Healthcare an unwinnable war – but small victories possible

THE latest ESRI population and health projections looking ahead to 2030 make for a stark wake-up call. The politics of health can’t be left to the caprice of politicians. A double whammy lies ahead.

A look at the current level of activity in hospitals reveals:

■ 1.2 million A&E attendances,

■ 1.6 million inpatient hospital visits,

■ 3.3 million outpatient appointments.

The prognosis points to a future full of trouble – for the number of hospital appointments will double over the next 20 years because of minimum overall population increases of 50,000 per year.

The thing to note is that the pension cohort expands by 30,000 per year.

As life expectancy increases (a baby girl born last night has a 50pc chance to live to 100), demands on our health service will grow disproportionately. Over-90year-olds attending emergency departments will increase by 20pc per year.

Medical breakthroughs mean more medicine and exponential costs.

This makes for jarring daily bulletins that are entirely negative: growing hospital waiting lists, trolley crises; gaps in community care, mental health provision; acute staff shortages.

But the most vehement criticism comes from vested interests within the sector.

The less trumpeted truth is that the number of total treatments has increased significantly and better outcomes have been achieved.

Politicians promulgate simplistic single silver-bullet strategies. Most make the situation worse. Mary Harney: co-locating private and public hospitals separately on the same campus. James Reilly: Universal Health Insurance funding model. The latest is Oireachtas health committee: Sláintecare, universal single-tier healthcare. All were false dawns.

Last week, the Pharmaceutical Managers’ Institute debated the motion ‘The phased elimination of private care from public hospitals’, which was the central recommendation of the health committee’s report. Informed and erudite speakers included Professor John Crown, Dr Martin Daly, Cormac Lucey and Simon Nugent.

The motion was almost unanimously defeated. Arguments for eliminating and segregation of private healthcare don’t stand up to scrutiny. It’s another political illusion. It distracts us from the crucial pragmatic debate of driving greater effectiveness and efficiency through and within the HSE.

Back in 1989, my first national political job was frontbench health spokesperson. It was during the Tallaght Strategy, when savage cuts were implemented. This resulted in wholesale hospital/bed closures.

I couldn’t propose more public expenditure solutions as they would surely trigger a government Dáil defeat, resulting in an election.

We envisioned abolishing eight health boards; replacing them with a singular structure of Bord Sláinte. It would ensure optimal scale in value purchasing of everything like eggs, cotton wool, syringes, medicines, electricity, telecoms and blankets. More efficient hospital stays for carrying out operations would drive up standards attainable for all.

Meanwhile, integrated finance software would facilitate standardised reduced costings, and expose waste.

When the HSE was finally established in 2005, politicians stunted its potential by retaining layers of unnecessary bureaucracy.

The wrong culture was created. Local politicians continuously obstruct consolidation plans regarding reconfiguring national maternity services, oncology care and emergency departments.

TDs champion nearby constituency facilities at the expense of the best regional or national outcomes.

Our current deployment of 28 acute and 49 total hospitals is wasteful and inefficient.

More local jobs does not translate into the best national healthcare.

There’s a contradiction in health debates. You hear simultaneously “We’ve a most underfunded health service – 3,000 hospital beds taken out of the system” and “we’ve the third highest health expenditure per capita out of 32 OECD states – 30pc more

‘A baby girl born last night has a 50pc chance to live to 100’

than the average”. So how do you explain the anomaly?

State expenditure is rapidly increasing: €13bn in 2015; €14.1bn in 2017; €15.3bn in 2018. But that’s only part of the story. To this you must add €2.9bn of funding from more than two million people with private health insurance. Plus a further €2.9bn of personal individual ‘out of pocket’ payments to doctors and pharmacists.

The total health spend amounts to 13pc of our Gross National Income, almost €21bn. Next year this breaks down to €5,700 per person. So we are in the top tier of per-capita health costs.

Throwing unlimited money indiscriminately at health is impossible in the context of our eurozone fiscal treaty rules.

Ultimately, public health expenditure can grow only in line with our national economic growth – 5pc per year is a nominal ceiling on extra annual funds. This ceiling matches demographic demand.

Constituency politics have a heavy cost. Removing €900m of revenue annually from private patients into public hospitals will ultimately denigrate State hospital services.

The hybrid model of combining public and private healthcare works best within GP practices and primary care. Narrow political thinking obscures the real challenge for Irish healthcare.

Best international practice requires investment in and implementation of electronic health records – consultant clinicians having their patients grouped together in adjacent parts of the hospital, carrying an iPad.

It also involves human resource systems that follow appropriate work rosters, with flexible demarcation of multidisciplinary practices.

Financial systems that expose delayed discharge procedures – clogging up essential beds, extending waiting times, are also insisted on.

Monopolies are antipatient. Pricing practices of Aspen Pharma’s cancer drugs or Vertex’s Cystic Fibrosis medicine Orkambi prove if you control the market you control price.

A hybrid model of public and private care prevents vested interests from exploiting taxpayers.

The National Treatment Purchase Fund is the ideal model for targeting extra resources (tripling of funds to €55m in 2018) on the basis of the money following the patient to the most costeffective provider.

It facilitates 60,000 patients on hospital inpatient waiting lists accessing the fastest contractual treatment.

Universal healthcare is another political wheeze.

Healthcare is ultimately an unwinnable war of infinite demand versus constrained capacity.

But we can win battles at the front line.

Despite its flaws, the HSE still represents our best hope of meeting the extra demands for future health care – if the focus is HSE modernisation and reform.