Saturday 16 February 2019

Richard Curran: Time to link spending to better health outcomes

Under pressure: The health system is still suffering from the cutbacks of the recession years combined with the increases in population, healthcare costs and more people over the age of 65. Stock image
Under pressure: The health system is still suffering from the cutbacks of the recession years combined with the increases in population, healthcare costs and more people over the age of 65. Stock image
Richard Curran

Richard Curran

Next year the Exchequer will spend more money providing healthcare to Irish citizens than ever before. In his Budget speech last week Finance Minister Paschal Donohoe emphasised just how much the State is throwing at the problems facing the health system.

There is no doubt that more money is very welcome for those working in the system and for those who use it, but will it solve the problems that are there?

Mr Donohoe said the health budget next year will be a record €17bn. It is possible, based on the overspend of recent years, that a lot more will actually be spent.

A €700m overspend this year is to be plugged by the sheer luck of landing an extra €700m in corporation taxes due to changes in international accountancy rules.

The additional spend on health in 2018 compared to 2017 is around €1.2bn. The question remains about what has been achieved with that extra €1.2bn and what will be achieved with the additional €1bn that will go in next year - assuming, of course, the health system comes in on budget.

There is no doubt that the cutbacks of the recession years combined with the increases in population, healthcare costs and more people over the age of 65, have all conspired to put enormous pressure on the system.

Yet, there is a sense of a lack of urgency about fixing some of the more fundamental and underlying problems in the system. Expert hospital consultants provide one set of reasons as to why the system doesn't work better, nursing unions or HSE managers, another.

As vital and urgent gaps in service need to be plugged with more money, such as waiting lists and the trolley crisis, it can appear that there can be less room for longer-term measures, such as moving to electronic patient records.

Strategic thinking can be left aside or simply go unfunded in an emergency. For example, should you spend your limited (and over-run) on budget hiring more nurses or investing in better records?

Ireland is playing a game of catch-up when it comes to Electronic Health Records (EHR). Switching over to a comprehensive electronic system through the health service might sound like a worthy long-term goal but it could help save thousands of lives. Therefore, any delays in funding this vital changeover, mean a loss of life.

Take sepsis, for example. It is something of a hidden killer, because public awareness levels are so low. Yet last year 3,000 patients died of sepsis here. That is about 320 more than in 2016.

The actual adult mortality rate among Irish patients has been falling, especially since a unit within the HSE really began focusing on the problem. But the number of actual sepsis patients is growing significantly each year. In 2017 there were around 2,250 more cases of sepsis than in 2016.

So, the system is improving on mortality rates but actual numbers have risen. Could many of these deaths be prevented?

The progress made by the HSE in getting the mortality rate down from 24pc in 2012 to 18.4pc last year, shows that focusing on it and perhaps doing things differently can work.

Health Minister Simon Harris referred to this 18.4pc figure as comparing well internationally. How come other places can have a much lower figure?

The largest healthcare provider in Hawaii decided to focus on the early identification and treatment of sepsis as a way of improving care and also reducing the length of hospital stays associated with it.

A sepsis reduction plan saw the percentage of patients who died from sepsis reduced from 13.75pc in 2012 to 9.89pc in 2016.

The average length of stay in hospital for those with sepsis fell from 11.32 days to 9.74 in the same period.

In Ireland the average length of stay is 20.9 days. Our average in 2012 was 25 days.

Michael Flynn is an Irish business consultant who persuaded the Mercy Hospital Group, a top five US healthcare provider, to engage with the HSE with a view to bringing its telemedicine expertise to Ireland.

He argues that US hospital groups like Mercy have already developed very effective systems for identifying sepsis early, monitoring those especially at risk and thereby reducing mortality rates.

He suggests that if our health system could achieve the rates achieved in Hawaii, it would mean that 1,391 who died as a result of sepsis in 2017 could still be alive today.

An average length of stay equal to that of the Hawaii group would free up 181,000 bed days in Irish hospitals which could be used to treat an extra 33,000 patients each year.

That is roughly equal to a new 500-bed hospital which might otherwise cost €500m to build.

"We are at least 10 years behind the more advanced US healthcare systems in terms of many patient care and outcomes. It seems to be a no-brainer if we formed partnerships with these groups who are achieving better outcomes, it could save a lot of time and effort. And we could also learn from their mistakes", he said.

A combination of technology, monitoring, focus and perhaps doing things differently could save thousands of lives and play a part in tackling overcrowded hospitals by reducing lengths of stay and freeing up beds for those stuck on trolleys.

That is where initiatives like EHR come in. The cost of having electronic patient records is estimated to be about €1bn. It might seem hard to justify such a cost on a long-term project, but it could begin to yield rapid results by allowing new systems for managing patient risks and treating things like sepsis.

The financial savings could be huge. Yet, progress has been very slow. Back in 2016 the HSE approved a business case for EHR technology, which then went to the Department of Health.

It has since been accepted but it was only in June 2018, two years after HSE sign-off, that the department said it would advertise a procurement process for an electronic health record system for public hospitals.

After last week's budget Simon Harris spelled out how he would use the extra €1bn in health spending next year. He committed to spending the required €1bn in the year ahead on electronic health records.

The money has been slow in coming. But last Friday it was announced that the European Investment Bank was backing Ireland's eHealth programme with a €225m loan to help drive improvements in the delivery of the service over the next 10 years.

Mr Harris said the "investment" marked a key step in the creation of a "modern patient-centred health service." The loan will be borrowed from the European Investment Bank (EIB) on behalf of the state by the NTMA.

This is the same body that borrows our sovereign debt on international markets. Right now, 10-year money borrowed by the Irish State through the NTMA is incredibly cheap.

Unless the EIB is lending us the money at an even cheaper rate, surely it would make more sense to just borrow on the open bond market. However, such a loan would be included in our Exchequer borrowing figures and go towards our budget deficit and fiscal targets.

By borrowing from the EIB it may be possible to exclude it from general Exchequer borrowing. Even if it borrowed at a higher rate and off the normal borrowing requirement books, it still represents about one-quarter of what is needed. Where will the rest come from and when?

According to the HSE, the new national children's hospital, currently under development, will be the first to deploy the new electronic technology. It will only be incrementally implemented to older hospitals.

The health service has been firefighting for a very long time. Such an atmosphere makes it difficult to embrace genuinely new ways of doing things. Billions is being spent to plug gaps, yet thousands may be dying needlessly.

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