New Ireland: Building a better healthcare system for all

Battered and bruised, and tired beyond belief, the health service is crawling away from a Covid-19 world towards the promise of a post-pandemic future.

Better funded than before, due to the crisis of the past 18 months, it is also riding high in public esteem. If the British health service enjoyed its "NHS moment" when showered with praise during the London Olympics, the HSE is having a similar purple patch thanks to the selfless efforts of staff in providing care during the pandemic.

The immediate legacy from the pandemic includes longer waiting lists, disrupted services and staff burnout

But what kind of health system can we create from the ashes of the Covid-19 crisis (not to mention the cyberattack that has crippled the service since May)? What have we learned from the emergency we have been through and can these lessons be applied to future healthcare provision?

Money, as ever, is the first issue. Last year, an additional €4 billion was added to the health budget, half of it to deal with the costs of the virus and the other half for other needs. Should the current spending of €22 billion a year be trimmed back now that the worst of the crisis is over?

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Tánaiste Leo Varadkar has suggested health should hold on to the extra money permanently so the additional investment in staff and other resources can be maintained and built upon. This dovetails with the funding requirements of Sláintecare, the consensus plan for the future of the health service, but housing and other competing priorities for spending are already looming large for the Government.

“That is an incredible figure but it comes with a responsibility for Government to spend it well and make a difference in people’s lives,” says Prof Alan Irvine, dermatologist and president of the Irish Hospital Consultants Association. “You can’t have a million people on waiting lists and still be spending €22 billion, except maybe just for a year, until things are sorted.”

Community-based care

The immediate legacy from the pandemic includes longer waiting lists, disrupted services and staff burnout.

But there have been many positives too. The crisis forced many changes on the system – new collaborations between disciplines, closer working between public and private medicine, the use of technology to overcome barriers, the rapid enactment of legislation.

Almost overnight, GPs switched to electronic prescribing and started seeing patients remotely, online or by phone, in large numbers. From testing to mental health, there was a greater emphasis on delivering care where it was needed, not in hospitals.

The lack of a single patient identifier was sorely felt during the early stages of the crisis, and the recent cyberattack further exposed the system's technology shortcomings

While personal health consultations have resumed, the teleclinic is now established as an additional way to deliver care in many branches of medicine.

Laura Magahy, head of the Sláintecare programme implementation office, enumerates the lessons of the pandemic for the future of the health service. First, she says, it highlights the need for steering care away from hospitals, where the infection risk is greatest. Treatment of chronic conditions should be provided, as far as possible, in the community.

Second, the pandemic highlighted the importance of e-health. The lack of a single patient identifier was sorely felt during the early stages of the crisis, and the recent cyberattack further exposed the system’s technology shortcomings.

“The deficit in infrastructure was also apparent – too few ICU beds, too many multi-bed wards, a lack of good air, so that patients could be protected from other people in hospitals,” Magahy says. As a result, there is a new emphasis on elective hospitals and fast-turnaround day surgeries.

“The fourth lesson from Covid was that poorer communities have poor health outcomes. Hence, a focus on health communities, to target extra resources on those who need them most.”

Growing population

A bigger health service will be needed for a bigger population, one that is growing by 60,000 a year. Within a decade, there will be more people aged over 65 than under 14, with more care needs. There will be one million people aged over 65 and 100,000 over 80 – a third more than now.

GP and outgoing Medical Council president Dr Rita Doyle believes the focus on patients needs to change post-pandemic. "We've lost our way on this. We should be prioritising patients on the basis of medical need, not the ability to pay."

“And with so many delays and backlogs in the system, we need to prioritise the appointment of medical staff. We don’t have enough consultants or GPs, for instance. We need to train more doctors – and not for export – while offering training routes for non-EU doctors who are here.”

Existing GPs are “out the door” busy, with patients at times struggling to find a family doctor, she says. “I don’t know a single GP who isn’t overworked.”

With many patients putting off their medical appointments during the pandemic or having them cancelled, doctors are now seeing growing evidence of delayed care, Doyle says. What might have been minor procedures if treated promptly, have become more serious medical challenges for many.

Staffing issues

Central to the challenges faced by the health service are staffing issues, with many workers feeling underappreciated and overmanaged.

“Healthcare workers are members of society too. The broader societal impact of the pandemic affected them,” Irvine observes. “It has forced many to reassess what they are doing with their lives, what they want out of them, and what their work-life balance is.”

While other areas of society might move to a hybrid model, part working at home, this isn’t an option for many healthcare staff, he points out.

After a bruising 18 months tackling Covid-19, the health service in May suffered the crippling cyberattack on the HSE’s computer systems. “It hit us at a time when people were really tired, with some devoid of spark. We were just getting out of the pandemic and then, this. In some ways, the effect was even more profound,” says Irvine.

He foresees younger staff, who have been inhibited from travelling, now taking up the chance to work abroad. A significant exodus is predicted at the next rotation of medical staff in July.

The question now is whether the appetite for radical change really exists, and whether flesh can be put on the bones of the Sláintecare vision

“Others will want to work less, or take early retirement. At least some people will say ‘I’ve had enough of this’.”

Sláintecare, the 10-year plan agreed by the main political parties, aims to deliver care “in the right place, at the right time, and given by the right team”.

That means getting rid of waiting lists, more care in the community and the construction of elective hospitals in Dublin, Cork and Galway.

More controversially, it proposes a single-tier system, with the removal of private care from public hospitals. A lack of funding hampered early progress in the plan, which is now four years old. Thanks to the pandemic, much more funding may be available. The question now is whether the appetite for radical change really exists, and whether flesh can be put on the bones of the Sláintecare vision.

Public-only contract

The future of healthcare will be local, Irvine predicts. “The best solutions for something as complicated as the health system are devolved and delegated. There was far too much centralisation in the first decade of the HSE.We learned in the pandemic that some things worked well centrally – such as purchasing – but most work better locally. We have to let people in Kilkenny or Donegal pick their own solutions.”

A new public-only contract for consultants is proposed, with an annual salary of €250,000. But the draft of this document has met with a hostile reaction from consultants and aspiring consultants. Some critics in Ireland say they will leave, and those who are training abroad say they won't return.

As former HSE boss Tony O’Brien has written, the ferocious reaction to the new contract “is as much an unleashing of unresolved grievances as it is a reaction to the contract itself”.

The State needs to be brave, and show it by nationalising some of our hospitals

These grievances include a 2012 cut to the pay of new entrants and other attempts to reduce the salaries of high earners. The current row doesn’t augur well for the reform programme, but some doctors feel the Government should go further.

“The State needs to be brave, and show it by nationalising some of our hospitals,” says Dublin GP Dr Mark Murphy, who says too much health provision is “sandwiched” between private medicine and the offerings of voluntary groups.

While acknowledging that governance shortcomings in much of the public system need to be remedied, he argues healthcare works better when the State has a larger role than it has in Ireland.

“We’re not going to get out of the quagmire we’re in until we tackle a system that is dominated by charities on the one hand and the free market on the other.”

Universally accessible

In mental health, for example, he believes current structures militate against the creation of a single, universally accessible service.

In Murphy’s view, the private sector delivers “super-charged medicine” but general practice is the bulwark against overprescribing and overtreatment.

Yet in private hospitals scanners work seven days a week and up to 16 hours a day. At present a public patient could wait up to 12 months for an outpatient appointment, another six months for a test and then have to wait further for a procedure to be carried out. On a bad week, surgeons might find themselves with just half a day’s space in theatre in a week, due to staff shortages and other constraints.

Irvine believes the public sector will have to be expanded “a lot” if it is to replace the work done by private health. At present, he claims, the private health system “delivers more” than the public system, with, for example, a greater capacity for carrying out scans.

According to many doctors in the system, the solution lies in more beds, more consultants, more operating theatres and more access to diagnostics.

Doyle foresees a “dangerous” interim period on the way to the one-tier system envisioned in Sláintecare if private options are eliminated too quickly. “We have to be sure that patients get the care they need. The interim phase could be really dangerous, so we need to keep upping the public access all the time.”

CANCER: ‘Cancer mortality in Ireland will be negatively impacted – potentially for up to a decade’

Fear and uncertainty are common to patients experiencing a cancer diagnosis, but the brutal limitations on healthcare provision caused by the Covid-19 pandemic have exacerbated the suffering of patients living with cancer.

Worry of contracting infection in the healthcare setting, attending medical appointments without the support of a loved one and the isolation of critically unwell patients in hospital unable to receive visitors at their lowest point – this represents only a fraction of the added burden on our cancer patients. Much of this has gone unseen, carried with quiet dignity and sadness by our most vulnerable patients and their families.

The full impact of delayed cancer diagnoses due to patient reluctance and/or inability to seek care for new symptoms, the suspension of cancer screening and reduced access to specialist care will not be evident for several years. Already operating without spare capacity pre-pandemic, Ireland’s stressed healthcare system now faces the challenge of addressing current cancer cases and clearing the already substantial backlog. An estimated one million cancer cases have been missed across the EU since the start of the pandemic.

Covid-19 has disrupted cancer care and increased cancer-related suffering, even as cancer remained the leading cause of death in Ireland for both men and women in 2020

It is inevitable cancer mortality in Ireland will be negatively impacted – potentially for up to a decade, but this will not be felt equally across all socio-economic groups. The pandemic has exacerbated pre-existing inequities in healthcare provision, which must be addressed to avoid worsening the disparity in cancer outcomes between wealthy and poor.

We need to urgently build a more resilient comprehensive cancer care system, to restore the confidence of our patients in cancer health services and develop innovative care pathways across cancer prevention, screening, diagnosis, treatment and survivorship. This requires prioritisation of Covid-free cancer care pathways through upgrading of basic hospital infrastructure and equipment, integration of digital healthcare solutions with centralised real-time data collection, and addressing workforce deficiencies.

Cancer clinical trials and laboratory-based cancer research came to an abrupt halt last year; the progress lost in cancer research is in stark contrast to achievements in Covid-related research. Investment in cancer research is essential to deliver the solutions needed to improve cancer outcomes in Ireland over the next decade. Covid-19 has disrupted cancer care and increased cancer-related suffering, even as cancer remained the leading cause of death in Ireland for both men and women in 2020.

As the vaccination programme progresses and society reopens, we urgently need to tackle the shortfall in access to screening and diagnostic tests for cancer and facilitate integration of research into innovative cancer care.

Prof Maeve Lowery, oncologist and joint director of the Trinity St James’s Cancer Institute

INFECTIOUS DISEASES: ‘We need to teach and train people to self-test, and to take ownership of their care’

As an infectious disease doctor my view is that with infections where there is a large number of the population who are asymptomatic or pre-symptomatic you can never test enough – as with hepatitis B and C, HIV and chlamydia. And of course now SARS-CoV-2. And these infections can be tested with home kits. Imagine if we didn’t look for these infections.

As was said last year, it is important with a virus to be the hunter not the prey. With the most educated population ever in Ireland, we need to teach and train people to self-test, and to take ownership of their care. We also need to move from our hospital-centric system to a community-based provision of care.

Anyway, I believe we are on a road to a better place. I think that a good piece would be to see how we prepare for autumn and winter now – to see what should be in place as we can expect other respiratory viruses to start circulating.

Prof Mary Horgan, infectious diseases consultant and president of the Royal College of Physicians of Ireland

OBSTETRICS: ‘The provision of large centralised clinics may not be the future'

Maternity services
Maternity services continued unabated during the pandemic, despite poor infrastructure in many areas and one of the lowest specialist to consultant numbers in the OECD. The pandemic exposed the narrow corridors and overcrowded outpatient clinics in use, which in the presence of an airborne easily transmissible virus was frightening to staff and women attending.

Despite this, there were few cases. Wards with multiple adjacent beds close together were previously inadequate for privacy; now they are unacceptable for infection control. New facilities are on the wish list before the next pandemic. The provision of large centralised clinics may not be the future.

The pandemic has taken its toll and many specialist frontline staff are reviewing their career options. Non-consultant doctors are also reflecting on a career with the highest litigation risk, unsocial hours and legislation which provides for criminal conviction in some areas. The recent Sláintecare contract does not seek to retain these highly trained and motivated doctors. Senior consultants worry about what this means for the future of services and impact on training.

Gynaecology
Gynaecology care suffered with many elective clinics and surgeries cancelled. To the HSE's credit, arrangements were made to continue cancer surgeries in private hospitals and, in gynae-oncology, this initiative was so successful that waiting times for surgery actually decreased for some units.

Abortion care could have been vulnerable in 2020 but HSE support ensured no services were cut. Travel restrictions out of Ireland added to urgency and unfortunately regional inequality and the three-day wait were added barriers. We continue to have abortion care provided by a moderate number of GPs in the community and a very small number of conscientiously committed cases in the hospitals. Obstruction and disinterest in provision will need to be overcome at local level.

Vaccination
The response of the HSE and the workforce was focused and agile with a low number of pregnant women affected by Covid and no mortalities. Vaccination was rolled out rapidly this year not far behind the US and UK. Autonomy and choice in pregnancy as a precept was, I think, crucial. We are not yet in a position where vaccination status and birth outcomes can be compared. Electronic health records should facilitate this and it could be a goal for future new vaccination programmes.

Dr Cliona Murphy, chairwoman of the Institute of Obstetricians and Gynaecologists