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Careful planning and resources are required

07 Sep 2016

IMO President Dr John Duddy discusses the union’s submission to the Oireachtas Committee on the Future of Healthcare, and how open debate and detailed planning will be essential for success

Late last month, the IMO submitted its vision for the healthcare system to the Oireachtas Committee on the Future of Healthcare. The IMO has been leading the debate on universal healthcare and welcomed the establishment of a cross-party committee to reach consensus on a 10-year strategy for healthcare in Ireland.

In the submission, the IMO states that the primary strategic goal over the next 10 years should be to develop a universal healthcare system that aims to secure access to adequate, quality healthcare for all when they need it and at an affordable cost.

However, Ireland faces a number of significant challenges to achieving a universal healthcare system. The first will be to enhance service provision and manpower capacity across the health system to meet the needs of a growing population and changing demographics.

The second major challenge will be the recruitment and retention of our highly qualified medical workforce. As the key decision-makers, doctors are a vital part of the healthcare system. With up to 60 per cent of interns planning to leave, the retention of our medical workforce must be a principal aim of any future healthcare strategy.

Finally, universal healthcare will require additional capacity and resources. In order to avoid a fiasco like the water charges, open debate is required on both the future vision of our health services and the cost, including the most appropriate funding model.

Health services, however, are complex and require detailed long-term planning. In this submission the IMO presents the evidence to support the best outcomes for patients, and which represent value for money for the State.

General practice

GP care is the cornerstone of any universal healthcare system. Continuity of care and the patient-centred approach that is specific to general practice is associated with lower patient mortality, equity of access, and more appropriate utilisation of services. International research from Starfield to Kringos et al demonstrates the unique role of the GP in terms of continuity and coordination of care.

Yet general practice in Ireland has been damaged by the FEMPI cuts that have removed €160 million or 38 per cent of funding. Ireland is also facing a shortage of GPs, with 17 per cent of family doctors reaching retirement age and an insufficient number of newly trained GPs to replace them. Some newly trained GPs see emigration as the only viable option.

In our submission, the IMO calls on the Department of Health and the HSE to agree a strategy with the IMO for the development of general practice over the coming decade.

The HSE estimates that by 2025 an additional 1,380 GPs are required to ensure the provision of GP services to the under-sixes and over-70s; to expand GP care to the entire population an additional 2,055 GPs are required by 2025.

The strategy must include a manpower action plan to address the growing shortage of GPs and an increase in the number of GP training places.

In order to halt the exodus of GP trainees, priority must be given to negotiating a new GP contract with the IMO that is properly resourced. It should include terms and conditions that ensure both existing and newly qualified GPs are attracted to a career in the Irish health service.

The strategy must ensure GPs have access to diagnostics and allied health and social care professionals in the community. And as per the Indecon report recommendations, incentives should be provided for the development of infrastructure, including premises, medical and diagnostic equipment, and IT systems.

Public hospitals

While investment in GP care is integral to managing demand on the hospital system it will not immediately resolve long waiting lists or the crisis in our Emergency Departments. Access to care in the public hospital system is primarily a capacity issue. There are too few consultants employed in our hospitals across all specialties and there are not enough acute hospital beds.

Waiting lists for specialist outpatient appointments and elective procedures will only be reduced following the introduction of a fully resourced consultant-delivered healthcare service.

In 2003, the Hanly Report recommended that a consultant-delivered hospital service would improve quality of care and patient safety. Research shows that consultant-delivered care improves patient outcomes and reduces length of stay.

Pic: Getty Images

While there has been a gradual increase in the number of consultants and NCHDs employed in the HSE, NCHDs still outnumber consultants 2:1 and currently one-in-eight consultant posts remains unfilled. Working conditions in overcrowded hospitals have led to unprecedented recruitment and retention issues. Many of our newly trained doctors are emigrating or planning to emigrate, while we in turn are becoming increasingly reliant on foreign-trained doctors.

Based on the calculations in the Hanly Report and current population figures, an additional 1,657 consultants are required now across all specialties to ensure a consultant-delivered service, while an additional 1,920 consultants would be needed by 2026.

In our submission, the IMO recommends that integrated medical manpower planning takes place at national level, which takes into account the number of consultants and specialist training posts required to provide consultant-delivered care. Measures must be taken immediately to improve training pathways, and the retention of Irish-trained medical graduates in Ireland.

These measures include the full implementation of the recommendations of the MacCraith Review of Medical Training and Career Structures and the negotiation of new contracts for both consultants and NCHDs.

Hospital capacity planning is complex and requires assessment of numerous dimensions of healthcare provision. In a number of jurisdictions, hospital bed capacity has been the traditional unit by which care has been planned. Increasingly, states are also using service volume and
activity to plan for capacity.

The IMO recommends a detailed assessment of the number of acute beds needed in the public hospital system to meet current and future demand. The assessment should be based on 85 per cent occupancy rates to ensure patient safety and provide for seasonal increases in demand. Capacity planning must also include an assessment of diagnostics, radiology and laboratory service requirements in both the hospital and community setting.

An immediate and effective plan must be implemented to meet current bed requirements. The reinstatement of the National Treatment Purchase Fund (NTPF) will not be sufficient to reduce waiting lists in the long term. Evidence from the Elective Surgery programme at the RCSI shows that waiting list initiatives such as the NTPF only have a short-term effect on numbers waiting for elective surgery.

The private sector does not sufficiently cater for frail or complex patients and even when we include both public and private beds the number of acute inpatient and day-case beds falls well below the European average. In terms of inpatient beds alone, Ireland needs an additional 3,500 hospital beds to bring us up to the West European average.

Long-term/ Rehab care

The IMO submission also recommends that demand for community and long-term care must be properly assessed and adequate resources provided, including capital investment, operational funding and manpower.

Older people and people with disabilities have the right to equal access to health and social care services, including rehabilitative care services and long-term community and residential care. Wren et al predict that based on 2006 utilisation and some decline in disability rates, by 2020 demand for long-term residential care, and formal and informal homecare, will increase by almost 60 per cent.

Mental health
The IMO has also called for a new strategy that places mental health on a par with physical health. In 2006, A Vision for Change laid out the blueprint for the transfer of mental health services from an institutional to a community-based setting over a period of seven-to-10 years. However, progress has been slow, with poor implementation and inadequate and uneven distribution of resources.

A new mental health strategy should include: the appointment of a national independent body to define mental health catchment areas; urgent investment to address deficits in Child and Adolescent Mental Health Services so that no child is admitted to an adult psychiatric unit; and direct access for GPs to counselling and psychological services in the community.

Public health

Public health doctors have expertise in epidemiology, health economics, health information and planning, health protection and health improvement. If properly resourced, public health doctors could play a pivotal role in commissioning services, analysing health data, conducting needs assessments, assembling the evidence base for interventions, monitoring services and quality assuring parts of the health service.

The IMO submission recommends that immediate action is taken to expand public health capacity and attract medical graduates to this discipline through consultant status and a new contract.

The IMO also recommends that health information and patient safety legislation ensures the public health planning function has access to appropriate data while at the same time ensuring confidential patient data is protected.

Prevention
Prevention is the most ethical and cost-effective intervention. Unhealthy lifestyle choices pose significant challenges to population health, while global health threats could undermine all planning. In 2013, the Government published Healthy Ireland — A Framework for Improved Health and Wellbeing 2013-2025, which lays out the Government’s strategy to improve health and well-being in Ireland from 2013 to 2025.

Many well thought out strategies fail through lack of a detailed implementation plan, resources or a dedicated person with overall responsibility. The IMO welcomes the goals of Healthy Ireland and is calling on the Government to develop a detailed implementation plan supported by ring-fenced funding.

The IMO recommends that Health Surveillance Programmes are enhanced and immediate priority is given to:
1. Developing a comprehensive multi-disciplinary programme to tackle childhood obesity;
2. Enactment of the Public Heath Alcohol Bill;
3. Full implementation of the recommendations for a Tobacco Free Ireland.

Integrated Care
Healthcare in Ireland is fragmented and poorly coordinated. Integrated care can improve the quality of care and efficiency in our health service.

In this submission, the IMO makes a number of recommendations to support integrated care including: investment in ICT; the development of clinical guidelines; and the effective management of resources.

In addition to integrated care, the IMO recommends that there must be an ongoing emphasis on quality improvement initiatives in the health service through a wide range of measures.

Conclusion
Universal healthcare will require additional capacity and resources. The IMO believes that with a substantial increase in resources the goal of universal healthcare can be achieved either through an expanded taxation model or eventually through a social insurance model.

However, what is required is open debate on both the future vision of our health services and the cost, as well as the most appropriate funding model.

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Click here to view the full article which appeared in Irish Medical Times: Opinion