Frectally speaking

Further to our last post examining some of those key elements that make up the society and economy of Ireland with a focus on the most acute issue confronting in 21st Century Ireland, i.e. housing people… we now use the same principles to delve into another area that is often a cause for concern/discussion in Ireland, that is supporting the populations healthcare needs.

We’re going to look at the healthcare system using the same lens that we looked at last time around, based on an approach to refreshing our worldview by Kate Raworth and her “7 Ways to think like a 21st Century Economist“. Now if someone says that healthcare doesn’t have anything to do with economics, please think again. I may have had that view myself way back in medical school through lack of knowledge, but some years later I know that healthcare has plenty to do with the world of economics.

As a baseline, we make the point that healthcare delivery in Ireland is often hitting the headlines with a range of negative stories/concerns in the news. The ongoing criticism it receives reflects the pressure to meet expectations of what a modern healthcare system should deliver, while also posing a real challenge to morale at the frontline. To my mind the state of our healthcare system is another “canary in the mine” of a society and economy under pressure.

To give some context as to the extent of the problem across Irelands healthcare system, the single best way to explain/expose it is to point out that few countries in this developed part of the world have endured  the pain of a National Emergency Department Trolley Crisis for the best part of 20 years, with little/no progress to speak of , month after month, year after year. Why such a crisis, why so long, why unsolved you may ask? You may well ask and you’ll find the usual mix of people, process, information and technology issues that face healthcare across the globe that we have explored elsewhere…

If you look at any healthcare system you will see that they all are closely related to the politics of place, each system reflecting the culture within which they reside.. from the individualist “sort yourself out” of the US to the “free for all” of the UKs NHS. Does the national shame of a trolley crisis which has eluded the Irish healthcare system for at least a decade reflect poorly on the culture in Irish healthcare? Certainly it has frustrated the politicsl order for some time….

So in order to avoid the swings in policy/ decision making that have beset the Irish healthcare sector for a decade of more, within the last year the political machinery in Ireland has made an unprecedented effort to try to forge a new way forward.  If you want to get right up to date on the latest healthcare policy in Ireland, you can check out this latest 192 page tome released in May 2017, named the “Committee on the Future of Healthcare : Sláintecare Report“.

I’m not going to get into the nitty gritty detail of this report here, but simply to say this is historic stuff, ie it’s the first time that there has been cross party political consensus on the way forward for the healthcare systems in Ireland in my living memory and it’s a comprehensive plan for 10 years of reform, no matter what you/I may think of that detail.

Now all of this exploration is very timely, as cross party endorsed SlainteCare was approved in May 2017, with a clear implementation plan to begin in July 2017, which would suggest that it should feature strongly in the following budget, i.e. within last weeks in October 2017, aka “Budget 2018”.

So aside from the # 1 issue on housing that needed to be tackled, where does the key concern of healthcare reform (i.e. this newly minted SlainteCare plan) feature in the numbers?

The short answer is that Budget18 was not the one to bite the bullet of healthcare reform that is SlainteCare, i.e. in the Budget 18 Financial Statement Slaintecare did not get a single mention. So with one move, already the SlainteCare plan is in the territory of risking sitting on a shelf. So if such a key/historic opportunity/move towards healthcare reform has not been grasped… why so?

Why would such a key building block to addressing/improving that most sacred of efforts, healthcare, be put on hold or only implemented in part?
The answer, though those of us with a healthcare background may not wish to admit it, is that there is quite simply much more to a society/economy than just its healthcare system, therefore there is a limit to the % of spending that a nation wants to put towards its healthcare and the budget ask for SlainteCare was too much to swallow on this occasion. Fair enough you may say, based on the significant % of GDP that Ireland already spends on its healthcare systems…there needs to be a better return on that spend.

So let’s use this key juncture between political will for healthcare reform, yet financial constraints in doing so, to look at 4 key societal/economics elements from our 21st Century thinkers picture in Kate Raworth’s excellent Economics book and consider some of the key issues at stake more closely.

In brief summary , the key points/ideas here to move on affordable reform include;

The State which is essential- so make it accountable – professionals should lead reform/ state should commission care wisely
The Market, which is powerful , so embed it wisely – disclose & tackle conflicts of interest while harnessing the private sector
The Household, which is core, so value its contribution – have honest discussion with public about realistic medicine and allow them to support their own care
The Commons, which are creative, so unleash their potential – tap into the potential of collaboration and reuse in pharma and medtech sectors

The State

In this time for reflection more generally on the role of the nation state, I’ll begin by suggesting that surely one of key roles of the state is to care after its most vulnerable in society? ie the sick and injured, those in pain etc, those requiring emergency care for instance?
Well if so, how has the interminable Irish  ED trolley crisis shame be tolerated for so long?
There is no doubt that the ED is the “canary in the mine” highlighting the broader failings of the Irish healthcare system, fitting a pattern of healthcare usage that is being seen in EDs across the globe.  Sure, some of the issues in Ireland are down to those broader forces but given the level of funding into Irish healthcare (Ireland has a relatively high % spend on healthcare compared to our neighbours and the health budget is already the largest % of state spending per department) some issues must surely reflect the structure and governance of our healthcare system.

Who leads the state on healthcare is an interesting question right now. Our Taoiseach is a young qualified doctor with some interest in healthcare, our Minister is a younger hard working man making an effort to do the right thing amidst a political system fixated on the next year/two, he means well by promoting longer term thinking that is SlainteCare, he doesn’t quite have the money. The Department of Health is the civil service branch that oversees policy etc, while the unpopular Health Service Executive fulfils the vital role of health service delivery. Can they swing into SlainteCare reform mode without the extra money?

Which raises a question about who should be leading this reform anyway?

The vital medical, nursing and other allied healthcare professionals who make up the large  numbers and the essence of healthcare delivery on behalf of the state is the essence of public service as most of us know it. The health and care professionals are the ones at the coal face of the health service and under the intense pressure that goes with that. So how do they feel about the need for this SlainteCare reform?

To that we need to look to the professional leaders, their unions you may say. OK lets look at what they say.. there in lies an immediate issue, who represents the professional leaders of the health service, the doctors for instance? The IMO, NAGP, IHCA? You will quickly note the profession is somewhat split. You may also note that support for SlainteCare from these professional bodies is by no means clear, i.e. simply put, the Irish medical profession is not leading on the rollout of this cross political healthcare reform programme from the front.
Let’s consider why not by switching hats and looking at this challenge from another perspective, that of the market.

The Market

“The Market is powerful, so embed it wisely.”

If you are looking at the Irish healthcare “system”, it doesn’t take long to notice its unusual mix  that is the spread across 2 “systems”, the public and private healthcare systems. In clearer terms that can be explained as healthcare delivery spanning both the “state” (public sector) and the “market” (private sector). In fact is the split between the public & private sector and the wish to focus on reform and improvement of the public sector alone that is fundamental to the SlainteCare report/recommendations.

Ireland unusual healthcare mix involves many staff spanning public/private sectors which is an unusual arrangement in any sector and it’s this involvement across the public/private divide which is seen as a potentially problematic conflict of interest. In particular for those medical professionals whose practice involves public and private practice. i.e. what incentive do they have to improve the public healthcare services if that may impact on their private practice? Whether the staff involved do/don’t feel that conflict, such perceived conflict is an unspoken dimension of the healthcare system which would be intolerable in other industries.

Why has this split developed and what is the SlainteCare plan aiming to do about it?
To answer that it is helpful to understand some background history. Healthcare delivery a century ago was delivered largely by stand alone doctors whose practice some patients were able to pay for and some were not. When the state/public sector system then came along to take greater care of people and doctors became salaried, they were expected to ensure a set/minimum number of hours were set out to cater for their public patients and in their spare time they could see additional private patients, a perk of the job perhaps in some eyes, or a way to cater for extra demand in other eyes. To the modern day it is widely known facet of the Irish healthcare system that some of it is delivered by the state (public system) and some by the market  (private system). Many doctors practice on both sides of that fence. We know that the casemix in public settings is generally more varied and challenging than in the private sector. We also know that staff seem to find more frustrations working within the public sector, less so in the private sector. Human nature being human nature, and with no malice intended, one can see how and why a subtle but important conflict of interest emerges from the mix.

So the SlainteCare plan aims at uncoupling that conflict and focussing reform on the public provision of healthcare in Ireland, seeking to lessen the need for private healthcare, remove private healthcare out of the public healthcare facilities – thereby reducing the overall spend on healthcare, while making the system more equitable in terms of access & outcomes etc.

So let’s not dodge that difficult issue that is perhaps the elephant in the room with regards to SlainteCare. Let me state it clearly here, if the essence of the SlainteCare report is aimed at reforming and improving the public healthcare system, while quietly sidelining the role of private healthcare system in Ireland, what are the chances of those Irish medical professionals who span that divide leading the related changes required? In my own humble opinion, this key issue needs to be brought out and dealt with for real reform to happen.

State v Market in Irish Healthcare –  tackling the conflict..

Now thats out in the open, let’s quickly explore how this potential conflict could/should be avoided?

Though the range of alternatives were not within the scope of the SlainteCare report, there has always been/will always be a range of solutions/approaches to the provision of healthcare.

The range spans from state led and tax funded healthcare provision to market let and generally insurance funded healthcare provision on the other hand. We know Ireland has a problematic mix of both. We know that a move towards a market led/ universal insurance based provision of healthcare was dismissed here in recent years with the mishandling of UHI (Universal Health Insurance) push . On the move towards a universal service such as healthcare, there is one important perhaps interim option that needs to be more widely discussed and understood, which may be explained as the “commissioner/provider” split in the healthcare delivery.

To explain how this might work let me simply suggest that this state led universal healthcare Slaintecare model could morph towards;

1. state led and tax based funding model of healthcare.. where key services are commissioned by the state.
2. state provision and market provision of healthcare.. to fulfil those key service requirements set out by the state.

On the commissioning side… Ireland already has some of that mix in place, i.e. the structure that is the HSE was/is to be replaced by a form of Commissioning Body at least in some shape/form. The commissioning arm of the state healthcare service could/would be absolutely vital. Indeed if the essence of the State is to protect its citizens, if the provision of healthcare is vital to that, who should be accountable/for what?
It could be argued that the role of the State is as vital in the effective commissioning of the good quality healthcare as it is to the provision of quality healthcare.
If healthcare commissioning is understood and embraced it should lean heavily on the learnings from the NHS (warts and all), the key feature being that Primary Care Professionals are the key decision makers in how monies are spent in their area. The SlainteCare report already spells out the vital role of Primary Care/GPs for a sustainable healthcare service. It makes brief mention of commissioning, yet it doesn’t go far enough in my view to put GPs in charge of the commissioning of services in their area.

On the provision side… as Ireland already has self employed GPs and many healthcare staff working in private setting, hospitals etc. It strikes me that this capacity should be leveraged by the state rather than sidelined.
While the inherent conflict of interest in the present state would not go away any time soon, this could /should be managed by professionals being registering a public register of interests. They could/should clarify if their work involved;

• State side Public commissioning of healthcare services
• State side Public provision of healthcare services
• Market side Private provision of healthcare services.

Most of the medical professionals I know are highly motivated people who wish to do the right thing and do it properly. My view is that as healthcare reform is required that medical professionals should be leading that from the front.
Regarding the conflict of interest issue, some potential conflict across those lines is unavoidable, particularly in the short term, so should be openly disclosed. At the very least such open disclosure would encourage folk to better understand the relationship between the state and the market in Irish healthcare and allow all parties to work together to improve on that in line with the SlainteCare framework.

If these issues are not confronted proactively, I would suggest that attempts to actively implement SlainteCare without the active leadership of the medical profession here could/will spell trouble ahead.
If these issues are confronted and dealt with, I would suggest this is a rare opportunity to move towards a new approach to healthcare delivery in Ireland.. one that anyone enduring a long wait on an ED trolley would say is long overdue.

The HouseHold

Now from yet another angle, one of the key changes that is required in the Irish healthcare system and outlined in the SlainteCare report is a shift to place the patient at the centre of their healthcare. Going back in time we know that in the past family doctors were able to provide cradle to grave healthcare. Then over time came a shift to centralise care, delivered in hospital more often, with a specialisation of the medical profession and a more team based delivery of modern healthcare, to the point we are at today where patients often have to do deal with a wide range of healthcare professionals and often a somewhat disconnected patient journey through the system.

We now know and the SlainteCare report acknowledges that we need to integrate the delivery of care, around the patient, i.e. a big push to deliver Integrated Care. To do so will involve a shift from the paternalistic approach to healthcare that we have seen in the past, were patients are told what to do, towards a more engaged and collaborative approach between professional and patient, towards shared decision making etc.

Having worked in the National Health Service in England for many years and seen the fantastic service delivered free at the point of care, in particular my years as a Consultant in Emergency Medicine there, caring for patients from arrival to discharge in line with the 4 hour ED standard, it was a revelation in how good healthcare can be, yet the real related challenge to be sustainable for years on end. I say sustainable in that as good as we were able to provide emergency care in such a timely fashion, the EDs in the NHS became victims of their own success, with ever greater numbers of attendances year on year, pointing to what some folk explain as an insatiable level of demand for healthcare.

If you look internationally at models of healthcare provision you will see a wide range of differing models, from state led /tax based systems towards more market led/insurance based systems and a wide range in between. Of note from Singapore is an interesting approach, whereby the state provides a MediShield (aka catastrophy insurance (in case of car accident or cancer)) along with a MediSave (savings account) which encourages and empowers individuals to take greater interest in their health and care with a view to using it wisely, ie spent on the gym etc, though a degree of choice too (eg cosmetic surgery) but the point is the individual has to take responsibility for their health and care, thereby helping to reduce demand on healthcare services and control costs (Singapore spends <7% of their GDP on healthcare with some of the best outcomes internationally.

The Chief Medical Officer in Scotland has been lauded for her push towards what she calls “Realistic Medicine“. So lets flag up the need to have an honest conversation with the people of Ireland on what is realistic to expect from a health service and a related conversation with professionals to encourage a shift from a paternalistic approach to healthcare to empowering people to more actively engage in looking after their own health and care.

Aside from looking after ourselves, we need to consider the vital valuable role of carers. When we think of the economy and the role of “the household” it is often ignored, not appreciated. When calculating our GDP figures we count the work of men and women in factories and offices yet not in their homes? How come? Is the cost of caring for our unwell and elderly in healthcare buildings a significant cost? Certainly so. Is caring for our unwell and elderly in homes free of cost? Hardly. These issues are explored in thought provoking ways in Kate Raworth great book and worth again mentioning here. If we think the role of the household doesn’t count in economic terms and the “value of work” /or cost of caring depends on where its delivered and by whom, then for now its suffice to say we need to think again.

The Commons
The terms “the commons” is not one hear spoken/mentioned in Ireland much, and in our last discussion we explored potentially better use of the physical commons, in the last exploration of housing and land in Ireland, we now consider the “knowledge commons”.

If Ireland has a low level of discussion/understanding of the physical commons then for a “smart economy” it has equally another blindspot on the importance of the “knowledge commons” in the 21^st Century.

In the next post I will specifically look at the expansive knowledge economy aspect to the software sector of Ireland’s economy and the small profile that an open knowledge commons has here. In advance of doing so, let me tackle another elephant in the room that is worth exploring, the knowledge commons with regards to pharmaceutical & medical devices.

Bearing in mind that we need to contain costs in healthcare around the world and bearing in mind that most innovation in healthcare is done within/alongside the publicly funded healthcare systems there are many questions to be asked about the relationship between the pharmaceutical & medical devices industries and what they could learn from the open source world.

Considering that pharmaceutical & medical devices industry has become a hugely important employer, one should tread carefully here perhaps. As I do, let me first raise the question to you the reader as to whether you believe that;

1. the healthcare industry should be understood as an essential industry, which is needed to ensure a healthy population can go about leading happy and fulfilled lives… while the cost of healthcare could/should be contained to reasonable limits so other monies can be spent on housing, education, transport, etc etc
2. the healthcare industry could/should be understood as a very promising “growth industry” where the aging population of the planet means that industry provides an opportunity to chase a greater market share of the pie on offer, greater GDP growth etc.  http://www.irishexaminer.com/business/columnists/joe-gill/to-fix-health-we-have-to-treat-it-as-a-growth-industry-439635.html

If you have any doubt about a) and  think b) is the right answer, I sguggest you now go elsewhere. If on the other hand you think a) may be reasonable.. have you considered how much Ireland pays for its medications and/or medical devices?
Did you know that despite/because the pharmaceutical industry is such a powerful player in Irish industry that the Irish Healthcare service has an inordinately high pharmaceutical bill, low rates of generic drug prescribing etc?
Do we know the major cost of medical devices in use in Ireland? Internationally, the average doctor does not.
Is there an argument that innovations in healthcare should be made widely available at reasonable cost and to a global healthcare commons? I would argue so..
Does that mean that innovators and suppliers shouldn’t make good money and profit from their ideas? Certainly not. Does that mean that Big Pharma & Med Tech shareholders are more important than other healthcare stakeholders? I don’t think so.

While there will always be innovations at the frontiers, in pharmaceuticals/medical devices/other industries that will be well rewarded, the question for Irish healthcare, as elsewhere, is shouldn’t we be innovating ourselves and sharing our efforts and ideas in better ways?

Perhaps in days gone by when money was aplenty such profligate spending in these areas could be justified, but with a country so heavily in debt and an healthcare system would costs are so hard to control?

Here are 2 ideas to throw into the mix;

• Why doesn’t some Irish company use generic pharmaceutical formulations to produce and deliver the most commonly needed medications at a great value price across the nation. Did you know you can buy 16 Paracetamol for 20p? Check it Out. https://twitter.com/frectally/status/717283993025167360
• What’s stopping an Irish company setting out/using open sourced 3D designs for key medical devices that could be used worldwide. Why would anyone do that? Check this out. https://twitter.com/Channel4/status/910799342423957505

While Ireland has a history of dependency on Foreign Direct Investment in these areas, where are the Irish men and women in these sectors with some creative flair that want to change the world in new ways along these lines?

We will return to this theme, with a focus on a digital commons to revolutionise Irish healthcare in our next post.

So we have done our tour of duty, we have explored the Irish healthcare challenge and opportunities in new ways.

The SlainteCare Report of 2017 marks a historic opportunity to reform the Irish healthcare system.
It has some key strengths, other weaknesses, some opportunities and some gaps.
I believe that the Irish medical profession should seize the opportunity and embrace this chance for reform .

We need to improve our society and our economy.
In these challenging times of Brexit and Trumpit in 2017, the best way to do that is to look at the world in new ways, with affordable healthcare reform a noble case in point.
To sum up let me go back to the book where some of these new perspectives came from and repeat some of the key lines that may resonate, as we look forward.

The State which is essential- so make it accountable – professionals should lead reform/ state should commission wisely
The Market, which is powerful , so embed it wisely – disclose & tackle conflicts of interest while harnessing the private sector
The Household, which is core, so value its contribution – have honest discussion with public about realistic medicine and allow them to support their own care
The Commons, which are creative, so unleash their potential – tap into the potential of collaboration and reuse in pharma and medtech sectors