Dara Gantly looks at some of the fallout from the most recent waiting list scandal, and a master politician in crisis battling on the front foot
I shan’t repeat the analysis I gave a few weeks back on the ups and downs of the NTPF and the origins and outcomes of the initial Waiting List Initiative (WLI) of 1993, (‘Ol’ NTPF is back in town’, January 27, 2017), but RTÉ’s Living on the List programme demands that I have another look at waiting lists.
There are so many facets to this problem that it’s hard to know where to start. A good place, however, might be the list itself, the construction and administration of which has come under heavy criticism in the wake of the RTÉ Investigates programme. Among other things, it was claimed that the number of patients waiting for operations or medical procedures was 60 per cent higher than the official figures published by the NTPF — some 49,000 higher than the figure for December 31 last, as it excluded patients classified as pre-admit or those awaiting pre-planned procedures.
Minister for Health Simon Harris said that the personal stories of the people waiting for treatment were deeply moving and their experiences were absolutely inexcusable. He reiterated in the Dáil last week that when he said he was ashamed, “that wasn’t just a word . . . I meant it”. Apart from his heartfelt empathy, his response was straight out of the ministerial fire-fighting handbook: partly defend what is being done ‘under his watch’, point out it has been like this for more than a decade before he was in charge, emphasise that significant changes are afoot, and place the ultimate blame elsewhere, at the feet of HSE management.
Indeed, reports emerged afterwards of a rift developing between the Minister and the Executive, after HSE National Director of Acute Hospitals Liam Woods was left to defend himself and the Executive after the Minister’s damning interview on the Claire Byrne show following the documentary. Things were probably not helped by the Minister’s apparent pledge to “shine a light” and “get under the bonnet” of the HSE. I can see a spanner or two in the works there.
“I understand the waiting list figures have been consistently counted the same way since the establishment of the NTPF and follow other international models, for example Sweden and Canada,” Minister Harris also pointed out, in reference to charges of so-called ‘hidden lists’, adding that this approach was in line with international protocols. But is it?
Yes, Canada does have two consecutive segments to its waiting list figures: time from referral by a GP to consultation with a specialist (nine weeks in 2016, by the way); and time from the consultation with a specialist to treatment (10.6 weeks).
But it also reports a median waiting time (20 weeks in 2016) between referral from GP to receipt of treatment.
And as for Sweden? Yes, Sweden has one of the highest healthcare spends per capita and is a technically excellent health system, but according to the recently released Euro Health Consumer Index (EHCI), it has the lowest score for accessibility among 35 EU countries surveyed — along with Ireland and Poland. Overall, Sweden is in 12th place, due to its “seemingly never-ending story of access/waiting time problems”, in spite of national efforts such as Vårdgaranti (National Guaranteed Access to Healthcare), which has thrown money at the problem. Sound familiar?
Even the target for a maximum wait in Sweden to see your GP (no more than seven days!) is underachieved only by Portugal. And in terms of waiting times of patients treated, Sweden only has figures for four procedures — hip replacements, knee replacements, cataracts and coronary bypasses — which is well below the international average.
We covered the EHCI report earlier this month (‘Double Irish insurance ‘a problem’, report suggests’, February 3), but again it is worth recording that Ireland remained down the list in 21st place. Commenting on Ireland’s target of having no more than an 18-month wait for a specialist appointment, the report commented: “Even if and when that target is reached, it will still be the worst waiting time situation in Europe.”
While making direct wait time comparison between countries is tricky, researchers have given it a good shot, particularly in the 2014 paper in Health Policy by Siciliani et al. (http://dx.doi.org/10.1016/j.healthpol.2014.08.011), who are the same authors of the comprehensive OECD Health Policy Studies report Waiting Time Policies in the Health Sector: What Works? (2013), which I may explore further next week.
In short, the authors point out that emerging best practice is to measure the waiting time of patients rather than the length of the waiting list, and that countries are moving beyond measuring only hospital waiting to measuring the total patient journey beginning back in primary care. You can just imagine the waiting times for that list in Ireland.
There have also been accusations of manipulating the waiting list. On the RTÉ programme, we heard of brave Darragh Cahill (7) from Kilkenny (who actually met Minister Harris last November on the issue of his long wait for scoliosis surgery), whose mother discovered through the Freedom of Information Act that her son was incorrectly placed on the waiting list in April 2016, rather than in August 2015 when he was first put forward for insertion of spinal growing rods. That’s an eight-month difference.
Crumlin Hospital first insisted that he was indeed correctly placed on the list, but eventually admitted that this was a case of human error, and they backdated Darragh to the correct time.
The NTPF is quite clear on this. According to its recently released ‘National Inpatient, Day Case, Planned Procedure (IDPP) Waiting List Management Protocol’ (2017): “Within three working days of receipt of the completed waiting list booking form [itself required within one working day after a clinician decides to admit] patients must be added to the electronic waiting list. Booking forms should be date-stamped on receipt in the booking office… The date that the ‘decision to admit’ was made must be entered on the system as the date added to the waiting list, this will inform the ‘start wait time’. This date must not be changed or altered by the hospital at any point during the patient’s journey through the scheduled care system [their emphasis].”
We have to accept Crumlin’s explanation, but how many other ‘human errors’ have been made in the system?
The NTPF is currently commissioning a research project examining updated international best practice around publication models and methodologies. Its Strategy & Action Plan 2017-2019, also published last month, details how it hopes to develop and deliver a suite of web-based data analysis reports to stakeholders, including the DoH, HSE Acute Hospitals Division, Hospital Groups and individual hospitals by Q4 of this year, and assess the feasibility of collecting additional waiting lists, specifically an extended outpatient waiting list, diagnostics waiting lists, and community based services waiting lists by the end of 2018, so that “all areas of the public health service can access data to support them to make evidence-based decisions”.
The Minister for Health’s decision to re-establish the individual patient-level commissioning role of the NTPF with associated enabling funding has brought the Fund back into the spotlight, but RTÉ has shown it not looking its best.
It has some work to do to convince the public of the completeness of its data, and whether it should, in fact, be counting something different. We will wait and see.