Minister for Health James Reilly has repeated his pre-election promise to solve the waiting list crisis within three years. What are the chances, asks our health correspondent EITHNE DONNELLAN
IN RECENT YEARS there have been several efforts to tackle hospital waiting lists. First there was the Waiting List Initiative. It had some success in reducing the percentage of adults waiting more than 12 months and children waiting more than six months for treatment but it also had serious weaknesses.
An examination of spending on the initiative from 1998 to 2002 by the then comptroller and auditor general, John Purcell, found that while the €172 million was supposed to be ring-fenced for patients waiting longest in a number of target specialities, it had become part of core hospital funding. Almost half the money allocated to health boards under the scheme in 2002 was spent employing staff, leaving thousands waiting to be admitted to hospital for surgery, some for many years.
It was replaced by the National Treatment Purchase Fund (NTPF). While it was the brainchild of the Progressive Democrats, it began its work within months of Fianna Fáil being returned to power in the 2002 general election having promised to bring an end to waiting lists within two years.
The fund’s first job was to remove from the lists those who had been waiting the longest. This included those waiting eight years for straightforward procedures such as hip operations, cataract removal and hernia repair.
By the end of last year, 200,000 people had been removed from the list at a cost of €598 million. It did so by buying private treatment for them, initially both at home and abroad.
While the latest figures indicate there are still more than 25,000 adults and children waiting more than three months for inpatient treatment, the NTPF says waiting times rather than numbers waiting are the key. Last December, the median waiting time for public patients seeking operations was down to 2.4 months.
But for those referred by a GP to a specialist in the outpatients’ department of a hospital, it’s an entirely different story. That can take years.
The Health Service Executive (HSE) has refused to release data under the Freedom of Information Act on outpatient waiting lists at its hospitals but the head of the NTPF told a conference in March he understood there were about 200,000 people waiting for outpatient appointments, some for up to five years. Last month the HSE West confirmed that 27,344 patients were on the outpatient waiting list at University Hospital Galway and a further 7,455 were on outpatient waiting lists for Merlin Park University Hospital in the city.
The Minister for Health, James Reilly, has now promised to tackle these waiting lists, as well as waiting times in hospital emergency departments, within three years. His predecessor, Mary Harney, also promised to tackle the waiting times in emergency departments with her 10 point plan. But the problem persists, despite the plan and a taskforce report on what is needed to be done to solve the problem.
Dr Reilly’s answer is another waiting list initiative: the Special Delivery Unit (SDU). It will raid the kitty of the NTPF initially to target waiting times in emergency departments as Dr Reilly doesn’t want his pledge that we will never again see 569 patients on trolleys – as there were when the crisis peaked in January – to come back to haunt him.
If the NTPF coffers are raided – it had a budget of just over €85 million this year and it’s understood about €45 million of this is already spent or committed to patient care – will it not just result in waiting lists getting longer?
Dr Reilly admits it could in the short term but insists his SDU, which is modelled on a similar programme in Northern Ireland, will work where other such initiatives have failed.
Some say his plan is to throw money at problem emergency departments, which will send out the wrong message to those that have improved, and that he will destroy years of effort by the NTPF to get hospitals to refer patients to it. But Dr Reilly, who has always been critical of the NTPF, will be happy to see the back of it. For the moment it will continue to treat patients it committed to working with three months previously, until the new head of the SDU, Dr Martin Connor, has drawn up a plan to reduce waiting lists. This plan is expected by September.
Information about how the SDU will go about its work is vague at this point. What is known is it will not be getting additional Exchequer funding, even though when a similar unit was set up in the North money was thrown at it.
In the rush to have it established within the Government’s first 100 days in office, as promised, much of the detail about how it will operate and use the resources of the NTPF, including its staff, has yet to be worked out.
In his first day on the job, Dr Connor, who is on a six-month contract worth €250,000 which includes a salary of €90,000 and funding to commission research, said it was possible to make significant improvements even at a time of constrained resources by doing things differently.
So is the SDU a good idea and can it make a bigger impact than the NTPF? Or is this just a new name over the NTPF door?
Charles Normand, Edward Kennedy professor of Health Policy Management at Trinity College Dublin, said it should be possible for the SDU to treat more patients for less. The NTPF was pretty successful at reducing inpatient waiting lists but “at quite a high cost”, he said. “Clearly it has advantages over the NTPF in that the NTPF’s job was essentially to buy from the private sector to plug gaps and this is meant to be . . . looking at other ways of reducing the waiting lists and waiting times as well,” he said.
A special initiative of any sort should only last a certain length of time, he said. “It’s typical for it to lose its effectiveness as time goes on, but also it begins to put the wrong kinds of incentives in place. If you take the case of the NTPF . . . it took pressure off the hospitals, because if they failed to bring down waiting times then somebody else would go and do it for them,” he said.
“These sorts of mechanisms can be used to sort out an acute problem but what you need for a long-term sustainable system that does not build up waiting lists involves looking very carefully at all the processes. You have to get the main providers to stop the problem re-emerging.”
Between 2005 and 2008, Dr Connor led a similar initiative when he was a special adviser in the department of health in Northern Ireland. When he was launching the SDU last week, Dr Reilly pointed out that Dr Connor got 57,000 patients off waiting lists in 18 months at a cost of £36 million (€41 million).
The hospitals were warned they would be fined if they couldn’t treat patients on waiting lists within strict timescales. Money would be withdrawn and the patient offered treatment in another hospital, possibly in the Republic.
The result was waiting lists were reduced dramatically, but now they have climbed back up again. The total number of patients waiting to be admitted to hospitals in Northern Ireland at the end of March stood at 52,880, up 16,839 on a year earlier and higher than figures produced in March 2005 when they stood at 49,250.
A further 106,000 patients were awaiting first outpatient appointments at the end of last March, some 19,726 more than at the end March 2010.
While politicians in the North have blamed cutbacks for the rise in waiting lists, Dr Connor didn’t wish to comment on why they had rocketed again if SDUs were so successful. Dr Reilly said it happened because Dr Connor had not been there for some time, there had been a change of health minister, and underlying reforms were not undertaken. “We don’t intend to repeat that error here,” he said.
Prof Normand said the North faced very significant cuts, especially hospitals in the Belfast area, and this was a factor in addition to the SDU initiative running out of steam. “The long-term solution is not new initiatives. It’s to have a system in place that tries to avoid the problem arising in the first place,” he said.
This will be the key to the success or failure of Dr Reilly’s SDU. Will he be able to ensure hospitals have proper processes and management systems in place that ensure the discharge of patients is not delayed thus freeing up beds for patients on waiting lists and those on trolleys in emergency departments?
At a time when the number of delayed discharge patients is running at more than 600 and growing as a result of the crisis in funding for the Fair Deal scheme this could be difficult.
More people are cancelling private health insurance, which could lead to more pressure on public hospital waiting lists. The HSE is already running a deficit of about €117 million for the first three months of the year, suggesting further cuts in services will be necessary, including the usual round of theatre closures, which could lengthen waiting lists further. And health budgets are likely to be cut further in the coming years.
While everyone wishes Dr Reilly luck in solving the crisis, it is an extraordinarily difficult, if not impossible, task.
There are still more than 25,000 adults and children waiting more than three months for inpatient treatment