The Strategic Challenge: A People Centred Health Service

12 Mar 2002

Address by David Begg, General Secretary, Irish Congress of Trade Unions to The Office for Health Management Lecture Series Galway 12 March 2002

 

The Society of St Vincent de Paul published a pamphlet in April last year in which they identified a number of key facts about the Irish health system. We have:

  • The worst life expectancy in Europe at 65 for both men and women;
  • The second lowest life expectancy for women at 79 years;
  • Highest rate of premature death from coronary health disease in Europe;
  • The second worst death rate from Cancer in Europe for Irish women;
  • The lowest acute bed ratio in Europe;
  • 15 per cent of acute beds closed due to staff shortages;
  • 28,000 people on public hospital waiting lists at end of 2000;
  • 5 year waiting list for children's orthodontic treatment.

Correcting this depressing picture is the objective of the Government's Health Strategy. It is a formidable task, for the current state of affairs is a product of a long period of under investment which has only begun to be reversed in the last couple of years.

Congress supports the Health Strategy document for it is the culmination of a very serious consultative exercise in which we and our affiliated unions in the health sector participated. It can be said to represent the collective wisdom of the people who work in the various professions in the sector and the public who contributed their views. If we have doubts, they are related, not to the strategy, but to the political will to find the resources to underpin it and to the capacity of management to implement it. But I am quite certain from discussions I have had with people in the health service that there is much goodwill towards the strategy and everybody desperately wants it to succeed.

By common consent the state of the health service is a major political issue. Many believe that it will dominate the general election. It is a major political issue in other European countries as well, most notably in Britain. Relations there between the Labour Party and the trade unions are at an all time low because of statements made by the Prime Minister about "wreckers" in the health service trade unions. My opposite number as General Secretary of the TUC in Britain, John Monks, is the most moderate of men but he is incensed by what he considers to be Mr Blair's attempts to find scapegoats for his inability to improve the NHS. The ultimate judgement on the success of the Labour Government is likely to be based on whether they sort out the NHS or not. The health service, and in particular waiting lists, were also a crucial factor in the defeat of the Social Democratic Government in Denmark recently.

Very few people can afford to be agnostic about health care. It is something that affects every family at some stage. Because of its importance there is intense media interest in it. The Irish Times carried a series of very interesting articles about health services in other countries towards the end of last year. Tommie Gorman's decision to go public about his cancer treatment in Sweden made a fascinating TV programme. Not alone that, it also unleashed a ferocious public debate involving the consultants about the relative standards and qualities of private versus public provided health care. The BBC carried a full day of coverage of real life NHS hospital situations. In fact it made quite amusing television at times. There was one very funny moment when Sophie Raworth attempted to interview a patient in the Accident & Emergency Department of the Leicester Royal Infirmary. The trouble was that the poor chap was suffering from concussion and was not best placed to offer an analysis of the finer points of health policy.

Congress has to take a very broad perspective in the matter of health policy. On the one hand 80,000 union members are employed in these services and their interests are very important to us. On the other hand we also have to defend the interests of the bulk of our membership and their families who are users of the service. In truth there is no real dichotomy here because everybody who works in the service should want it to be of a high quality. I mention this point merely to establish that we represent both a provider and a user interest.

The Health Strategy is constructed on a platform of four principles, viz:

  • Equality and Fairness;
  • A People Centred Service;
  • Quality of Care;
  • Clear Accountability.

My brief this afternoon is to discuss the principle of people centred services although, in fact, the four principles are mutually re-inforcing and it is hard to talk about one without touching on the other. So, you will forgive me if I stray a little from my brief.

The report on the consultative process used in formulating the strategy published by the Department last month was most interesting particularly the insights offered by ordinary people who made submissions. The four most important aspects of the health service mentioned by the 1,500 people surveyed as part of the consultation process were:

 
 Positive %Negative %
Acute In-patient Care4555
Accident & Emergency1783
Community Care4456
Out Patient Clinics2575

 

While Accident & Emergency received a total of only 17 per cent positive mentions, the corresponding percentage for Acute In-patient Care was 45 per cent, suggesting that when people get into hospital they are relatively satisfied with the care they receive.

This would accord exactly with my personal experience.

The situation in Accident & Emergency appears to be getting worse instead of better. We saw on television a couple of weeks ago where Beaumont Hospital had 100 people on trolleys and had to close for two hours. It has reached a point where one would have a real fear about getting sick or injured.

As far as I can make out the problem is a combination of staff shortages and an insufficient supply of beds. According to research done by Miriam Wyley of the ESRI, the numbers of inpatient hospital beds decreased by 0.73 per cent between 1990 and 1999 while casualty attendances increased by 9.78 per cent.

The current action being taken by nurses is to try to get some improvement now in Accident & Emergency. There is a real and present crisis and there is so much strategising for the future that there is no engagement with the current problems. As one of the nurses' leaders put it to me "We know how many over 65's will need attention in 2005; what we don't know is how many will turn up in casualty this evening". The nurses feel that the Health Board Chief Executives do not want to focus on the immediate operational shortcomings of the health service or to engage with the unions to solve the problem.

I am absolutely certain unions do not want to be involved in this sort of protest. There is nothing in it for them but unless they try to force the issue there is no one else who can.

It also has to be understood that to speak of increasing the number of beds without considering the staff to service them means nothing. I am not saying that the plan does this. I accept that staffing increases are provided for but making that happen will not be easy. The plan provides actually for 10,000 extra nurses but creating the conditions to attract them into the health service must also be priority. There are 15,000 registered but non practising nurses in Ireland. We have to ask why they have not chosen to pursue a professional life.

Similarly there are significant vacancies for radiographers, physiotherapists and more or less the complete range of medical professionals. The availability of these people is to an extent dependent on the output of the Third Level Colleges. Towards the end of last year my own GP told me he had a letter from St Vincent's Hospital suspending x-rays for two weeks because of a shortage of radiographers. This is also a time sensitive issue. Even if all the right decisions are made now it will probably take 3 or 4 years to show an impact.

Concerns about the treatment of older people featured prominently in the consultation

The father of a friend of mine died after an illness lasting several months last year. It was a nightmare period for the family because the health service did not want anything to do with him. He needed 24-hour care and, even though there are 11 children in the family, it was an awful strain on them trying to look after him. But at least there was a big family. How that man would have fared in different circumstances is another question.

With changing demographic and changing social practices, care of the elderly is set to become an even bigger issue in health care. People are living longer but as they do their medical needs increase. Last Friday the Irish Health Foundation pointed out an example of this in that there are 80,000 people suffering from heart failure today but that by the end of the decade the figure is likely to be closer to 150,000 because of ageing. This is something which needs very careful management because apparently between 30 and 50 per cent of people have to return to hospital within 3 months of being discharged after having a heart attack. As people live longer more of them will fall within this category of vulnerability.

In the past it would have been easier to care for the elderly within the family structure. Usually the caring was done by a female relative. With increased female labour force participation this is more problematic. At the Lisbon Summit the EU target for female participation in the workforce was set at 60 per cent. In Ireland it is now 46 per cent but it will increase. Caring for both young and old will increasingly become an increasing social and economic issue for our country.

What I think we all want for our old age is maximum independence. We want to live at home as long as we can. It makes sense to try to provide as much care within the community as possible for elderly people, rather than having them go into nursing homes. Nursing homes are so expensive that many people cannot afford them anyway. Some cases like Alzheimer's Disease probably leave little option but to require residential care, but otherwise I think it should be the very last option. In fairness I think this is something which is accepted within the new Health Strategy.

The third aspect of health care that I would like to mention is cancer treatment. Here again I would cite the experience of a family friend from Sligo who developed breast cancer. She had to travel up to St Luke's every week for treatment. In practice it involved a three-day absence for a treatment that took just a few minutes. Her circumstances were complicated by trying to conceal her illness from her elderly mother whom she normally visited every day. In fairness nobody could design a health service to deal with complications of this nature. Nevertheless, this is real life for people and these complications arise whether we like it or not.

Life would have been so much easier for my friend if she could have accessed the radiography services closer to home. I know that it is now planned to have this service in Dublin, Cork and Galway which will improve matters a little, but not that much. I see that there is a big campaign to have a treatment centre in the South East. According to the local Health Board only 20 per cent of patients are getting radiography when best practices suggests 60 per cent should have it.

I understand the argument that centres of excellence are the best means of improving the quality of cancer treatment. But if you judge the issue by the criterion of people centredness then I do not see how you can be dogmatic about excellence. It seems to me that access to cancer treatment is at the core of the issue and it will decide whether the principles have meaning or whether they are just rhetoric.

It is difficult to think of a people centred health service separate from the issue of equity. Equity, in my opinion, is more than equal access.

People's socio economic background is the primary determinant of their risk of serious illness and premature death. The recent ESRI report "Critique of Shaping a Healthier Future: A strategy for effective health care in the 1990s" highlighted the importance of socio economic inequalities in Health. The report noted that research across a range of countries has consistently shown that "those at the bottom of the social class ladder have at least twice the risk of serious illness and premature death as those at the top."

The ESRI Report noted that in Ireland:

  • the unskilled manual group have about two and a half times the mortality rate of the professional group.
  • the unskilled manual group have about two and a half times the mortality rate of the professional group.
  • men at the top of the social class scale have rates of self reported chronic illness almost one third lower than men from the unskilled manual class.
  • the social gradient in health reflects material disadvantage and the effects of insecurity, anxiety and lack of social integration.
  • even in employment, continuing anxiety and lack of control over one's work situation, particularly when accompanied by chronic insecurity and low self-esteem can have powerful effects on the health of the individual, their social networks and their family.

The ESRI went on to point out that "understanding the scale and causes of health inequalities has major implications for the development of a new health strategy. Rather than seeing health policy as aimed solely as providing more/better health services and persuading individuals to adopt better health behaviours to reduce health inequalities health policy will also have to aim to create the right socio-economic structures and integrated communities for health."

These are matters of concern to Congress and the Government's Health Strategy will have to cover these as well as the need to resource, manage and deliver an equitable health service. Congress wants to see the development of a health system, including primary care, that ensures universal access to the health care required by the patient based on their medical needs.

In the matter of access to health services I doubt if there is anybody in the country who does not believe we have a two-tier health system. The study carried out by Miriam Wyley, which I referred to earlier, concluded that for each category of admissions, including planned (elective), emergency and day care, utilisation by private patients has been increasing at a faster rate compared with the utilisation by public patients. What is of particular interest is her finding that private patients account for close to 30 per cent of planned admissions, even though only around 20 per cent of acute inpatient hospital beds at the national level are supposed to be designated as private.

The new Health Strategy does contain specific measures focused solely on public provision and these are welcome. I have some doubt, however, about the efficacy of maintaining two waiting lists and holding the private list stationary if the rate of admission goes out of kilter with respect to the 80:20 ratio. I think this is an area that could be fraught with legal difficulties. At best you will get a situation where people will want to sign on for both lists.

Congress believes that the most effective way to get an immediate improvement in access would be to change medical card entitlement conditions. Without going into this in too much detail, most people will quickly see that children should be targeted. For a young working family €30 or €40 to see a GP, plus the same again perhaps for an antibiotic is a big hit on a family budget. Giving medical cards to children would be a very progressive step which we would urge on Government. It would be a complement to the child benefit increases which have been quite effective in helping to reduce absolute poverty.

We have discussed this issue of medical cards with the Minister and we anticipate that he will make some changes next year in line with the PPF Working Party recommendations. He has also instructed Health Boards to ensure social welfare increases in the last budget do not disqualify anybody previously entitled to a medical card.

I said at the outset that Congress supports the Health Strategy and our concern was related to whether the will and resources exist to make it a reality.

Achieving change in a large organisation is not easy. It is not easy in the UK and it will not be easy here.

It is implied from time to time that vested interests amongst the staff will frustrate implementation - that there is an Irish equivalent of Tony Blair's "wreckers". Let me try to take this head on. From what I have encountered in discussions with the individual unions I believe that everybody sincerely wants the strategy to work.

In my working life I have negotiated more change in the public sector than most. Of course it is not easy. Of course people will seek to protect earning levels and any other conditions of employment threatened by change. These things can be managed. What will derail implementation of change is management putting forward proposals which people on the ground know will not work. That type of thing undermines the credibility of the whole process and it is a more acute problem if levels of trust are low. Unfortunately, this is an area that the Minister does not have much control over. So much depends on the quality of management that this aspect cannot be overstated.

The involvement of the private sector in the NHS is a big political issue in the UK. For the most part I suspect that most people do not care who carries out their operation so long as it is done competently and quickly. Congress will not be taking any ideological stand to prevent waiting lists being shortened by greater levels of purchasing from the private sector.

What we would oppose, though, is using tax payers' money to build the capacity of the private sector through long-term public private partnerships relating to service provision. Any available investment from the Exchequer should be used to build the capacity of the public sector. The relationship between the public and the private sector must be carefully handled and fully transparent. As Wyley has again pointed out:

"It would also seem that there is capacity in the private hospital sector to provide such procedures (cataracts, hip replacements and vein ligations) as some of the funding from the waiting list initiative has been used by public health authorities to contract with private hospitals for the provision of waiting list procedures to public patients. What this, in turn, means is that the State is paying twice over for the provision of certain types of services. Previous research has shown that there is a substantial State subsidy for the provision of private care in public hospitals. Where private patients in a public hospital receive procedures for which there is a pubic waiting list, the State subsidies this care and may then provide funding for the purchase of these State procedures from the private hospital sector on behalf of public patients."

The second major impediment to implementation is of course funding. The ramshackle nature of areas of our health service today is the result of a long period of inadequate investment during the 1980s and early 1990s. Today we stand at a level of expenditure which is 6.8 per cent of GDP. It is the same as the UK but less than Germany at 10.3 per cent and France at 9.3 per cent. For those, by the way, who extol the virtues of US medicine as against European, it is interesting to note that according to the January 12th issue of "The Economist" the World Health Organisation rates France as the best of 191 countries. The US spends 13 per cent of its GDP - 3.7 per cent more - and comes 37th. Ireland ranked 19th in the survey. In real money terms Ireland ranks 10th in the European spending league. Germany, Luxembourg, The Netherlands, Denmark, Belgium and France all devoted over $2000 per capita, PPP to total health expenditure. The figure for Ireland was $1,534 PPP.

Having regard to the investment gap we have to make up and the differences in real money terms between ourselves and the better European performers we will have to spend a lot of money over the next few years. Professor John Fitzgerald of ESRI estimates that it will take 7 per cent of our national wealth each year for the next ten years to bring our total public services and infrastructure up to the level of the EU average.

Whether we can achieve this or not depends on our economic performance in the first instance. The downturn in the economy has had a marked effect on our public finances. From a strong surplus over the last few years the Department of Finance is now predicting a deficit for the next two years.

A lot depends on what growth levels we achieve. It would appear that 3.5 per cent would allow expansion in public spending of 9 or 10 per cent per annum. But if we managed 5 per cent growth then the available money could be quite respectable.

Although the level of public spending in Ireland has increased over the last couple of years it is increasing from a low base and stands at about 31 per cent of GDP. The EU average is 43 per cent. I recall Ken Clarke saying during last year's election for leader of the Tory Party that you cannot hope to provide reasonable quality public services for less than 40 per cent of GDP. If that is what a former Tory Chancellor thinks, then Charlie McCreevy still has a lot of headroom before his liberal economic credentials are called into question.

Finally, in this context, a word about national partnerships agreements. Over the last 15 years the financial side of these agreements have been structured on a wage/tax combination. I think the scope for that type of deal has more or less run out. The imperative to maintain social services means that we cannot continue indefinitely to erode the tax base of the economy. This fact will constitute a major challenge for the Government and Social Partners when we meet to consider a replacement for PPF next Autumn.

It is also important that in the election campaign political parties do not try to perpetuate the myth that you can simultaneously improve public services and reduce taxation.

In conclusion I would say I am optimistic about creating a health service which is people centred. The Minister enjoys a lot of public confidence. His bona fides are accepted and people want him to succeed.

While there is a lot of uncertainty in the economic sphere, made worse in the last few weeks by job losses, there are signs of recovery in the American economy. If it turns out that we have had a soft landing and can maintain near to full employment then there are very positive spin-offs for a much improved dependency ratio.

We do face new challenges in the field of health from an aging population. There are new challenges too from such things as increased obesity in children and teenagers which they try to correct by smoking. Heavy investment in the area of preventative health and health promotion could return long-term benefits. The good thing is that all these issues have been well analysed and there has been very extensive public engagement with the Health Strategy - of which this lecture series is an example.

If I had a final world of caution to offer the Minister it is this. All my experience of managing change has thought me that if you offer people a vision of a new future and then do not deliver it, this last position will be worse than the first. People will be totally demoralised. It is known to sociologists as the "Hawthorn Effect". Congress and our affiliated unions stand ready to help turn the vision into reality. It is in the interests of all workers and their families to make it so.