Frectally speaking

Having attended the Health Reform Alliance launch event in Dublin earlier in May and aware of the timely announcement of a 10 year cross party plan for Healthcare… I thought it would be useful to share some ideas on the future of healthcare in Ireland.

To begin, its worth a few words about the broader issues of governance and politics in Ireland.
As Ireland is recognised as being very globally connected, so the politics here is now influenced by a range of ideas, from Birmingham to Boston and to Berlin. The Irish are acknowledged to be a fairly worldly aware, reasonably patient yet industrious lot …. a moderate people. Still less than a century old as an independent nation, the politics here may have swung left and right over the last decades but at this stage the politics here is probably described as fairly centrist..  perhaps a little more centre left/centre right depending on your point of view.

From a healthcare perspective, in common with many other “western” countries, Ireland has a health system that has been on the edge of crisis for a long time now. In many respects the well known symptom of this malaise which is the perpetual Emergency Department trolley crisis in Ireland reflects a wider global issue of “healthcare under pressure”, yet there some particular issues local to Ireland seem to have held meaningful progress back.

One particular issue that gets a lot of attention/criticism is the “2-tier” nature of the Irish health service, that mixes public and private provision, with differing experiences and outcomes based on ones ability to pay. Other dimensions that have been at play has been the close relationship between church and state in the historical delivery of healthcare, plus the relative immaturity of the primary care sector alongside the more established hospital sector.

A very brief/rough guide to the history of Irish healthcare

Over the life time of the Irish nation , a national health service grew out of local GPs and hospitals to being coordinated at a regional health board level, to then the establishment of a national Health Service Executive (HSE). As healthcare is a complex adaptive system, delivering healthcare at a national level is a highly complex endeavour. So along with every other western healthcare system the challenge of scaling and maintaining high quality, low risk, timely, cost effective healthcare has not yet been met. As the public’s awareness and understanding of these issues has grown, so too has dissatisfaction with the HSE which for a time became a bit of a public punchbag. While many people know that pockets of excellence exist throughout the system, the ongoing public narrative involves the pockets of crisis.

While there has always been a blend of public and private provision of healthcare in Ireland, over the decades that mounting pressure on the public healthcare system has led to an increasing percentage of the population taking out private insurance, essentially aimed at safe guarding their healthcare. The take up of health insurance in Ireland had reached up to 50.9%  before financial crash, yet despite that crash and related recession that figure never fell far below 40% and is back at 45.9%which indicates how dearly it is being held onto.…”for dear life”..

As the public healthcare system has lurched through a series of crises and in the context of that high uptake of health insurance, the last government made an attempt towards healthcare reform with a move towards a Universal Health Insurance (UHI) model, based on a European model of healthcare (the Netherlands to be precise). However well intention-ed this push was, the details of its delivery were never made clear enough, it was essentially poorly handled from a public communications perspective and quickly fell out of favour with the political establishment.  Since the end of the Universal Health Insurance push in the last 2 years there again been a move in the public discussion, a swing back to the merits of return back to a tax based approach to healthcare funding… though little discussion on the pros/cons.. or how that might fit within a particularly Irish context.

Post crash Irish politics has mobilised the public in a manner not seen in Irish politics for some time. Yet while folk have come together onto the streets about water bills, the need for healthcare reform has not progressed as a public movement for change in any meaningful manner. Perhaps this can be explained by the complex nature of healthcare reform and the challenge in aligning the effort and energy of the many agendas involved.

Engaging the nation on the road to (healthcare) reform?

5 noble principles to aim for

So how can this need and appetite for change in Irish healthcare be directed to engage the public and politicians alike? The Health Reform Alliance are gathering a diverse group of stakeholders from the bottom up and are keen to get public opinion behind this common cause. A first glance at their 5 key principles suggest a very good effort, a short and punchy attempt to focus the mind of these important issues . Yet the gap between policy aspiration and reform reality will always be hard to bridge, so let’s take a quick look and then delve a little. Here are the 5 key candidate principles of Healthcare Reform Alliance in Ireland.

1. The health and social care system treats everyone equally.
2. The health and social care system is focused on the needs of all social groups in society.
3. People have an entitlement to health and social care, free at the point of access.
4. The different elements of the health and social care system work together and are connected.
5. The health and social care system is a universal, publicly funded system

Short and punchy, they are noble ambitions and should help focus minds and actions.

2 Challenges to be confronted

Yet can these noble ambitions translate into actions? There are 2 issues I sense need to be tackled early on here to get this right for an Irish context.

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Firstly and most importantly perhaps , “People have an entitlement to health and social care, free at the point of access”.
With a background of 15+ years in emergency medicine in the NHS, I like the idea of course, its very noble indeed. Yet to be blunt we all (doctors and others) now need to challenge the notion that all forms of healthcare can be delivered to everyone, all of the time, for free. Its not that its the wrong motive, its simply that those of us that live on this planet need to accept we are a planet with limited resources, so like it or not we cannot spend everything on healthcare. I say that simply to acknowledge that housing and education and transport and other public services are needed to, so we need to have some limit on healthcare spending. We also need to acknowledge that there is an insatiable appetite for healthcare if we all think we can live forever, which we can not. So between public demand and professional services we need to make clear that healthcare can and should be delivered very well, but there are limits to what can and should be done in the name of healthcare.
Therefore, though it may be a bit unpopular to say so (?) , along with the peoples entitlement to health and social care, we need to make clear a related responsibility.. particularly for people to take greater responsibility for managing their own health… by managing their diet, exercise etc etc. In doing so we can and should empower people to take more control of their own healthcare too.
Now to be clear, my view is that if people are unwell or injured, they should of course have an entitlement to quality, timely health and social care, regardless of their ability to pay. Beyond that they have a responsibility to look after their own health too. More on how these issues can be addressed shortly below..
Of course this issue isn’t local to just the Irish setting , these is universal truth which needs to be declared more openly, so patients, doctors and politicians can have a more honest and frank discussion on how to deliver good quality, timely healthcare from a fair % of a nations monies. That is the only sustainable future for healthcare.

Secondly, “The health and social care system is a universal, publicly funded system”.
Once again with a background of 15+ years in emergency medicine in the NHS, I’d happily agree to same. Yet in an Irish context, given the Boston to Berlin dimension, this risks being particularly divisive I fear. What this principle doesn’t acknowledge is the 40+% of those people who have private health insurance, for the reasonable reasons we noted earlier. Nor does it factor in the private healthcare providers that are already a significant feature of the admittedly 2 tier Irish healthcare service. So my instinct is the noble aim here needs to be teased out alongside an option to achieve that in the Irish setting, more on this below…

2 ideas from abroad

So…. while these 5 principles are a really great start towards healthcare reform in Ireland, I’m now going to quickly introduce 2 other axes to this discussion, which I sense may be key to resolving the gap between aspiration and actual implementation here.  These 2 key aspects to healthcare policy debate are ones I’ve picked up from my understanding of other healthcare systems in both the UK & Singapore. There are many others axes one could explore, but to keep this discussion focussed I’m introducing just these 2.

Commissioning and Provision – recent moves within the NHS

In the NHS in England, as the UK began to grow a world leading National Health Service, the primary care physicians (General Practitioners/GPs) began to take on a crucial role responsible for their patients health from patient to grave. Their strength in primary care is widely acknowledged to be a strength within the system, the antithesis to the (specialist led and therefore more fragmented and costly) US Healthcare system. In recent decades their power and influence has increased with the advent of “GP fund holding” in the 1990s and since then the split between the commissioning and the provision of healthcare.

The key issue here is that GPs now lead Clinical Commissioning Groups and as GPs are well placed to take a holistic view of their populations needs and commission health and care services on their behalf. Most of those services will be provided by public providers (e.g. NHS trusts and local authorities) though others services are provided by the private sector. The patients involved don’t necessary want or need to know about this split, but as far as they are concerned their care is taken care of by the NHS. So you have in effect a universal/egalitarian healthcare system with a mix of public and private provision, well regarded with good outcomes in many areas for about an 8% spend on their GDP.

Translated to an Irish setting one can see that if a universal health insurance model doesn’t hold up, that commissioning from the public purse might be the only other option? In doing so it could help ensure principles around quality, timely and equal access for serious illness and injury are built into that process…while a mix of public and private provision deliver the health and social care required.

Healthcare Rights and Responsibilities- lessons from Singapore

Over on the other side of the world, if we look at Singapore we look at another interesting approach to healthcare. Singapore city state story also took off after the second world war, under the benevolent but firm hand of Mr Lee. Their healthcare system which provides good outcomes for about 6 % of their GDP is another interesting approach.

The most interesting dimension here is the split between rights and responsibilities. As an emergency physician I’m an advocate of an egalitarian system, that treats based on clinical need rather than ones ability to pay, to ensure a basic human right to quality timely healthcare.

The Singaporean approach  takes an interesting twist on that universal right. Its offers universal healthcare to all those who suffer in a form of “catastrophe” insurance (e.g if affected by a car accident or cancer) known as MediShield so no one is left to suffer needlessly or financially.

Along with that right to healthcare is a related responsibility.. via a compulsory medical savings account known as MediSave.. so that citizens understand they need to spend that money wisely on looking after their health.. My understanding is that can be spent on going the gym, a health check-up or an elective procedure perhaps, which gives the patient a good degree of choice in how their personal budget is spent.

Translated to an Irish context this may equate to universal healthcare protection to all those who suffer a “catastrophe”, i.e. serious illness/injury in the public healthcare system. Alongside that by re-imagining private health insurance as a health and social care savings account, with state subsidy for those who cannot afford it, citizens are encouraged and empowered to get more involved in the looking after their own health and care. The key here is to shift the emphasis to preventative health care measures, underpinned by good primary care, which might also be supplemented by the private sector for beneficial elective investigations, procedures etc..

My instinct is these 2 key axes, the split between the Commissioning/Provision of Healthcare and clear healthcare Rights/Responsibility are key to the future of the Irish Healthcare system.

5 Fair Principles to action?  
Now that we have outlined the 5 Health Reform Alliance principles and highlighted some challenges that can be expected, lets look at those 5 key principles with some related modifications to see if they hold up/seem reasonable/may help with the important debate needed in this area.

So here are the Health Reform Alliance five principles that underpin their Charter for reform of the Irish health & social care system, with some small but hopefully useful tweaks..

1 The health and social care system treats everyone equally

2 The health and social care system is focused on the needs of all social groups in society

3 People who are unwell/injured have an entitlement to quality health and social care, with a related responsibility to look after their own health while they are well.

4 The different elements of the health and social care system work together and are connected

5 The health and social care system offers universal, publicly funded, health and care protection to citizens, alongside a health and care savings scheme to incentivise better population health.

To discuss….

Related Links

Health Reform Alliance
http://healthreformalliance.ie/wordpress/

NHS Commissioning
https://www.england.nhs.uk/commissioning/

Affordable Excellence : The Singapore Health Care System
http://www.brookings.edu/research/books/2013/affordableexcellence