Prevention better than cure if service is to make ends meet
SECOND OPINION:The EU-IMF-ECB troika insists that the Government stay within the 2013 health budget of €13.6 billion and also make savings of €780 million. This is not going to happen while the Irish health services are demand-led. Unless the budget (input) is matched to services (output) which focus on results (outcomes), taxpayers will continue to face inevitable overspending.
Demand for health services has increased dramatically and the budget will never be enough unless there is less demand, which means keeping people well and out of hospital.
During the boom times only a tiny fraction of the HSE budget was spent on promoting health and preventing illness. And now, when it is more important than ever to save money, there is even less emphasis on wellbeing. The new policy, Your Health is Your Wealth: a policy framework for a healthier Ireland 2012-2020, promised in late 2011, has still not been published.
Budget 2013 could have been used as an opportunity to reorient health services towards prevention and it failed dismally: no sugar taxes, no fat taxes, and a miserable 10 cent on cigarettes and a pint of beer.
The health allocation announcement did not even refer to keeping people well. In the same week as the budget, the Economic and Social Research Institute (ESRI) published the report Work and Poverty in Ireland, which showed that unemployment now is more than double the rate in other EU countries.
Jobless adults are less likely to live with other working adults and more likely to live with children. Unemployment is strongly associated with poverty and deprivation which, in turn, is linked to ill health and chronic disease.
Chronic disease is also linked to smoking, poor diet, excessive alcohol use and low levels of physical activity. A 2012 King’s Fund, London, report, Clustering of Unhealthy Behaviours over time: implications for policy and practice, shows that poor people are five times more likely to engage in all four risk behaviours than those in higher socioeconomic groups.
This perfect storm of joblessness, poverty, health behaviour and public policy that focuses on illness services, not wellbeing, will increase demand for services exponentially.
The HSE has an impossible task when it tries to make ends meet. Between 2005 and 2012 the number of people with medical cards nearly doubled, from just over one million in 2005 to 1.8 million in 2012. Acute hospitals did more procedures in 2012 than last year, with 22,000 more emergency admissions, 40,000 more inpatients and 43,000 more day cases.
Community services are also experiencing massively increased demand with 54,000 more people on long-term illness schemes since 2011 and drug repayments for a million extra prescription items.
Under the medical card scheme a staggering 61.5 million items were prescribed in 2012. Although people need to be using fewer antibiotics, consumption has actually increased in hospital and community settings.
Health spending is tightly controlled but controls are the wrong ones: equivalent to training racehorses using ploughing harnesses. We know everything about on what, where and when the money is being spent. But almost nothing about the how and why. Is best practice used in every service? Who knows?
Health promotion solutions to people’s problems, such as haemorrhoids or type 2 diabetes, are hardly ever considered. Very detailed reports are produced every month on spending, activity and staffing levels, categorised by acute hospital and community level services.
These reports are silent about outcomes and better health, which is the whole purpose of having a health service. The ESRI also collects detailed information and the report, Activity in Acute Public Hospitals in Ireland 2011, sorts the 1.4 million day and inpatients into their respective diagnostic category.
This report says nothing about outcomes or that about half of the diseases and disorders treated in hospitals can be prevented. Almost €14 billion was spent on health services in 2012 and no one has any idea if this has produced better health.
The good news is that the Health Information and Quality Authority is beginning a series of health technology assessments which will identify the effectiveness of high-volume scheduled surgical procedures, such as tonsillectomies and varicose vein operations.
There was a huge increase in these operations in 2012 and the HSE needs to know if people are having unnecessary procedures.
The recession may finally bring about what should have been done since the 1970s: promote health, prevent disease and keep people out of hospital.
Dr JACKY JONESis a former HSE regional manager of health promotion