deal nursing home scheme is reﬂected in a reduction in length of stay ﬁgures. Nursing

home places will increase by just 344 in 2016 and while 2015 home-help hours will be maintained

there are 2 million fewer of them than before the economic crisis.

A current review says the Government could decrease this ﬁgure to cut the amount of State support.

The assets such as savings and properties that currently have to be contributed under the scheme is

capped at 7.5%. The review states that this could be increased to 10%.

Those availing of the scheme are currently required to contribute 7.5% of the value of their family home

each year for a maximum of three years. The review says this three-year cap could be reconsidered.As

it stands people are asked to contribute 80% of their income. The review states that consideration

could be given to increasing this level for those with incomes in excess of the State old age pension.

The review also says that the Government could consider amending the law to allow for Fair Deal

charges to be attached to earnings or deducted at source from pensions.

Extras not mentioned in the Programme for Government

Protection of Life during Pregnancy Act 2013

enacted and implementation guidelines published

2014.

Protection of Children’s Health (Tobacco Smoke in

Mechanically Propelled Vehicles) Bill passed pro-

viding for a ban on smoking in cars and plain

packaging.

Magdalene Restorative Justice Scheme established

in June 2013 for women who were admitted to and

worked in the Magdalene Laundries with 804

applications and €23m paid out to date

New Suicide Prevention Strategy, Connecting for

Life 2015–2020, launched in June 2015 and setting

a target to reduce suicide and self-harm by 10%

over the ﬁve year period.

An additional €4m was allocated in 2014 and 2015

to assist in implementing the Progressing Disabil-

ity Services Programme for children. This equates

to approximately 80 / 90 additional therapy posts

to expand the provision of speech and language

therapy in primary care and the development of

therapy services.

The Planning application is being ﬁnalised for the

redevelopment of the National Maternity Hospital

on the St Vincent’s Campus.

The planning application for the new children’s

hospital at St James’s hospital campus and the

satellite centres at Tallaght and Blanchardstown

was submitted in August 2015.

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