Proposed health cuts are the wrong way to go
Here is the article that appeared in Irish Times on 3 August. I am taking August off so this site will be quiet for the month. Will be back in September. Keep the comments coming and enjoy any sun we get!
THE McCARTHY report is comprehensive and provides an overview of the piecemeal nature of Irish policy-making, alongside unparalleled increases in Government spending which dominated the past 12 years.
However, the “menu” of cuts in the health sector is unsatisfactory and, in some instances, based on erroneous assumptions. This is significant because more than one-fifth of the €5.3 billion proposed budget cuts are in health. The top three health savings suggested are: reducing HSE staff by 6,000 (saving €300 million) plus efficiencies (€90 million); opening up contracts with GPs, opticians, pharmacists and dentists to tender and presumably negotiating better deals (€370 million); revising down income eligibility for medical cards (€100 million).
Speaking on the night of the publication of the report, Colm McCarthy said: “There is scope for economies in staffing throughout the health service, there have been enormous increases in staffing . . . Everyone knows the staffing ratios are now high by international standards in certain parts of the health service.”
Is McCarthy right? There have been large increases in staffing in the health system in recent years – from 92,996 in 2001 to 111,800 in 2009. Are Irish health service staffing ratios high by international standards? According to the OECD in 2008, the total health and social care employment in the Irish public sector was 30.8 staff per 1,000 inhabitants, below the OECD average. Remember, we are still making up for decades of underinvestment in health and the cuts of the 1980s. And much of the staff increase was in neglected areas of older people and disability.
By any international comparison, we still have fewer doctors, consultants and GPs. In nursing, comparative Irish figures look above the OECD average, yet these are problematic. Comparisons do not take account of the fact that most Irish nurses work part-time nor do they take into account the absence of other staff, eg, there are virtually no nurse assistants in the Irish health system whereas in France there is a nurse assistant for every nurse.
In that same interview, McCarthy said “it is widely acknowledged that the health service has accumulated not just a large number of administrative staff but there has also been an inflation in grades”.
An administrative staff assessment of the Irish health system found 16 per cent of staff in administration, which is broadly in line with Northern Ireland, Scotland and Wales, and below English levels. It also found that there were too many senior managers, a fact backed up by the finding that there were 379 grade eight personnel when the HSE was established in January 2005 and 563 in December 2008.
Instead of rationalising personnel when the HSE was set up, many senior roles were duplicated in regional and central offices.
However, the vast majority of the Irish health system is not overstaffed. In July/August 2009, the impact of a constrained health budget is already evident in ward closures, longer waiting times for some treatments, and increased difficulty in accessing essential social care such as home care packages.
Reducing HSE staff by 6,000 more will hit those who need these services most – the old, the sick, the poor, people with disabilities.
A stand-off between the HSE management and the unions means previously announced early retirement, paid leave and career breaks schemes are not happening in the health system. Under existing efficiency measures introduced during 2008 and 2009, the HSE is already reducing staff by 3,000. Where an additional 6,000 staff cuts can be made without hitting patient care is very hard to see. McCarthy went on to say “there has also been an extraordinary increase in the health budget, we are in this odd situation now where we have what is by international standards a rather costly health service with which everyone is dissatisfied”. This view of health spending is propagated by public and political rhetoric and unsubstantiated by the facts.
Newly published OECD health data shows that Ireland still spends less than the OECD average on health – 7.8 per cent versus 8.9 per cent. A representative survey of patients, Insight 07, found very high satisfaction ratings with the health service, despite the obstacles of access.
There is no doubt that there is waste in the system and McCarthy’s report is critical of deals done with unions and professional bodies which have hampered reform.
Achieving better use of public money and new contracts with professionals is essential if the delivery of health and social care is to be sustainable, but once again the Minister and the HSE’s track record in achieving this is virtually non-existent.
The third area of revising medical card thresholds downwards will hit those who need services most. We know that poorer people get sick more often and die younger. We know the medical card acts as a safety net for those on low income. Why on earth any government would take medical cards away when they are most needed is unfathomable.
This proposal, alongside a range of increases in charges, will hit patients’ purses and not raise much money. It just doesn’t make sense. So money needs to be found in other areas. Not implementing the ridiculously high wage increases for consultants would save €140 million this year and more next year and the year after, if the higher numbers of consultants are delivered. (Before the hike, starting salaries for Irish consultants were over double the European average).
A greater use of generic drugs is recommended by McCarthy but the report says this would yield just €30 million. Other estimates are much higher. Ireland has a very low usage of generic drugs. Raising usage from the current 12 per cent to more than 50 per cent, plus renegotiating a better deal with pharmaceutical companies, could yield €200 million within a year and more thereafter.
Banning the use of private management consultancy firms and advisers could save more than €50 million a year, while remedying the sloppy banking practices would yield €20 million. A decision not to spend public money on private care could provide an additional €90 million by withdrawing the budget for the National Treatment Purchase Fund. A €2 increase on cigarettes could generate €420 million.
There are ways to stop waste and inefficiencies and to generate new money without hitting patient care. These are political choices that just have not been chosen. Unfortunately McCarthy’s shopping list of health cuts does not bring us much closer to them.