A speech not of ‘national importance’
Reductions in waiting lists achieved by throwing resources at the problem is not a sustainable solution. Here is my Medical Independent column from 20 February 2014.
At the end of another long, wet, windy day towards the end of January, Dr James Reilly’s spin doctor called to say the Minister was about to make a “historic speech” on health policy of “national importance” in the Dáil. Top of Minister Reilly’s list of achievements was “a 95 per cent reduction in the number of people waiting more than 12 months for an outpatient appointment”. He detailed how a year ago, there were more than 110,000 people waiting over one year for that first, crucial out-patient appointment with a hospital consultant. The figures presented (as yet unpublished) show less than 5,000 people waiting this long in December 2013.
Dr Reilly must be given credit to be the first minister to oversee the collection of out-patient data and to champion the truth that ‘to wait a year is far too long’. He must also be credited with his resolve to bring down the numbers waiting on trolleys in emergency departments (EDs) and the waiting times for hospital treatment.
Two days after the speech, the Minister was on the RTE Radio One programme Today with Sean O’Rourke, reiterating points made during the speech. O’Rourke questioned how on earth he got those figures down so quickly, accurately pointing out that in September 2013, there were more than 84,000 people waiting for more than a year for their first out-patient appointment.
Dr Reilly responded by talking about how, during the course of the year the Special Delivery Unit (SDU), in conjunction with Mr Ian Carter (whose remit as National Director of Hospitals includes being the head of the SDU) and frontline staff, he set about ‘tackling the lists in an orderly fashion’. He spoke about the approach being to treat the longest waiters, after the most urgent are treated, thereby eliminating or hugely reducing this group. He acknowledged the ‘herculean’ effort of front line staff and the role of the clinical programmes in achieving reductions in waiting times.
Again, pushed by O’Rourke, who asked whether “smoke, mirrors or magic” were used to bring down those numbers so quickly, the Minister responded that a huge amount of activity took place inside and outside of the system with extra clinics, right into Christmas week and New Year.
So what? Surely getting each one of those people seen quicker is a good thing. And it is. However the fact that there were more than 86,000 people waiting in September shows a system that is unable to manage the reduction in a systematic or sustainable way. 25,692 people waiting over a year got appointments between January and September, 28,153 were seen in October and November and 51,644 in December, when the system is at its busiest.
What the Minister did not reveal was that, in the weeks before Christmas, very senior HSE officials were hammering their phones, persuading private hospitals to do as many outpatient appointments as they could for them. The HSE confirmed that 23,037 “outpatient appointments were outsourced” to eight hospitals.
The HSE would not give answers on how much was paid for these outsourced appointments, or in which specialities. The only response given was that “€18 million was made available to maintain ED access and to reduce waiting lists for planned inpatient and elective outpatient care”. The same statement also said that “the targeted initiative has led to 98 per cent compliance with the national eight month target for inpatient waiting times”. What this does not tell us is that in November 2013, there were more people waiting over three, six, nine and 12 months for hospital treatment than there were in the same month in 2012.
There is no doubting that the Health Minister is intent on and committed to improving access to hospitals and patient care. And some progress has been made under his stewardship. However, what the figures above show is that it is very difficult or impossible to reach the targets set with ever constraining money and staff in a health system, where increasing numbers of patients are seeking more complex care.
A year ago, the Francis Report into hundreds of unnecessary deaths in a Stafford Hospital in England, criticised the “oppressive reactions” of the system to hospitals that ran into trouble with budgets and hitting targets. One year on from its publication, a review of progress in English hospitals by the Nuffield Trust warns that “financial pressures could get in the way of the drive to improve care”.
If Dr Reilly had made a speech on the complexity of reform and the difficulty of balancing ambitious targets with budget and staff cuts while trying to improve care, that would have been an historic speech of national importance.