Time to think and act outside the rickety box

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Denis Doherty
Denis Doherty

Denis Doherty explores how our health services could meet the needs of our vastly increased population.

Our population is now 5,123,536, higher than at any time since 1841. Post famine, our population declined steadily up until the census of 1971 and has increased steadily since then. Since the health boards came into being in 1971, the population has increased by 72% and by 31% since the HSE came into being in 2005.

Our economy has improved steadily also. Ireland is a net contributor to the EU and is one of the wealthiest countries in the world. It is considered to be a liberal democracy and is a respected and active member of the EU and the United Nations.

Is our health service fit to meet the healthcare needs of more than five million users? Few would argue that it is but many would argue that it performs well when regard is had to the constraints it works under. COVID-19 is a recent example of a sterling performance, which rated among the best in Europe. Very good results were achieved despite the fact that hospital beds numbers generally and ICU beds in particular were seriously inadequate.

It is remarkable and to the great credit of the health services that the sudden influx of going on 50,000 refugees, with full public healthcare entitlements, from war torn Ukraine, is being coped with.

On other hand, our mental health services, for children, adolescents, and adults, are underfunded, understaffed and often delivered from facilities that are patently not fit for purpose. The policies that underpinned the move away from mental hospitals and other congregated settings were sound but were not capable of being met from the funds provided and faced with the shortages of suitable staff that the changes required.

The Minister for Health and/or the HSE could procure services from privately owned and operated hospitals that would cater for public patients only.

Children’s services generally are shamefully poor in many respects. Surgical services for children with scoliosis and mental health services for children and adolescents are examples of intolerable neglect.

Some commentators and some politicians regard our health services as a cost center that devours money and must be endured. They show little interest in significant demographic changes and the expanding role technology can play in modern health care delivery. The demoralising effect that constant, gratuitous criticism is having on the recruitment and retention of essential staff doesn’t appear to concern them.

Mention of private hospitals can sometimes give rise to strong views but, in reality, they are major providers of essential healthcare here. Nearly half of our population holds private health insurance to be able to avail of the services they provide when they require them. They provided a valuable back-up service during COVID. The very fact that their facilities could be made available when required was important.

The services provided by private hospitals are easier to plan, organise and deliver than public hospital services are. There is more autonomy, less bureaucracy and a more businesslike approach generally in the private sector.

Technology has the potential to modernise the delivery of our health services, reduce administrative costs, compensate, to some extent, for the difficulties being experienced in recruiting staff in the numbers required and increase job satisfaction. Our health services are seriously under resourced in all areas of modern technology use and worryingly this weakness does not feature in public discussion as an area requiring urgent attention.  It is at the opposite end of a spectrum that has the changes at the ED in Navan Hospital at the other but rarely features in political debate or media coverage of the health services. When the 2022 edition of RTE’s ‘Reeling in the Years’ is assembled it will surely feature the Navan Hospital controversy as one of the main healthcare issues of the year; underinvestment in IT in our health services is unlikely to feature.

Traditional professional boundaries are perhaps not as strong in some places as they were in the past and hierarchical structures are not as insisted upon now as they were in the past either. Do they really have a place in modern healthcare delivery? Enlightened HR policies and practices, based on the principles of ‘parity of esteem’ and ‘respect for diversity’, as advocated by John Hume throughout his political career, would facilitate effective modern approaches to healthcare delivery. Enlightened and progressive corporate culture and people policies and practices are what really count.

The co-location hospitals idea, whereby private hospitals would be developed adjacent to public hospitals died a death, on ideological grounds, but the additional hospital beds that would have resulted have not been provided on any other basis. Section 38 of the Health Act, 2004, empowers the Minister for Health to purchase health services from private health service providers.  There is discussion currently on the role  ‘elective hospitals’ could play in increasing hospital capacity.  Discussion so far envisages these hospitals being owned by the State and operated by public employees.  In addition, The Minister for Health and/or the HSE could procure services from privately owned and operated hospitals that would cater for public patients only. For example, a hospital of this nature could be built and owned by a property developer who would then lease it to a specialist hospital services operator who would contract with the HSE to provide a specified volume and range of services to public patients.

The benefits of arrangements of this nature would be that the capital cost involved would be borne by the private sector. Revenue costs would be negotiated and contracts would form the basis of the arrangements between the commissioner and the provider. Importantly provision of the additional public patient beds required would be accelerated. A highly professional procurement and compliance unit would, of course, be essential to ensure that service quality and value for money are achieved. 

The Sláintecare report envisages an Ireland in which everyone in the State would be entitled to receive their entire healthcare needs free of charge, or at subsidised cost, at the point of delivery. Even in the unlikely event of that proposition ever being affordable or offered, entitlement could be offered and delivered at the type of Section 38 hospital described above. This form of arrangement could also be deployed in relation to a range of other healthcare services.