An "Irish NHS" - what needs to change?

trixi001

Pandiculation wrote: »

I had the discussion about the centralised health data system, which was being much lauded in Denmark during the vaccine rollout, and I found a lot of people wouldn’t be all that comfortable with such a system, despite its usefulness.

If you could imagine all your health data, possibly including very personal details about physical health, mental health and potentially social worker type information all being held in a state database, probably linked to your PPSN.

Personally, I wouldn’t be at all comfortably with that.

I could see a role for limited, efficient data interchange for things like records flying back and forth between a consultant and your GP, medical imaging etc but a big huge treasure trove of information on single database is always a data breach or misuse waiting to happen be it through malicious use or function creep.

I prefer data to be shared only when needed and to be largely within the control of the person to whom it relates.

]

The Data on each person isn't actually on a single database in the North, the GP's have a database, A&E another etc, but each organisation has access to the other organisations database..

It's a system that generally works well, so if your GP is waiting for your scan results, he can log into the hospitals database and see if they are in yet etc, but at the same time your data is more secure, and you are only allowed to check someones data on a different server if you have a genuine need too, and logs are maintained of who has accessed it

Note: As far as i am aware this system is unique to the HSC in the North within the wider NHS (or at least it was at the time)

atilladehun

Geuze wrote: »

Is it helpful to separate financing from provision of healthcare?

While I think everybody should have access to h/c, and the State should regulate that, I don't think the State should provide all h/c.

Is there an example worldwide where a move like that isn't the thin end of the wedge. Start putting in external bodies, they start edging up the prices.

One of the things missed regarding the United States is that even with their hugely privatised system that cripples families all the time their government spends a higher % of GDP on health care than nearly every other country. Privatising has benefited only the wealthy.

jimmycrackcorm

BrianD3 wrote:

Unions are a factor but it is too simplistic to continually point at them. With such fundamental and long standing problems, it may be the case that some of the unions are keeping the system from collapsing entirely by forcing some structure to the mess. Without unions would we see situations along the lines of nurses being dragged away from their jobs to do the work of porters because "the porter is sick and we've got nobody to cover for him", in effect bailing out management.

The unions are the number one blocker as they make the system impossible to reform. That's why the HSE didn't get rid of duplicate administration functions when it was amalgamated from the health boards.

Geuze

atilladehun wrote: »

Is there an example worldwide where a move like that isn't the thin end of the wedge. Start putting in external bodies, they start edging up the prices.

One of the things missed regarding the United States is that even with their hugely privatised system that cripples families all the time their government spends a higher % of GDP on health care than nearly every other country. Privatising has benefited only the wealthy.

French and German systems have a mix of providers, AFAIK, but everybody has insurance.

Stovepipe

People here won't even pay for water ffs. They think clean drinking water magically arrives from the reservoir to their taps courtesy of nature.

Untrue. We all pay for water if we pay road tax as part of the national road tax fund has been diverted to pay local councils to maintain the existing water services. It was one of the main planks of the water objecters, as it effectively meant water taxation on the double. Apart from that,a significant amount of the population use wells or are in private water schemes anyway,as the quality of water provided by the State has often fallen below par. Also, if you build a house anywhere in Ireland,you will pay a development levy (whether you like it or not) and part of that goes to provide water.

Stovepipe

Geuze wrote: »

French and German systems have a mix of providers, AFAIK, but everybody has insurance.

Everybody has health insurance,in effect by force, as there are virtually no exceptions to paying insurance. Same with cars. Germans even have a form of liability insurance for their houses and property,so if someone has an accident in your house, they claim off your insurance. In some places in Germany, you can't buy or sell a house until you show proof of having liability insurance for the property. In the case of Continental Europe, most countries have had insurance like this since, medical/auto/liability since after WW 2 and their countries had to be rebuilt from the ground up. Germans do like to go to law to sort things out so having insurance for everything is a norm there.

back on topic: the Irish medical system is dominated by consultants and change will not be effected without their cooperation. They have more power than all of the non-consultant unions combined and that is how they always win.

Pandiculation

There’s a very interesting article about how the Sweepstakes funding, very much a key part of Irish healthcare finance for much of Ireland’s 20th century, distorted the shape of our health system.

Excellent piece by Prof. Mary E. Daly

http://historyhub.ie/the-curse-of-the-irish-hospitals-sweepstake


It goes a long way toward explaining why we’ve so much focus on hospitals and similar institutions, while very very little on primary care. The funding was available only for hospitals, so that’s where most of our healthcare took place.

It setup a very consultant and hospital driven model that I think we are still seeing the legacy of today.

I suspect it also suited a culture where powerful institutions, notably religious congregations, were both guaranteed a source of income and retained their influence as gatekeepers to healthcare and wide aspects of social care.

Had we democratised the healthcare systems, pumping money into community clinics and GP care, it may have evolved very differently.

I think it’s important to understand the history though. The government often had relatively little role in healthcare here until after the 1970s, even if a lot of public money was going in to capital projects and running costs, the instituons, until the first wave of modern health board hospitals began to emerge in the late 70s.

For the most part, we pretty much limped on with a system that didn’t look much different to the Poor Law model until well into the later half of the 20th C.

I’d even argue our system isn’t consultant driven. They sort of float around like contractors above and outside the hospitals. It sometimes feels like Irish hospitals (public and private) are more like coworking spaces where they breeze in and out.

hustlenbustle

I think the Irish Medical system is quite good when you get in but it takes far too long to get there. Waiting lists are huge. I am a believer as someone else here said that nothing should be free. Even if you're on a very low income you should have to pay something. For example at the GP - many people seem to go with very little wrong with them because they have a medical card. If even 5 euro was the cost per visit for these medical card holders they wouldn't go unless absolutely necessary. The same with hospital there should be some charge - nothing free. The only people I would accept getting a fully free service with no charge would be those who are seriously ill or disabled. I pay 60 euro per visit so you can be sure I don't go too often!!
I also think once in hospital everyone should pay - again graded according to your income. A very low charge for medical card holders and whatevers there at the moment for the rest of us. They should have better out of hospital services so that an acute hospital isn't the only option depending on what's wrong with you. It seems like everyone packs into the one place - a hospital- regardless of the problem. Again I'd charge for this service.
It seems to me if we want a better health service we have to pay for it - after all even if you get it for free someone has to pay for it. If everyone paid something it would help a lot but I feel that today we expect too much for nothing.

Pandiculation

I find the French system a bit excessively complex.

You pay €25 to go to a GP as an adult and €30 for a child, which is weirdly more expensive.

Then you pay between €46 and €60 for a consultant visit, which varies depending on how complicated the issues is.

Then you apply for a remboursement and get 70% of this back.

So in reality it costs €7.50 to go to the GP. The downside is that if you’re cash strapped, you might put it off, even if it’s going to be reimbursed.

There’s a “carte vitale” which is basically the national health insurance card for settling payments with various services and you’ve got the new version of it which has some degree of health records linked to it but it’s still patchy.

Then there’s an extra layer medical card like system “Complémentaire santé solidaire” for people who qualify and they don’t pay anything up front. There are also various other schemes like that for people who qualify for various reasons.

For a very socialist place and a top notch public system it’s not all state owned and you’re tons of private hospitals, clinics, the majority of GPs are sole traders ans so on.

CrabRevolution

Pandiculation wrote: »

There’s a very interesting article about how the Sweepstakes funding, very much a key part of Irish healthcare finance for much of Ireland’s 20th century, distorted the shape of our health system.

Excellent piece by Prof. Mary E. Daly

http://historyhub.ie/the-curse-of-the-irish-hospitals-sweepstake


It goes a long way toward explaining why we’ve so much focus on hospitals and similar institutions, while very very little on primary care. The funding was available only for hospitals, so that’s where most of our healthcare took place.

It setup a very consultant and hospital driven model that I think we are still seeing the legacy of today.

I suspect it also suited a culture where powerful institutions, notably religious congregations, were both guaranteed a source of income and retained their influence as gatekeepers to healthcare and wide aspects of social care.

Had we democratised the healthcare systems, pumping money into community clinics and GP care, it may have evolved very differently.

I think it’s important to understand the history though. The government often had relatively little role in healthcare here until after the 1970s, even if a lot of public money was going in to capital projects and running costs, the instituons, until the first wave of modern health board hospitals began to emerge in the late 70s.

For the most part, we pretty much limped on with a system that didn’t look much different to the Poor Law model until well into the later half of the 20th C.

I’d even argue our system isn’t consultant driven. They sort of float around like contractors above and outside the hospitals. It sometimes feels like Irish hospitals (public and private) are more like coworking spaces where they breeze in and out.

That's a fascinating article.

It was recognised early in the 20th century that having small acute hospitals in every little town and village lead to terrible health care, yet even today you have people claiming the pandemic wouldn't have been as bad had their local 10 bed "Hospital" not been closed down in the 1980s....

It's also funny to how Noel Browne is specifically mentioned as having contributed to the mess, considering mentioning his name has become a lazy cliché for people who want to criticise the church/health system etc. but aren't bothered doing any real reading on the subject.

Pandiculation

It’s a complex history, but I think the key problem was we never evolved past the poor law hospital type setup, which saw health and welfare as something that was an act of charity, rather than a state service. That’s why the religious institutions retained a tight grip on it for so long.

I don’t think it absolves either the church institutions, who definitely wanted control over the levers of power through being gate keepers to health, welfare and particularly education, but it also shows a rather weak early state that seemed to be more focused on anything except those three areas and was very opposed to building a post war welfare state model until much later than either the U.K. or continental European counterparts.

We were very late to modernity really, which is I think why you’re still seeing odd approaches to this huge aspect of public service here.

You still get the sense in Irish public healthcare that you’re being “given” something for free rather than that it’s a public service we are all paying for though taxation, be it though income tax or a array of indirect taxation.

In a way I guess you could see Ireland as having skipped post war European modernising efforts and arriving at that stage really from the 70s onwards, effectively after we joined the EEC, and when you start to see serious FDI and other flows of economic development.

I think we have to accept it is what it is and we need to reform and rethink it.

daheff

Never gonna happen because we can't afford it.

Stovepipe

Even if you're on a very low income you should have to pay something.
I also think once in hospital everyone should pay - again graded according to your income.

Well, given the amount of lies people tell about their income anyway,do you really think people are going to tell a hospital what they earn, so that they can pay more for their visit? Hospital administrators are fed up chasing people for hospital bills already. We have a medical system that can't employ enough consultants because they think 200 grand a year, working for the HSE, is penury and they can charge silly money in the Beacon and get it and they want the right to nixer in the Beacon enshrined in their contracts.

The first thing that needs to change for our healthcare to match NHS levels of catatrophe is the patients. They want radiography and X-Rays and consultants and the best of everything with a cherry on top. This has to change.

McGiver

What needs to change?

Taxes.

McGiver

Geuze wrote:

French and German systems have a mix of providers, AFAIK, but everybody has insurance.

Germany has essentially a private system, surprisingly. But it is extremely well regulated. Including the medical insurance framework.

It's neither Irish union leeches, corrupted bloated management and private doctors cannibalising the public system by working in both. Nor it's the American health care & insurance greed on steroids, healthcare companies effectively writing the legislation and capturing the state.

Geuze

Pandiculation wrote: »

I find the French system a bit excessively complex.

You pay €25 to go to a GP as an adult and €30 for a child, which is weirdly more expensive.

Then you pay between €46 and €60 for a consultant visit, which varies depending on how complicated the issues is.

Then you apply for a remboursement and get 70% of this back.

So in reality it costs €7.50 to go to the GP. The downside is that if you’re cash strapped, you might put it off, even if it’s going to be reimbursed.
.

I often wonder how French GPs manage charging 25 compared to 50+ here?

I think it's because rhe high private fee here is used to subsidise the GMS fee income?


That info on consultant's fees in France is news to me, thank you.

Can I rely on that data?

Geuze

Pandiculation wrote: »

I find the French system a bit excessively complex.

You pay €25 to go to a GP as an adult and €30 for a child, which is weirdly more expensive.

Then you pay between €46 and €60 for a consultant visit, which varies depending on how complicated the issues is.

Then you apply for a remboursement and get 70% of this back.

So in reality it costs €7.50 to go to the GP. The downside is that if you’re cash strapped, you might put it off, even if it’s going to be reimbursed.

There’s a “carte vitale” which is basically the national health insurance card for settling payments with various services and you’ve got the new version of it which has some degree of health records linked to it but it’s still patchy.

Then there’s an extra layer medical card like system “Complémentaire santé solidaire” for people who qualify and they don’t pay anything up front. There are also various other schemes like that for people who qualify for various reasons.

For a very socialist place and a top notch public system it’s not all state owned and you’re tons of private hospitals, clinics, the majority of GPs are sole traders ans so on.

Yes, everybody has access, but the actual provision is left to a mix of providers.

State regulation + the benefits of market provision

What worries me about Slaintecare is that it moves us more towards the State being a major/sole provider.

That leads to excessive union power / high costs / low productivity.

Geuze

daheff wrote: »

Never gonna happen because we can't afford it.

We can't afford what?

Bear in mind that we already over-spend on healthcare.

So an improved model should be cheaper.

McGiver

Pandiculation wrote:

We still could create that model though. I think we’re getting a bit over fixated on recreating the NHS, even though it’s not necessarily possible in the system we have evolved.

Agree.

The NHS is a British system, built at a very specific place and a very specific time and very close specific circumstances. Not possible to copy and shouldn't be copied. It would fail - trying to do something in a wrong place, at a wrong time, under wrong circumstances and with wrong preconditions. Ireland needs to look way beyond the cliffs of Wales in terms of the policy really...

Just take a few best models from the Continent especially focusing on small to the medium countries, analyse them, take the best features out of them and adapt to the local circumstances.

PhoneMain

I'd argue it's not our system of funding that's the issue, it's our overall attitude to change, particularly driven by the unions. In this day and age its ridiculous that hospital staff still operate on a 9 to 5, monday to friday system. Patients who get admitted to hospital on a weekend have generally very little done. Couple that with elective surgeries not taking place and outpatient departments being shut leads to longer waiting lists, more emergency theatres, people occupying hospital beds for longer etc.

The general public also have to change their attitude to hospitals as well. Theres loads of small, inefficient hospitals around the country that cant be shut down as the public wont tolerate their local town not having 1 and having to travel an extra 10 mins to get to a hospital (dont mention emergencies cos often you will have ambulances blue lighting past these hospitals in the case of heart attacks, strokes etc). We have far too many hospitals for our population and this just leads to cost duplication and inefficiencies.

McGiver

Geuze wrote:

What worries me about Slaintecare is that it moves us more towards the State being a major/sole provider.

So you'd prefer the German or Swiss model?

What is important in both is family doctors, GPs and primary care...

pauly58

Fourty years ago the NHS worked superbly, the National Insurance contribution was reasonable & basically the system worked, fast forward & now they treat the world & his wife for free & it's all overloaded. Nye Bevan never envisaged such levels of immigration when the NHS was devised. If they charged anyone without a National Insurance number as do the Canadians, it might work.

Geuze

PhoneMain wrote: »

The general public also have to change their attitude to hospitals as well. Theres loads of small, inefficient hospitals around the country that cant be shut down as the public wont tolerate their local town not having 1 and having to travel an extra 10 mins to get to a hospital (dont mention emergencies cos often you will have ambulances blue lighting past these hospitals in the case of heart attacks, strokes etc). We have far too many hospitals for our population and this just leads to cost duplication and inefficiencies.

Yes, 50-54 hosps does seem way too much for 5m people.

Do I count six in Dublin?

Beaumont
James Connolly
Mater
St. James
Tallaght
St. Vincent's

And that excludes the three maternity hosps!!!!

Geuze

McGiver wrote: »

So you'd prefer the German or Swiss model?

What is important in both is family doctors, GPs and primary care...

I like the idea of money following the patient.

The provider gets paid per patient.

Under UHI, hosps would not be financed by the HSE, instead they would send bills to the insurers.

However, I worry about excessive costs/profits of insurers.

One feature of the German system is that the 200+ insurers are not-for-profit.

RandomViewer

Geuze wrote: »

I like the idea of money following the patient.

The provider gets paid per patient.

Under UHI, hosps would not be financed by the HSE, instead they would send bills to the insurers.

However, I worry about excessive costs/profits of insurers.

One feature of the German system is that the 200+ insurers are not-for-profit.

Wasn't this Reillys plan in 2011, got canned when they were looking at payments of 5k a head

Pandiculation

RandomViewer wrote: »

Wasn't this Reillys plan in 2011, got canned when they were looking at payments of 5k a head

The total cost of healthcare here is $5,276 / head. We just don’t see it as it is coming largely from general taxation and a mixture of other sources and that would need to continue. You aren’t going to suddenly be able to shift that exclusively to contributions as it would place all the charges on income tax which would be hugely burdensome. In reality it’s being met by all government revenue streams.

Systems on the continent also don’t exclusively fund from those insurance systems. A significant % is also flowing in from general taxation and you’ve a significant % of the population where their contributions are effectively made for them.

If you were to move the entire cost of healthcare to insurance collected on your income, you would shock people with huge bills and would suddenly have regressive income taxation if it were structured incorrectly.

The order challenge with any system is the regulation. My concern about the universal insurance model here would be a risk of American style escalation of costs. I’d you look at the USA in the 1990s healthcare was comparable to costs in the most high cost European systems, now it’s $11,072 per capita, which just isn’t sustainable. It’s actually becoming an enormous burden on disposable income and on state finances, and even with all that is far from universal.

You would need to design the system in such a way that it’s fair and doesn’t incentivise annual insurance hikes. The US system has had a tendency to just inflate and inflate and insurance costs have gone up and up to match and because of limited competition and the fact it’s basically essential to have insurance, those ever expanding budgets aren’t sufficiently challenged.

Charles Babbage

Geuze wrote: »

We can't afford what?

Bear in mind that we already over-spend on healthcare.

So an improved model should be cheaper.

Exactly. What we need is an improved accounting system which actually reflects costs and not "budgets".

In the Irish health system you have false economy, you save €1000/week by not having an additional person in the diagnostics dept, which results in operations being delayed by a day costing €10,000/week because patients spend an extra day in hospital. But there is never a rational comparison of these costs. If things were run efficiently then the present budget would pretty much provide free health care, charging patients €20 for a doctor might still be advisable for policy reasons.

Pandiculation

That’s just bad management and lack of seeing the big picture. It’s something you’ll see in any kind of large bureaucracy, both public and private when there’s limited power given to local management to adapt to budgets or argue for efficient use of money.

Sometimes working without the right tools and resources is extremely inefficient, but if you’re only measuring spend and not looking at the overall unit’s performance, then you’ll keep doing that.

It’s basic management and a well known organisational issue in companies.

Trex.

Charles Babbage wrote: »

Exactly. What we need is an improved accounting system which actually reflects costs and not "budgets".

In the Irish health system you have false economy, you save €1000/week by not having an additional person in the diagnostics dept, which results in operations being delayed by a day costing €10,000/week because patients spend an extra day in hospital. But there is never a rational comparison of these costs. If things were run efficiently then the present budget would pretty much provide free health care, charging patients €20 for a doctor might still be advisable for policy reasons.

Are they not waiting for the operating theatre to free up anyway,?

It's hardly the case that the surgical staff are put on hold