Aontú stands for a new realism and a fresh start in healthcare reform
The Irish Health System is broken. Aontú is pledged to work to fix what is a national crisis, one to which this government has become increasingly desensitised. Medical, nursing and allied healthcare professionals struggle to keep the health system functioning, yet government have demonstrated time and time again an inability to engage positively and proactively with professionals to strengthen the system, to increase productivity and to improve its capacity to deliver better health, social and economic outcomes.
These developments reflect deeper structural problems that have not been properly addressed.
- A lack of accountability
- Shortages of staff
- A lack of capacity in our hospitals
- Under-investment in Primary care and in Community-based services
Slaintecare – the government’s long-term strategy for reforming the system without necessary funding and staff buy-in now lacks credibility. Aontú stands for a new realism and a fresh start.
Aontú is committed to work with other stakeholders to reshape healthcare through targeted investment in high-priority initiatives and through working with healthcare professionals to ease bottlenecks in access to the system. This approach will also strengthen our capacity to better manage medium and longer-term pressures related to an ageing population profile and longer life expectancies.
Government and the HSE have long pointed out that investing in primary care leads to better health outcomes at lower costs. They have not delivered. The Sláintecare Report, set out a target for people to receive 70% of their healthcare needs in their community, rather than having to travel to the nearest acute hospital. However, only 4.5% of the current Health Budget is spent on primary care.
This means that the critical mass of Primary Care locations or staff – such as doctors, nurses, physiotherapists, psychologists and social workers – that are needed to deliver integrated care in their community are simply not in place. Aontú believes this will require resolving supply-side issues relating to the training and location of GPs, especially in areas of greatest social need. Aontú will consult closely with GPs who have established innovative and socially responsive practices in order to replicate, so far as possible, such models more widely.
As part of its strategy to re-pivot healthcare away from its overdependence on the acute system, Aontú will press for 10% of the current health budget being assigned to the development and delivery of Primary Care in communities.
GPs interact with every individual and every family. They should be at the heart of a responsive, proactive and cost-effective health system. Aontú believes GP’s should be incentivized to offer a wider range of services, either directly or through an Integrated Group Practice. It is clear that with increased investment in facilities and staff, GP’s can offer a much wider set of services, from minor surgical procedures to mental health, if facilities and space are provided. This makes sense, both in terms of patient-friendly delivery of care and also relieving pressures on the acute system. Pharmacists must also have a greater role in the delivery of Healthcare to citizens.
Midwife led care needs to be looked at as something that could take pressure off maternity units in large hospitals by having low risk pregnancies managed by community midwives at primary care centres, initially through 35 weeks of pregnancy, with a view to creating midwife led pregnancy centres that can take a woman through from early pregnancy to postpartum care, as is seen in other countries. There is strong research to show midwife led care in low risk pregnancies is more beneficial than consultant or doctor led care in a hospital.
A more balanced and responsive Healthcare system will require greater integration of Primary, Secondary and Tertiary care. Indicative Care Pathways, based on Best Practice, should be used to channel patient flows between Emergency Departments (EDs), Out-Patient Departments (OPDs) and delivering care that is more appropriately delivered in a community setting.
Ireland has 2.8 acute hospital beds per 1,000 of the population, compared with an Organisation for Economic Co-operation and Development (OECD) average of 4.3 per 1000. Even with a significant increase in day-case surgery there is still a significant shortage of beds to an extent that is wholly out of line with best international practice. Around 1,600-1,800 hospital beds were lost in austerity-era cutbacks overseen by a Fine Gael/Labour Coalition government. The effects of short-term “savings” through the closure of beds and cuts in staffing are still evident. These cutbacks were implemented notwithstanding all of the evidence that such cutbacks are radically counter-productive, both in terms of health and the long-term costs of rebuilding the system, including staff morale and public trust.
Action is needed in the short term, as well as the medium term. ED services are not functioning as they should – the same cycle of “crises” occur year after year. Repeated promises by Fine Gael to “fix” the system have been empty. A record number of 110,000 people were forced onto trolleys last year in 2018 because of a lack of capacity and bottlenecks within the wider system.
We know that being on a trolley often leads to delayed diagnosis, delayed treatment and patients who have an increased risk of morbidity and mortality. According to the Irish Association for Emergency Medicine “some 300 to 350 of our citizens die avoidably every year as a direct result of the failure to address this issue”. This is a wholly unacceptable situation but one to which the government has become desensitised.
Aontú believes that overcrowded EDs are a blight on our health system. They impose enormous pressures on medical and nursing staff and highlight a lack of bed capacity as well as inefficient and poorly resourced discharge programmes. They are part of a wider systemic failure. 750,000 people are currently on hospital Waiting Lists. People are now forced to wait for years in bad health. Many have to withdraw from work, many require carers and most will have to have more expensive, and in some instances invasive, treatment in the long run. There is no humanitarian, medical, or economic logic to leaving people waiting on hospital waiting lists.
Public patients are faced with long waits for outpatient appointments because of a lack of capacity, including unfilled staff appointments. There is an additional problem: under-funded public hospitals are given targets for maximising private patient income via Private Health Insurance (PHI). This is unfair, regressive and wilfully inefficient. Aontú seeks a publically funded health service. We are though practical in our approach and realise that this is not going to be achieved in the short term. In the short term all available capacity – private as well as public – should be used to mitigate and then eliminate our excessive waiting lists and that the public system should be properly funded.
This means an end to the annual charade of underfunding/“overspending”, leading to Supplementary Budgets. It also provides a robust and sensible platform for a dialogue with healthcare professions on the very necessary challenge of increasing the productivity of the system.
LACK OF STEP DOWN FACILITIES
Ireland’s bed occupancy ratio is excessively high by international standards. Over and above the shortage of capacity this reflects constraints on discharges. The Government have failed to adequately address the scarcity of “step-down” services from acute care. Addressing this issue would facilitate earlier hospital discharges and ensure that the best use was made of scarce, and expensive, hospital beds. Aontú believe that additional “Home Care” services, together with more nursing home capacity, would deliver a more balanced and cost-effective healthcare service. This is a long-standing problem where new thinking and closer integration of Acute and Community care is required. Aontú is fully supportive of this approach.
INEQUALITY AND POVERTY
Notwithstanding the imperative of delivering non-elective healthcare solely on the basis of medical need, access still depends, to an unacceptable extent, on income, location whether urban or rural and health status. Those caught in a poverty trap or homeless, and frequently with the greatest need, all too often have the greatest difficulty in accessing care.
Voluntary organizations play a crucial role in providing support for individuals and families caught up in addiction. The scale and depth of Ireland’s addiction crisis – with all of its devastating consequences including the burden on our Healthcare system requires a much more proactive response by the state in supporting their work. New models, such as “Safety Net” established by GP Dr Austen O’Carroll, which delivers primary care to those most in need including those in hostels and on our streets, need to be developed.
There should not be a situation in Ireland where having more money allows a person to receive better care. In any context this is a two tier system. Private hospital care should not be better or quicker than public hospital care, or put differently; public healthcare should be at least as efficient, timely and experienced as private healthcare. This would mean that while a private system may exist, no person accessing the public system is at a disadvantage medically speaking for having less money. Anything less than this is facilitating a fundamental inequality.
USING ALL AVAILABLE CAPACITY
Aontú is committed to working to strengthen the Public system in the interest of fairness and equality of access. This will require more capacity not alone to “catch up” on previous under-investment but also to meet emerging needs.
Aontú also understand that what the public and healthcare staff want is less rhetoric and more realism and practicality. Building the Public system to the extent that Aontú believe is necessary now and even more so looking to the future is imperative. In the meantime, the overriding need is to use all available capacity, including private capacity, to meet the non-elective needs of our public patients. Funding for the National Treatment Purchase Fund (NTPF) should be front-loaded not randomly rationed year after year so as to eliminate the present unacceptable waiting times for public patients. Private hospitals must provide a full range of services on a 24/7 basis and commit to readmission of complicated patient care episodes where clinically necessary so that the burden does not fall back on the public system.
GOVERNANCE MANAGEMENT AND ACCOUNTABILITY
The governance and performance of the HSE is central to delivering the best quality, and most cost-effective care to patients and families. This requires a stronger system of oversight and accountability. This means ensuring that all Board appointments have relevant experience and operate within a culture that is robust in terms of risk management, at every level. We have seen the human costs of falling short.
In this context, the recommendations of the Scally Report must be resourced and implemented. Equally, line management is opaque and overly complex. It would be strengthened by more external recruitment. There is also a bureaucratic burden that needs to be addressed. Each government that introduces significant restructuring creates never ending change management. This invariably sees an increase in senior management posts with little effect on front line services.
Aontú will press for realistic funding for the HSE in terms of commitments set out in Service Plans. Systematic underfunding inevitably leads to so-called “overspending” – triggering a deeply negative bureaucratic process to correct the “overspend” and Supplementary Budgets. Proper accountability can only function in a realistic funding environment and in the absence of scapegoating by government.
Aontú also supports rolling, three year budgeting, based on multi annual projections to give greater certainty to service providers, to respond to emerging needs and to avoid damaging cutbacks in service provision. Many sections within the HSE only find out what their budget allocation will be on Budget day. This makes it impossible to plan in advance.
The National Children’s Hospital debacle is a prime example of the lack of accountability within both the health service and the political systems responsible for its oversight. The scale of the problems, the failure to identify and mitigate emerging pressures at a much earlier stage and the opportunity-cost of the overruns demonstrate just why healthcare is in broken and “reform” a recurrent failure.
There will, as usual, be numerous Committees investigating what happened and, as usual, there will likely be no consequences within the politico/policy process. Aontú have a very different perspective. We will hold staff, management and Ministers to account.
Aontú will press for the establishment of an, independent “Oversight and Risk Management” team, tasked with constantly monitoring for systemic problems in the Health service. This would help to minimize the possibility of events such as the Cervical Scan tragedy, with all of its harrowing consequences, arising and managing them effectively at a much earlier stage.
INFORMATION TECHNOLOGY AND COMMUNICATIONS
The HSE has not embraced Information Communications Technology (ICT) to the necessary levels. The Health Service needs to have the ability to manage all aspects of the delivery of healthcare in a digital environment. One of the oldest truisms of management is; what can’t be measured cannot be (effectively) managed, and this remains of compelling relevance to Healthcare. This includes staffing and administration, the digitising and transferability of patient records electronically across different domains and developing the capability to align to rapidly evolving E-medicine.
STAFF RETENTION AND RECRUITMENT
One of the many damaging consequences of austerity on our Healthcare system was the forced migration of thousands of health professionals. Nurses and midwives, doctors and medical consultants as well as allied health professionals were forced to emigrate. The effects are still evident on service provision, difficulties in retaining existing staff and attracting much needed consultant and specialist staff. There has been a breakdown of trust in relation to contractual arrangements, including the first strike by our nursing profession in more than a generation.
Aontú believes that rebuilding the health system requires rebuilding trust between government and the health professions. Implementing reform and increasing real productivity of the system necessitates engagement in good faith.
The health sector now operates internationally. To retain and recruit staff means competing internationally on pay and conditions and ensuring parity across equivalently qualified staff. The same government who claimed “inability to pay” presided over the biggest single financial overspend in the history of the state. If the government does not live up to its responsibilities then expensively trained staff will continue to be lost to countries only too willing to welcome them.
Aontú will therefore advocate for an independent national analysis to examine and report on all aspects of contractual arrangements between Government and healthcare professionals and their representative bodies. This will include training, retention, recruitment and capacity-building, and will encompass our health professionals working abroad. It will also seek views and insights as to how best to increase the productivity of the health system especially in the fields of risk management, ICT and innovation.