The case against the de Buitléir report

We must adopt pragmatic policies to fund and deliver healthcare for this century

What do we want from our public health service? What is a reasonable expectation? What is a reasonable cost? What is the value of excellent care and timely access?

These are questions that continuously arise in contemporary Irish political discourse. Many admirers of the single-minded Aneurin Bevan propose to replicate in Ireland his feat of establishing the National Health Service in the UK despite opposition from many, including those within his own party. However, such a single-minded approach, which may have seemed appropriate for an exclusive, class-ridden country in a regimented society after a tumultuous world war that was on the edge of bankruptcy, may or may not be the optimal model for our society today. It is worth exploring the similarities and the differences between then, and now. Clearly, Bevan’s actions were justified by the initial successes of the NHS. However, in the 1940s and 1950s, life expectancy was relatively short and there were few complex, expensive therapies. Medicine was relatively unsophisticated, most serious illnesses were rapidly fatal, and public expectations of healthcare were comparatively modest.

We live in a different society. Bevan’s dogmatic, autocratic approach might not be appropriate, or even appreciated, in a contemporary Ireland that has developed into an affluent, liberal, inclusive, egalitarian democracy. Both society and medicine have changed dramatically since the NHS was founded. Medical science has become exponentially more complex and sophisticated. Outcomes for infectious diseases, coronary artery disease and cancer have improved dramatically over the last few decades. What is even more important is that the pace of innovation in medicine shows no signs of slackening, so progressive increase in life span and quality-of-life are more likely than not.

This is great news for the average Irish citizen. But there are problems that will need to be addressed if we are to succeed in delivering the best healthcare and outcomes for Irish patients. Foremost among these problems will be the cost of healthcare. Healthcare costs are directly related to life expectancy, and as we all live longer, healthcare costs inevitably increase. Impoverished societies with relatively short life expectancies can achieve dramatic gains in life span with relatively modest healthcare investment. In affluent societies, where the average life span exceeds 80 years of age, such as in Ireland, prolonging life span and improving healthcare are staggeringly expensive.

Presently, public healthcare in Ireland, starved of vital funding during a recessionary decade, is struggling to address significant obstacles. Population growth, an ageing society, changing societal expectations of healthcare professionals and lack of capacity present healthcare professions with a Sisyphean task. Crucially, the shortages of human and physical capacity in the public hospitals has a direct effect on the productivity, efficiency, effectiveness and safety of the public acute hospitals. Doctors, nurses, hospital beds, operating theatres, intensive care beds, and access to acute psychiatric care are all in short supply. The failures of the public health system are almost exclusively a direct consequence of these capacity constraints. There is a stark reality that healthcare initiatives that do not address capacity will rapidly fail, and fail spectacularly. The Government in 2017 belatedly recognised this reality with a proposal to commission 2,600 hospital beds, but have subsequently failed to act on their own proposals.

De Buitléir and Sláintecare

I have an agenda. Most people do, even if they are loath to admit it. I am very open about mine. I want to see everyone — man, woman, child — having access to all services, diagnostics and therapy within six weeks. At the time of writing this article, there is much talk of Sláintecare and de Buitléir and what effect removing private practice from public hospitals will have on capacity and access in the public sector. I would like to explore this.

We are all aware that the healthcare shortages we face currently arose from the financial constraints that were imposed during the recession. Correcting these shortages, addressing the capacity constraints of the acute public hospitals, will come with an enormous price tag. In this context, the current proposals to deprive the acute public hospitals of their €600 million annual revenue from private patients, who are generally admitted to the public hospital system with a life-threatening medical or surgical problem, and who will continue to do so into the foreseeable future, can only be regarded as a mindless pre-election stunt that will not have any effect on public hospital capacity.

The notion that this particular intervention will increase capacity in the public hospital by 2,000 beds can only be regarded as delusional. If we remove private practice from our public hospitals, all the patients who present with strokes, heart attacks, traumatic injuries, serious infections and tumours will still require the 24/7 complex care that is provided in our public hospitals. Those patients will still present to our public EDs. Our public hospitals are where the majority of complex care is provided, and rightly so.

It is vitally important for the public to understand that in depriving the acute hospitals of €600 million annual income, the underfunded public hospitals will become modern-day poorhouses, replicating conditions in University Hospital Waterford on a national scale. For most politicians, this would be regarded as an appalling political legacy.

Private insurance

We must ask ourselves, why do half our population have private health insurance? In most cases, people take it out because they don’t trust the public health system to provide them with timely access to care. They know that the public system is generally excellent, once you get in. They also know usually, this means via the emergency department (ED) and that may well mean a night, or two, or three on a trolley. That prospect is horrible for all, but it is terrifying for our elderly population, many of whom will avoid this at all costs, to the extent of delayed presentations when they desperately need tertiary care.

Most people who have private health insurance use it for elective access, and with good reason. But where is this elective work happening? Increasingly, it is in the private sector. Why? Elective activity in our public hospitals has decreased by 54 per cent in the past decade. Why? We don’t have the capacity in our public hospitals. As already discussed, most people who are admitted are emergency presentations admitted via ED with strokes, heart attacks, traumatic injuries, serious infections, acute presentations of tumours. Even the most serious elective cases are often cancelled repeatedly on the day of surgery because of a lack of capacity; often, lack of an ICU bed for those major surgeries that require an ICU stay post-operatively. It is worth acknowledging that despite an excellent HSE Prospectus report in 2009 saying we needed to double our number of ICU beds, we now have 40 fewer ICU beds than at the time the report was written.

Investment

Who will provide the healthcare finance and investment that will be needed to repair the damage done to our health system during the recession decade, yet simultaneously exploit expensive novel therapies that improve the quality and duration of our patients’ lives? Bevan’s monolithic, centrally-planned model relied exclusively upon funding from the state, with care provided free at the point of delivery. But that system, embodied in the NHS, and now struggling to cope with the familiar challenges of increased demand and expensive innovative therapies, will not serve our future needs.

European models of healthcare financing rely upon a wide range of central funding, social insurance and private insurance. Our European neighbours don’t see any problem when they adopt a pragmatic and flexible view to financing healthcare, mixing a variety of financial instruments in order to provide adequate healthcare capacity. Ireland’s healthcare finance, where half our population hold private insurance, is consistent with other European healthcare financial models, and certainly is neither bizarre nor perverse. To be pragmatic, the willingness of patients to voluntarily subscribe to private insurance must be exploited to generate additional revenue for our public health system. I do not believe the central exchequer will make up the deficit should private revenue be removed from public hospitals. In reality, ideological principles and utopian solutions will not cure cancer, deliver a baby, treat sepsis or heal a stroke and they certainly will not suffice to fill a €600 million budget deficit.  

How then will we in Ireland address our current healthcare needs and plan to improve the quality of healthcare in line with public expectations? Given the enormity of the healthcare challenges that we face, we must adopt pragmatic, real-world financial, logistic and bureaucratic policies, to fund and deliver healthcare for this century and not the last one. Yesterday’s ideological solutions, quick fixes and pre-election babble that have consistently failed our patients in the past will not cure our current healthcare ills.

If we tackle capacity in the our public hospitals, front-load the promised 2,600 beds, fill the empty consultant posts, staff the front-line teams, unleash the potential of the regional integrated community organisations with strong devolved governance and achieve a six-week wait for all, what will happen? We will restore faith in our public system. How we fund it is a matter for Government to decide and it is time for honest discussions about strategy and implementation that have impact for patients, with one million on waiting lists. This is a national emergency. Doctors, nurses, allied health professionals, all front-line staff — we all want to work in a system that works for patients. A system in which everyone has access when they need it and adverse outcomes are unrelated to excessive waits. Too many people with serious symptoms are waiting too long for access and some of them are suffering additional morbidity and mortality as a result.

An increased capacity is more than beds and staff, although that is a great start. Solid clinical governance is crucial so we spend money where it matters: On the patient, their experience and outcome. Paul Reid has had a baptism of fire in his first six months and it is clear he is serious about delivering for patients. Now it is up to all of us to send a strong message to Government. He should be given the resources he needs so that we can all deliver for patients.

I hope you all have a great Christmas and thank you for welcoming me to the Medical Independent team this year. I look forward to joining you again in the new year.