Saving our public health service in midst of the economic crisis – an opportunity or an insurmountable task?
Here is a very long paper I gave to the INMO annual conference yesterday. Also a podcast of it and other speeches is here along with the Minister’s.
Good afternoon and thank you for inviting me here. I am very honoured and somewhat daunted to be addressing you. During the next half hour I am going to do three things, I am going to give an overview of where are we now. I am going to detail recent budgetary measures and their impact on the health system. I am going to talk about the value of our public health service and then make some concluding remarks in relation to whether the task on hand is an opportunity or an insurmountable obstacle.
Where are we now?
In order to understand where we are now, we need briefly to look at the journey that got us here. Irish health services and policy for the last ten years has been developed in the context of ‘Quality and Fairness, A Health System for You’.
Published in 2001, this policy was meant to lay the foundations for a new health system – based on the principles of ‘equity, people centredness, quality and accountability’. 121 actions were outlined including addressing the crisis in Emergency Departments, reducing waiting times for public patients, increasing the numbers of hospital beds, of public nursing home beds, increased staffing and increased investment in the health system, specifically in the primary care system.
Fianna Fail/PD government went to the electorate in 2002, saying we have a new health strategy, reelect us and we will reform the health system. Simultaneously, in the run up to 2002 election, McCreevy gave medical cards to all over 70s. They threw money at the situation to get the FF/PD vote out, just like the promised decentralisation in the run up to the 2004 local elections and the SSIAs bonanza in the run up to the 2007 election.
Once re-elected in 2002, the reins were pulled in and it became very clear that the much promised and needed investment and reform in the health system was not going to happen.
So what happened since?
A range of reports were commissioned reviewing the structures of the health system, the Brennan report on financial management and control systems and the Hanly report on staffing and reorganisation of hospital services.
From this the Health Service Reform Programme was published in June 2003 which recommended the abolition of the health boards and amalgamation into one unified health service executive along with a range of other health agencies including hospitals.
The new HSE would take the local politics out of health by removing politicians from the health boards and would allow for consistent quality patient care no matter who you were or what part of the country you lived in.
In January 2005, the HSE was set up, with much confusion, no clarity on new structures and no leader. People going into work in the first week in January 2005 did not know who they would be reporting to, what had changed. In effect, little changed on the frontline, nurses and doctors and health service staff went on with their day-to-day work.
In August 2005, Brendan Drumm took up post as HSE CEO and at the end of 2006 the Transformation programme was published.
This Transformation policy (not the health strategy) has set the agenda on how health services are provided and structured in the last four years. The Transformation programme is based on 13 priorities but primarily is focussed on shifting from inpatient hospital care to day care, from hospital care to primary, community and continuing care, a focus on an integrated care journey for patients, on reconfiguring hospitals, central to all of this is the involvement of staff in all that change.
Driving much of this is cost – it is cheaper to provide care on a day case basis than an inpatient basis, in the community than in the hospital. However, this is not always so. And there has been a continuous effort ‘to do more with less’.
There has been a significant increase in the health budget from €3.6 billion in 1998 to €15.3 billion allocated this year. But this increase was in the context of making up for decades of neglect, a health system that is providing more care to more people, to a growing ageing population, experiencing a baby boom, with increasing prevalence of chronic diseases, more expensive and effective medical care, a greater demand for health services and in recent times doing all this with fewer staff and a smaller budget.
While the health budget quadrupled, there has been a levelling off since 2007 and this year for the first time a cut in the overall health budget.
And also what happened during the boom, was a very quiet but steady privatisation of many aspects of the health system. We have always had a complicated public private mix in Ireland but the increased privatisation and specifically the entry of for-profit medicine and healthcare in Ireland was kick started by Charlie McCreevy’s changes to the Finance Act in 2001 and 2002 which mean that now 1 in 3 hospital beds are in the largely private for-profit sector and 2 in 3 nursing homes beds are in the private for profit sector.
The privatisation is evident in the hundreds of millions and the political priority given to the National Treatment Purchase Fund. Instead of solving the problems of the causes of long waits for public patients in public hospitals, our political leaders choose to invest in private hospitals for that care. And those long waits still exist for public patients.
Figures published last week in the NTPF annual report show that three private hospitals received over €40 million in payments for NTPF work. The government health strategy promised that ‘no public patient will wait longer than three months for treatment following referral from an outpatient department by the end of 2004’.
The NTPF annual report for 2009 published last week shows that over 18,500 adults and children were waiting more than three months for treatment in December 2009.
Minister Mary Harney ably took up the increased privatisation of health when she came into office in September 2004, most evident in the co-location project. The fact that this looks unlikely now is not due to the political will behind it but instead to the stronger economic winds we are currently surrounded by. Each year, for the last three years, the HSE Service Plan says co-location will go ahead ‘subject to satisfactory banking arrangements’.
What happened over the last decade was investment without any real reform. There was a lot of restructuring, what people in England are currently referring to as ‘disorganisation’.
Speaking three weeks ago at a conference run by the Adelaide Hospital Society on Financing Universal Health Care, Minister Mary Harney said ‘a pure one tier health system is not on offer’. She went on to clarify that there will always be a mix of public, private and voluntary care, that unless one banned private care, this would not be possible.
However what the Minister failed to acknowledge is what we have in Ireland is utterly unique in that we provide and incentivise private care within the public hospital system.
Earlier in her wide ranging 5,000 word speech, Minister Harney said “We believe that public health services should be provided on the basis of medical need. We believe that where people choose to pay privately for certain health services, as they will in any system, this should not be at the expense of people who use public services in terms of their access to, or quality of, care.”
This statement does not stand up to the facts and the policies that this government has pursued. Minister Harney over sees a health system which actively promotes private care in public hospitals, she supervised the agreement of the new, very expensive consultants contract which institutionalises the two tier system, a system where by 70% of consultants work publicly and privately, where consultants working public only contracts are penalised by their hospitals as the hospitals are loosing out on revenue from private patients cared for public only consultants.
We still have the same system that caused Susie Long to wait seven long months for her cancer diagnosis. And while there has been some progress made, eg there is attention and has been progress on reducing wait times for urgent colonoscopy, you can still get a colonoscopy quicker as private patient than as a public patient.
Essentially we still have a two tier public hospital system, where by doctors and hospitals are paid differently for public and private patients. They are paid salaries and lump sums for public patients no matter how many patients they see nor what the quality of the care and they are paid a fee for each private patient.
Ask any economist, incentives matter. The main economic incentive in the Irish public hospital system is to treat more private patients quicker.
As a result we still have a system whereby the 50% of the population who have private health insurance can get faster access in to the public hospital system and where most public hospitals carry out well in excess of the 20% private care. It is a system whereby up to 80% of the care of private patients in public hospitals is subsidised out of public money.
In my opinion, in time when we look back on the boom, we will identify one of the many crimes of the boom as the failure to dismantle our two tier system of public hospital care, the government’s failure to lead and to provide a quality, universal one tiered, public health system where access is based on need not ability to pay.
Quite clearly in the words of the Minister ‘a pure one tier health system is not on offer’. However “a pure one tier health system is not offer’ because none of our political leaders have had the courage or the vision to provide such a system. Our current unequal system of care is merely a political choice that consistent governments have chosen to maintain.
Interestingly for the first time in the history of the State all opposition parties are now advocating a one tier universal health system, albeit in different forms. Even the radical bastion of the Irish Medical Organisation is now proposing such a system. And I will come back to this.
Impact of crisis measures on health
While most public services did not feel the hit of the economic crisis til 2008/9, the health system began to feel it in 2006/7 with cutting of hospital budgets in line with the plan to move services from hospital to the community.
The first cost containment measures were introduced by the HSE in September 2007. These included a range of measures such as restrictions on travel, training budgets, conferences, the staff embargo. It also resulted in measures such as reduced surgery times, closed wards, the cancellation of out patient clinics and elective care.
These has been felt particularly by patients and front line staff, including nursing with the non replacement of staff, no locums for leave, and a clamp down on agency staff. According to the HSE’s own figures in September 2007 there was 112,771 staff. By December 2009, there was 109,755 staff, 3,016 fewer, many of whom were nurses.
While staff reductions and efficiencies may not seem like such a big deal, loosing over 3,000 staff out of a system trying to provide more care to more people with less money is a big deal.
It means that nurses like you have to make decisions about can you ration the changing of incontinence wear to just three times a day instead of four or five to reduce mileage costs. Or making the call between providing wound management clinics and palliative care for dying people. On wards, it results in nurses being run off their feet so they have less and less patient care time, more and more reporting and but less time to care and carry out essential clinical duties. In maternity wards, it results in babies being born in corridors and women in labour waiting in queues to get into the ward where they will give birth.
These are the choices that result from a system that is over stressed and under staffed with a staff moratorium in place.
We all know that there are inefficiencies in the Irish health system, some of these are being addressed, but some are not, yet continuing to cut frontline public health services before moving to greater generic drugs, continuing to cut frontline public health services before stopping putting public money into private care, closing hospital wards and beds without sufficiently investing in primary and community services, just does not make sense to me.
Impact of the economic crisis on health:
There have been three budgets since the onset of the international economic crisis – in October 2008, in April 2009 and then the last budget in December 2009. Just briefly I’d like to make a point in relation to the mantra – that our economic crisis is not our making that it is just part of a broader international economic downturn, but our economic crisis is spectacularly Irish in its making caused by a decade of eroding the tax base, of an over heated property market, of unregulated banking, of a ‘spend while you have it mentality’, putting little or nothing away for times like now when we need it most.
Likewise one often hears our political health leaders say that health systems all over the world are under pressure, are struggling with how best to finance and organise them and that it is true but in Ireland we have our own particularly specific health crisis in that we have failed to solve even high profile issues like A&E, like waiting times for public patients, and central to this failure is our unique, complicated, unfair mix of public and private health care.
How is it that the English targets of a four hour wait time in EDs and a 18 week wait between referral to GP and seeing a consultant as an outpatient have been met and kept, meeting the target 95-97% in the time yet we have consistently failed to address these problems here, evident in trolley watch and wait times already outlined.
But back to the budgetary measures. In October 2008, by far the most high profile health aspect of the budget was the removal of medical cards for over 70 year olds.
In each of the three budgets we have seen increased charges for patients evident in emergency dept charges going up, hospital beds charges up, payments for drugs for the 70% of the population who have no medical cards going up from €100 to €120 per month and in the last budget the introduction of prescription charges for medical card holders.
These measures show two clear things, the determination of this government to remove of any universal aspect of the health system and the transfer of payment for healthcare from the State on to the patient, particularly hitting hardest those who can least afford it.
Also there has been a 26% cut in capital budgets for two years running as well as an 4.2% budget cut in health, and this is hitting hospitals more than primary, community and continuing care services.
Simultaneously, there have also been cuts in public sector wages between 5-15%, the introduction of range of levies and two cuts to those on social welfare of 2% and 4%.
As well as a transfer of more payments for care from people’s pockets, people also have less in their pockets.
We know that these measures are hitting people on low incomes hardest who are also those who most need the public health system most. Poorer people get sick more often and die younger.
This combined with a staffing moratorium in place and the shifting care to community (1,500 fewer hospital beds btw Jan 08 – 10) are all being felt by users and staff in the public health services.
YET… WE KNOW
Cutting budgets, staff & services impacts most on those who need them most.
Cutting health & social care costs more in both short & long term, both economically and socially.
We know from the 1980s that closing beds and wards and hospitals in an unplanned way as a mechanism for saving money can take decades to catch up from and be more expensive in the long term.
We know that the staff moratorium means that agency staff are being hired to fill some gaps at the cost and a half of what that same job would cost. This does not make economic sense plus it is doing people trained and qualified out of a real job.
We know that training a nurse costs about €100,000 of public money and yet this years hundreds of nurses (on whom 100s of 1000s of public money has been spent training them) will emigrate because there are no posts for them.
We know that meagre measures like introducing a 50 cent charge per prescription item puts people off taking what can be essential and life saving drugs. The evidence from the Cochrane collaboration (the medical gold standard) is that charging people even the smallest of charges can be detrimental and this is particularly true for people with chronic conditions such as asthma and diabetes and those with mental illnesses.
In each of our neighbouring countries (England, N Ireland, Scotland and Wales) where there are minimum charges for prescriptions, certain people including those on the lowest income, those with chronic diseases, pregnant women, cancer patients are exempt from any prescription charge – what is our government doing – introducing a charge on those who need those drugs most, on whom it will hit hardest, on those whom our neighbours exempt. The evidence is quite clear yet Minister Harney maintains she “is a fan of co-payments”.
The great scandal of the boom, as I have already said is that the government failed to provide leadership on any real reform and to introduce a one tiered quality universal public health system.
The great scandal of the bust will be to loose the progress and investment made during the boom.
And while I am often considered critical of the system we have, some progress has been made. Nurses prescribing drugs, improvements in the quality of cancer care, the introduction of homehelp hours and some real improvements in services for people with disabilities and older people are all areas where progress has been made.
Lets not loose that progress despite the current crisis.
The value of a public health system
Briefly, lets look at the international literature on privatising public health system
Universal, accessible, uncomplicated public health systems produce better health outcomes, are less expensive, more equitable and efficient (OECD comparative health systems).
Allocating resources on the basis of need is a means to enhancing the value of spending on health. (European Observatory on Health Systems, 2010)
Recent report published by the Westminster parliamentary select committee on health based on work carried out by the National Audit Office in the UK found that ‘commissioning’ – which was the English government’s attempt to introduce a divide between purchaser and provider care within the NHS was a “costly failure”, costing 14% of overall budget in administration and management and “may need to be scrapped”. They noted that poor commissioning was made worse by consistent reorganisation and of the NHS and a high turnover of staff.
Spending on health now, saves money in the future – economic argument put forward in England in 2002 Wanless report – which specifically recommended investment in prevention to as to secure future sustainability of the NHS.
Human capital contributes to economic growth and health is a key component of human capital (EU Commission, WHO Europe and Commission on Macro Economics 2001, BMJ).
TO back all this up, one needs to prove that health systems improve health and can do so cost effectively. Evidence shows about half of increased life expectancy due to improved health care, in cardiovascular health 60/40%.
Health service is a major economic sector providing jobs, stimulating R&D, a motor for economic growth (Galbraith)
The Marmot Report in England which follows the WHO work on the social determinants of health calls for “building of universal health care systems based on equity principles”. It says “the system needs to improve the mechanisms for identifying and rectifying inequalities in delivery of the services and develop further the capability to take social determinants of health approach”. (Marmot, 2010)
So where does that leave us – is the current crisis an opportunity or an insurmountable task?
Briefly I want to talk about who is entitled to what in the Irish health system?
Currently the Department of Health is reviewing eligibility in the Irish health system. This has been ongoing since 2001.
Eligibility means who is entitled to what.
The outcome of this review is absolutely crucial as it will determine for the next generation or two who is entitled to what.
At the moment we have a very complex, unclear web of entitlements eg if you are a medical card holder, you can go to your GP for free, you will soon pay 50 cent per prescription item and access public hospitals services for free – although you may have to wait a long time to get in.
If you have a doctor only medical card, you can go to your GP for free, you pay for your own medication (which is often much more expensive than the cost of the visit) and can access public hospitals for free (once you pay for 10 nights – €700) – although you may have to wait a long time.
If you are not a medical card holder, you pay to see your GP, pay for your medications up to €120 per month and can access public hospitals for free (once you pay for 10 nights – €700) – although you may have to wait a long time.
If you are a non medical card holder with private health insurance, you pay for your GP and drugs (up to €120 per month) and can access public hospitals quicker.
Could it be more complicated and less clear?
And what about other essential health professionals like physios, OTs or public health nurses – am I entitled to these services without paying for them if I do not have a medical card? The answer is no. But you can get them in some parts of the country.
Does any of this make sense? The answer quite clearly is no.
So perhaps this crisis is what you make it.
You are a powerful force – you are one third of the health service work force.
Perhaps it is time to think about what is ‘enough’.
What is enough at a societal level?
For far too long, some people have had far too much while many have had not half enough.
We need to rethink what sort of society we want to be in and you as nurses, as this powerful force, you need to think about what is your role in rethinking and reshaping the society we live in and the health service of which you are an integral part.
If we apply this concept of ‘enough’ to the health system, what is it we have had enough of?
Have we had enough of privatisation?
Enough of cutting frontline services?
Enough of transferring the cost of care from the State to patients?
Enough of cutting wages of those on low income, who experience the poorest health and the shortest lives?
Enough of patients waiting on trolleys?
Enough of public patients waiting longer than private patients?
Enough of so called ‘reform’ with out really investing in frontline services or any real reform?
And if we or you have had enough of that, what can you do about?
You can keep on providing care day in day out, for the patients, for that is your core duty. But you also have duties as health service staff and as citizens, a duty to bring about change. A duty to turn this crisis into an opportunity.
With this crisis comes opportunity. The only alternative is an alternative. The people and policies that got us into this mess cannot get us out of it.
The INMO has been extremely successful in the past in highlighting the ongoing delays and poor conditions in Emergency Departments through its Trolley Watch.
Perhaps now it is time to broaden your canvass – to begin a national campaign about the type of health service we want to have in five or ten years time, to begin to campaign and to shape that health service. To campaign for a public health service that is universal, high quality and accessible to all on the basis of need.
And if it is universal, high quality and accessible to all on the basis of need, none of those obstacles like paying for care or waiting long times would be an inherent part of the system as they are now.
Advocating a one tier universal public health system is not a radical step – it is a sensible one – it is the norm in all other western European countries.
There is a growing momentum in support of such a system – all opposition parties, the IMO, the ICTU, other more progressive groups like CORI, tasc and Is feidir Linn are also calling for this.
But such a movement needs to be led – who better to lead it than the people in the health services who garner most respect from the public – you the nurses?
By leading such a movement, for a one tier universal health system, you can build solidarity with family and friends who are users of the public health system, with colleagues, family and friends in the private sector who are also dependent on the public health system.
Speaking on a documentary on Tuesday night on RTE, award winning novelist Colum McCann spoke about how ‘true optimism has to acknowledge despair’.
So while there are many insurmountable obstacles in the way, and while there is currently much despair, maybe the time has come to turn that despair into true optimism and start a campaign for a health system that all Irish citizens are entitled to – a quality, universal, one tiered, public health system where access is based on need not ability to pay.
Thank you very much for your attention.