Wednesday 11 December 2019

It's Groundhog Day for broken health system - and will be until we reform it

Health Minister Simon Harris. Photo: Tom Burke
Health Minister Simon Harris. Photo: Tom Burke

Ray Kinsella

Simon Harris is the latest in a long line of health ministers who are "doing their best". That will never be enough until either governments get real about the economics of acute health care, or voters get serious about displacing administrations that are not doing enough.

So, once again, we're trapped in 'Groundhog Day'. Same news stories - same advice to "go to your GP".

Does this sound familiar? "For some time, it has been evident that the capacity of our acute hospital system has not kept pace with the increasing demands being imposed on it. The consequences of that under-capacity are well known, ie cancellation of elective admissions, long delays in accident and emergency departments, waiting lists for elective procedures and unacceptably high bed occupancy levels in the major hospitals…"

That was, former health minister Micheál Martin when introducing 'Acute Hospital Bed Capacity: A National Review' back in 2002. It could have been written today. He pointed out that an additional 3,000 beds would be needed by 2011. Read it and weep.

We don't need more reviews. All of the information that's needed is familiar to specialists in emergency medicine, and to directors of nursing - they know the problem and what needs to be done. In any event, the Department of Health's website is groaning under the weight of excellent reports, analysis, strategies, proposals… we simply never close out the game - and so the cycle of 'crisis meetings' goes on.

What's happening in A&E departments around the country, therefore, is not a crisis. It's the way things are done in Ireland. The increased prevalence of flu in winter is not a surprise. We really should have seen it coming last budget time; many medics did.

The A&E 'crisis' is part of a wider systemic problem: it's about health status; it's about the primary care system and the constraints on how it's allowed to function; and it's about the acute system itself, of which the A&E department is one part. Think of it as a railway terminus: whether a terminus functions in an orderly way, or as a kind of travel bedlam, depends upon anticipating the inflow of travellers, about the systems that guide them when they get there and, crucially, having the trains in place to get them out to the right destination. It's not rocket science - but it's not happening.

Over-pressured and underfunded, GP services are not in a position to mitigate what is happening with relentless consistency in A&E departments within the acute sector. They could - the primary care sector has enormous potential to provide alternative services for many patients who now go to A&E departments.

But the kind and quality of a GP clinic-based 'gatekeeping service' to the acute sector, which would reduce pressure on A&E, has simply not been sufficiently developed.

So if, for example, you have a child sick and in distress in Cork, or in Dublin, you're going to head for the nearest acute hospital - even though the facilities and kind of medical and nurse-practitioner skill-mix to deal with, say, respiratory problems, could be provided in a primary care setting - one where, if necessary, a GP could refer the child directly in to the ward in an acute hospital, skipping the whole bedlam of A&E.

As for the acute hospital system, it's brutally basic. There's not enough 'capacity' (beds), nursing staff, consultants and theatre slots. Look at the international figures and where Ireland stands - less than three beds per 1,000, compared to more than 15 per 1,000 in Japan and Norway.

Overcrowding in A&E is related to a lack of acute beds. We closed them - rationalised/restructured them, whatever way you want to put it. So, large groups of sick people congregate in a crowded environment. Many leave after registering - some with children, which is worrying. Many others, with time-sensitive conditions, can be delayed for hours, or at worse days, before being admitted - they are 'crowded out' by overcrowding. But, you know, this is not a new issue. Doling out a few million every year in 'home-care' packages is, at best, a sticking plaster.

We have daft funding models. We need an enormous increase in capital spending. The evidence of underfunding on the capital side in the last five years is incontrovertible. The budgetary routine of doling out wholly inadequate allocations for capital spending (much of it pre-committed) makes no sense.

So, let's not get too impressed by "reviews", "crisis meetings with the HSE" and adding some beds to hospitals. It's largely smoke and mirrors.

Equally, it will take more than a few hundred new nursing recruits to mitigate the impact of the thousands that were cut three or four years ago.

Then there is the nonsense of not making sufficient use of capacity in the independent sector for fear that we would 'exceed our annual allocation'. Everyone wants an adequately-funded public hospital system. But we don't have one. Also, the fact is the independent sector has been highly innovative and extremely cost-effective. It has a vital role to play within the total health system.

There is sufficient scope there to wipe out many of the waiting lists - if we had a proactive funding system. It could seriously mitigate the present crisis. Think about it. Hotels plan for a season. They don't put tourists in lounges. They plan capacity. They recruit enough and the right mix of staff. They learn from excess/deficient demand.

Our health system doesn't learn. Instead, what it calls 'planning' is spending just enough to get by, with a minimum amount of political flack. Until there is a system-wide change, nothing else will change.

The old canard "we are where we are" is not an adequate response. A consensus that accommodated these cuts - and now says it is "doing its best"- has little credibility. Neither is the cliché "health is a bottomless pit" robust. Not so. It's an economic investment.

Mr Harris holds the health portfolio. But really, it's the system. The health of the nation is the responsibility of every minister sitting around the Cabinet table. It's what they fought the election on - pledges were made by every side. As matters stand, the subliminal message from Cabinet table over the years is - "it's rationing -get used to it"... but there are options.

Economist Ray Kinsella is professor of banking and financial services, and healthcare at UCD

Irish Independent

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