An "Irish NHS" - what needs to change?

Traumadoc

karlitob wrote: »

Can you explain that? How would consultants on comparable contracts (a, b or c) earn less in a hospital in the country rather than city?

In terms of C , it is down to the large number of patients with PHI and the large number of private hospitals.

For B contract it is down to the large number of private patients that use the public hospital and may be billed

For A contracts there is less , but although A contracts may not engage in Private practice - they may work in private hospitals so long as they do not bill the patients eg private emergency departments

17% of contracts are the A , the rest are B or C or I or II

Traumadoc

conorhal wrote: »

When it comes to solutions, I have a few suggestions.

1) Train enough doctors.
At minimum we need to double the number of doctors we train, why are we not doing this?
Fund the places in colleges and put the infrastructure in place to produce enough doctors to meet our needs. we piss billions up the wall when mere millions are not being spent to address a root cause of the issue.

2)Retaining graduates from medical school.
I think most people would agree that graduates in medicine are a resource that the state has invested a significant amount of time and money training but year after year nothing is done to retain such vital resources in the state.
We should be offering those good enough to get into medicine zero fees, free accomodation and a per-diem to students that constitute a critical resource that we require.
However, these benefits should only be offered on the basis that those in reciept of them are obliged to work within the Irish hospital system for 10 years. If that doesn't suit them and they want to hop on the first plane to the UK or the US instead then then would be required to pay back the cost of their education in full or chose to pay it in full from the outset.

3) Wages in medicine need to go down and so do the hours worked.
You can make a hell of a lot of money as a doctor, if you're prepared to burn out fast.
Some kind of balance needs to be created where we pay less but provide medical professionals better conditions in compensation for that. No doctor should have to work more then a 40hr week and shift work should accomodate a life.
That means more doctors working fewer hours on less pay. I personally know a couple of doctors that have left high paying jobs to have a work life balance.

We already train more than enough doctors , - the highest in the eurozone pro rate ( not including non- nationals)- but there are better and more opportunities in the UK , Australia, Canada, US New Zealand so many leave .

The department of health hates doctors and nurse does not value them- sees them as an inconvenience.
We really need to start asking why public hospitals including Dublin ones cannot recruit consultants and why the department of health has made them fee so unwelcome- it is quite an achievement

Geuze

Traumadoc wrote: »

We already train more than enough doctors , - the highest in the eurozone pro rate ( not including non- nationals)- but there are better and more opportunities in the UK , Australia, Canada, US New Zealand so many leave .

GPs in France charge 25, versus 50+ here.

Consultants in France charge 46-60, versus 150+ here (I think 175/180-200 for first consultation, less afterwards?)


As the rates of pay are so high here, double what French doctors earn, why are doctors leaving here?

Is it to do with training/experience? As in, I will go and train in a large busy hosp abroad?

Traumadoc

Geuze wrote: »

GPs in France charge 25, versus 50+ here.

Consultants in France charge 46-60, versus 150+ here (I think 175/180-200 for first consultation, less afterwards?)


As the rates of pay are so high here, double what French doctors earn, why are doctors leaving here?

Is it to do with training/experience? As in, I will go and train in a large busy hosp abroad?

Perhaps you could ask why French doctors ( or indeed Northern Irish ones) are not coming here.

Irish Doctors are not leaving here to go to France, they re going to Australia, UK, Canada, US, New Zealand .

https://www.jpsmedical.com.au/emergency-jobs/emergency-medicine-consultant-head-of-department-clinical-director/3212922?source=Indeed

Remember the effective tax rate is less than 30%

Junior doctors in Australia would take home more than consultants in Ireland.

Anita Blow

Geuze wrote: »

GPs in France charge 25, versus 50+ here.

Consultants in France charge 46-60, versus 150+ here (I think 175/180-200 for first consultation, less afterwards?)


As the rates of pay are so high here, double what French doctors earn, why are doctors leaving here?

Is it to do with training/experience? As in, I will go and train in a large busy hosp abroad?

The cost doesn’t mean much though without considering overheads.
From speaking to GPs who are friends about it, the reason why the private GP charge is so high is to offset the pittance they get for GMS patients. This is even more true now that Under 6s are free. The GP gets a relatively small flat rate per year for under 6s and over 70s which are among the biggest users of the service. They have to make up the funding elsewhere thereafter.

Geuze

Traumadoc wrote: »

Perhaps you could ask why French doctors ( or indeed Northern Irish ones) are not coming here.

I presume this is partly due to language?

The countries you list are all English-speaking.

It seems our doctors mainly migrate to English-speaking countries?

Geuze

Anita Blow wrote: »

From speaking to GPs who are friends about it, the reason why the private GP charge is so high is to offset the pittance they get for GMS patients. This is even more true now that Under 6s are free. The GP gets a relatively small flat rate per year for under 6s and over 70s which are among the biggest users of the service. They have to make up the funding elsewhere thereafter.

Yes, I had heard this.

I know that GMS rates are fixed pa, not per consultation.

So high usage GMS patients means a low payment per consultation.

Fair enough.

I wonder what the weighted average fee is?

I wonder is this why I see a GP surgery in Galway charging 40 - they don't have any/much GMS patients to pull down their average price?

PhoneMain

Geuze wrote: »

Yes, I had heard this.

I know that GMS rates are fixed pa, not per consultation.

So high usage GMS patients means a low payment per consultation.

Fair enough.

I wonder what the weighted average fee is?

I wonder is this why I see a GP surgery in Galway charging 40 - they don't have any/much GMS patients to pull down their average price?

Yes it's much more nuanced than just charging per patient. It's not as if a GP is making €60 per every 10/15 minute consultaiton throughout the day.

Some GPs have a larger percentage of private patients e.g. certain parts of south dublin whereas other areas have larger percentages of public patients. This can even vary greatly across smaller towns like Athlone, Tullamore!

The fees for GMS patients that GPs receive e.g. capitation rates are pretty low e.g. €125 for under 6s (i.e. no matter how many times an under 6 patient presents, the GP will just receive €125 for the year and some attend a lot more than others!).
For completeness of information however, there are also other fees that GPs receive from the HSE e.g. Special Type Consultations (STCs) for doing things like putting in certain long active contraceptives or emergency ECGs and also things like the mother and child scheme (antenatal scheme) and childhood immunisation scheme.

karlitob

About ⅓ of all GP consultations are musculoskeletal.

https://www.england.nhs.uk/ourwork/clinical-policy/ltc/our-work-on-long-term-conditions/musculoskeletal/

Chartered physiotherapists are experts in musculoskeletal assessment, diagnosis and triage. Approx 24 Advanced practice physiotherapists in physio led triage has removed 125000 people from the ortho and rheum waiting lists. Which is the most successful waiting list management intervention ever in our state. It’s funny how there’s no investment in another 24. We’re cheap and effective. And yet - I’ve heard moaning from senior orthopods - at national conferences - that it’s made them busier. Instead of 1in5 needing surgery it was now 1:3 - or numbers to that effect. Patient centred, eh.

https://www.imj.ie/wp-content/uploads/2020/09/Reduction-of-Orthopaedic-and-Rheumatology-Outpatient-Waiting-Lists-The-National-Musculoskeletal-Physiotherapy-Triage-Initiative.pdf

http://advancedpractice.physio/

https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-018-2106-7


Investment in healthcare professionals other than doctors and nurses; Investment in our training, our practice and our interventions; could have significant benefit from all involved.

Imagine an advanced practice physiotherapist is every GP practice in the country. The patients would be seen quicker, be assessed, diagnosed and treated better, and would have better clinical outcomes. Physios have can order and have limited ability to interpret bloods and images. Physios have limited prescribing rights for common analgesics. Patients who need to be reviewed by the GP can be - and sure what with all the time they’ll have with a ⅓ of their patients taken from them. Everyone’s a winner!

mick087

There is no reason Europe could not have a NHS style service.
We could do away with all private care in Europe and nationalize all health care in Europe.

No one person no matter how rich they are should have the right to buy better quicker treatment.

mariaalice

mick087 wrote: »

There is no reason Europe could not have a NHS style service.
We could do away with all private care Europe and nationalize all health care in Europe.

No one person no matter how rich they are should have the right to buy better quicker treatment.

You do not get better treatment that is a myth quicker treatment is a different matter.

mariaalice

karlitob wrote: »

About ⅓ of all GP consultations are musculoskeletal.

https://www.england.nhs.uk/ourwork/clinical-policy/ltc/our-work-on-long-term-conditions/musculoskeletal/

Chartered physiotherapists are experts in musculoskeletal assessment, diagnosis and triage. Approx 24 Advanced practice physiotherapists in physio led triage has removed 125000 people from the ortho and rheum waiting lists. Which is the most successful waiting list management intervention ever in our state. It’s funny how there’s no investment in another 24. We’re cheap and effective. And yet - I’ve heard moaning from senior orthopods - at national conferences - that it’s made them busier. Instead of 1in5 needing surgery it was now 1:3 - or numbers to that effect. Patient centred, eh.

https://www.imj.ie/wp-content/uploads/2020/09/Reduction-of-Orthopaedic-and-Rheumatology-Outpatient-Waiting-Lists-The-National-Musculoskeletal-Physiotherapy-Triage-Initiative.pdf

http://advancedpractice.physio/

https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-018-2106-7


Investment in healthcare professionals other than doctors and nurses; Investment in our training, our practice and our interventions; could have significant benefit from all involved.

Imagine an advanced practice physiotherapist is every GP practice in the country. The patients would be seen quicker, be assessed, diagnosed and treated better, and would have better clinical outcomes. Physios have can order and have limited ability to interpret bloods and images. Physios have limited prescribing rights for common analgesics. Patients who need to be reviewed by the GP can be - and sure what with all the time they’ll have with a ⅓ of their patients taken from them. Everyone’s a winner!

As long as they are very highly trained a physiotherapist misdiagnosed me.

dulpit

mariaalice wrote: »

You do not get better treatment that is a myth quicker treatment is a different matter.

In a lot of cases though, quicker treatment = better treatment.

mick087

mariaalice wrote: »

You do not get better treatment that is a myth quicker treatment is a different matter.

Don't be so naive of course you can get better treatment if your willing to pay for better treatment.

Better and quicker treatment are 2 of the same thing to me. In the year 2021 shocking its allowed to go on.

karlitob

mariaalice wrote: »

You do not get better treatment that is a myth quicker treatment is a different matter.

100%. The same people who treat private, treat public. They don’t practice to a poorer ability depending on whether you pay. They might make you feel nice about yourself to justify to charge.

People who work private only however - I’ve perhaps an unfair perception that - in general - they wouldn’t be ‘as good’ as public or public/private.

No evidence for that. Just a notion I’ve developed.

karlitob

mick087 wrote: »

Don't be so naive of course you can get better treatment if your willing to pay for better treatment.

Better and quicker treatment are 2 of the same thing to me. In the year 2021 shocking its allowed to go on.

Better treatment and better outcomes are different.

If you get cancer services early (and we are very good at that in ireland) then you’re outcomes are better. If you’ve to wait months for an endoscopy so as to see whether you need to access cancer services (which we’re not so good at) are time dependent. Earlier is generally better and this is what private pays for - time. But regardless of when you present, the treatment is the same. If a patient only gets their endoscopy 12 months post referral - the ‘assessment’ and ‘treatment’ that they get is too quality.

I know it’s a much of a muchness but I think it’s an important difference. You pay for time, not quality. Time does not always relate to outcomes. Cancer is the obvious thing to point to but there are a wealth of other services that private doesn’t provide - or are too expensive. Rehab for example.

karlitob

mick087 wrote: »

Don't be so naive of course you can get better treatment if your willing to pay for better treatment.

Better and quicker treatment are 2 of the same thing to me. In the year 2021 shocking its allowed to go on.

Was it less shocking in 2020?

Economics101

mick087 wrote: »

There is no reason Europe could not have a NHS style service.
We could do away with all private care in Europe and nationalize all health care in Europe.

No one person no matter how rich they are should have the right to buy better quicker treatment.

Does Europe have a problem with public versus private waiting times? If it does it's only a small fraction of what goes on in Ireland, and probably in the UK too, where some have private insurance, partly to avoid NHS queues. I would hesitate to call it queue-jumping, because privately insured patients bring more resources into the system as a whole (public+private).

As for "nationalise all health care", that sort of totalitarian leftwing claptrap would never survive a constitutional challenge, never mind European human rights.

karlitob

mariaalice wrote: »

As long as they are very highly trained a physiotherapist misdiagnosed me.

All physios are very highly trained. A number are more highly trained. Physios already diagnose MSK conditions for decades. My point above is that scope can be increased for greater capacity for patients. Doctors misdiagnose also. Lots of them. Lots of times. Issues with competence can be referred to regulators. I can get you corus details if you wish.
‘Missed disgnosis’ and working diagnosis can also be misunderstood.

mick087

Economics101 wrote: »

Does Europe have a problem with public versus private waiting times? If it does it's only a small fraction of what goes on in Ireland, and probably in the UK too, where some have private insurance, partly to avoid NHS queues. I would hesitate to call it queue-jumping, because privately insured patients bring more resources into the system as a whole (public+private).

As for "nationalise all health care", that sort of totalitarian leftwing claptrap would never survive a constitutional challenge, never mind European human rights.

A European free health service is the way to go.

Private health care services are not acceptable. Individuals should not have the right for better quicker services.

Citizens have the right to challenge change constitutions this can be slow but can and does happen.

I agree its a European human rights issue. A issue thats in favor of the rich.

mick087

karlitob wrote: »

Was it less shocking in 2020?

Yes, each year that passes is another year of an unequal health service.

karlitob

mick087 wrote: »

Yes, each year that passes is another year of an unequal health service.

So it’s getting more unequal each year?

Do you mean life expectancy? Or do only mean access?

Weve been living longer every year for the past 100. But women live longer than men through all those years. So I suppose that’s unequal.

mick087

karlitob wrote: »

So it’s getting more unequal each year?

Do you mean life expectancy? Or do only mean access?

Weve been living longer every year for the past 100. But women live longer than men through all those years. So I suppose that’s unequal.

Access is becoming more unequal to many parts of health services.

Yes we are living longer and those with better access to health services expect and do live longer.

If the services was equal and we all get the same treatment why would some have private health care? My guess is because they get a better service.

karlitob

mick087 wrote: »

Access is becoming more unequal to many parts of health services.

Yes we are living longer and those with better access to health services expect and do live longer.

If the services was equal and we all get the same treatment why would some have private health care? My guess is because they get a better service.

I’m still not clear in what instances is it becoming *more* unequal?

I presume when you mean equal, you mean in relation to access, not equal outcome. Women live longer than men, do you think women have more access to healthcare services and that’s why they live longer?

When you speak about access? Do you mean timely or equal in relation to finance only? There’s access policy written that is unequal - ie we only see these types of people first (take your pick of identifies in modern ireland) and these type of people second. Timeliness - based on increase demand and poor supply - is not the same as inequity in my view. Paying for the privilege of being seen early cos you can pay for it is unequal. By definition you are not being treated on the basis of need but on the basis of your ability to pay. Healthcare professionals who provide a private service perpetuate that. It’s in there interest for the such a private service to continue. Of course it is. I’m sure someone will tell me that they’re providing a service that the state doesn’t - and I can accept that but it’s always like they’re doing us w favour. I can’t tell you the amount of expensive exams, bloods and images that docs in private suites order. The same dose wouldn’t do it in the public clinic. It’s also in the interests of those who can pay (the vaccine sequencing has been a great leveller as to who is prioritised on the basis of need and risk). It’s also in the interest of government as they don’t need to invest what’s needed to remove the scale of private practice in Ireland.

Access to healthcare is not necessarily related to your health. A wide range of socioeconomic factors are related to your health. The poorest in society have the poorest health - they all have medical cards, all have access to GPs and all have access to medicines.

The kings fund estimate that only about 10% of a person health is related to healthcare. The rest being wealth, education, housing, etc etc.


Also, we’re not living longer. We’ve always lived to the same ages. Instead, it’s people who used to die at 50 no longer die at 50, people who used to die at no longer die at 60. It’s not that we live longer, we just die later. A much of a muchness you might say, but I thought I’d make the point. M


People chose private healthcare for a wealth of reasons. I don’t have it. I don’t see the point of it. I can’t tell you how many public patients I’ve treated for them all to say ‘I have VHI that’s why I’m being looked after so well’. It’s not. They were admitted as public patients - cos that’s where you go when you’re sick - a public hospital. (EDs don’t close which is why blackrock ‘ED’ is not an ED. It’s hard to call the beacons Ed and Ed when it’s on the first floor). Health insurance is like car insurance - if you don’t use it in that year it’s not worth much to you. I also don’t see the point any person ‘going private’ for their pregnancy. Same doctors, same midwives, same hospitals. If you’re unwell, you’ll be treated by expert clinicians regardless if you private consultant says it’s a good idea to eat your placenta. Irish women could single handedly wipe out private practice in Ireland for one single area of healthcare in one fell swoop.


That’s was all just a bit of a ramble.

karlitob

Economics101 wrote: »

I would hesitate to call it queue-jumping, because privately insured patients bring more resources into the system as a whole (public+private)..

I’m interested in this bit. You might comment further.

As I see it, it is queue jumping - but based on ability to pay not need. You could be in the zone 3 in an ED getting a stitch put in, or in the waiting room waiting to be seen - but when a zone 1 comes in they jump the queue.


As for the second bit, and perhaps an ideology on my part - they’re bringing more into the private system. Not the public system. Private patients pay for appointments (some return are not always necessary), you pay for tests (some are not always necessary) you pay for procedures (some are not always necessary). The public system buys private services - ntpf. We buy the straight forward easy stuff, rather than doing it ourselves. Sure it’s the same docs usually - walk down the underground corridor from SVUH to svph or Mater to Mater private. They don’t / can’t take the hard stuff and it’s not financially viable for them. They more we pay them. They more we don’t invest in us.

And while I take the point that private patients are public tax payers, a bit of me thinks that (in my naive ideology that I haven’t thought through well enough) why can’t they pay more taxes with that money rather than private insurance.

What I do know is our funding model is very broken. We find our health service through 4% health levy formally in the prai and now in asc. Not everyone pays into it. ?40% of the population has a medical card - which should be for the poorest but has become a political tool and is not fit for purpose and not based on need as Frank a Murray reported in a review of medical cards a few years back for RCSI. ?40% have private health insurance. Our entire primary health service has private companies as gate keepers (GPs) and private companies dispensing (pharmacists).
It all just feels wrong.

But again. What would I know.

Geuze

mick087 wrote: »

A European free health service is the way to go.

Private health care services are not acceptable. Individuals should not have the right for better quicker services.

In France and Germany much healthcare provision is by the private sector.

FR and DE may have universal health insurance, but the provision of healthcare is not 100% State.

Do not assume that because 100% of the population have insurance in some European countries, then that means that the State are providing all the healthcare.

Geuze

mick087 wrote: »

A European free health service is the way to go.

Private health care services are not acceptable. Individuals should not have the right for better quicker services.

Free???

Healthcare is FR and DE is based on insurance.

People pay insurance premium every month.

Germans pay 15% approx of salary for health insurance.

Free!!!!

Geuze

karlitob wrote: »

What I do know is our funding model is very broken. We find our health service through 4% health levy formally in the prai and now in asc. Not everyone pays into it.

Health spending is financed by tax.

The 2% Health Levy is gone, it was replaced by the USC, which is simply another tax.

Economics101

karlitob wrote: »

I’m interested in this bit. You might comment further.

As I see it, it is queue jumping - but based on ability to pay not need. You could be in the zone 3 in an ED getting a stitch put in, or in the waiting room waiting to be seen - but when a zone 1 comes in they jump the queue.

I think that ED (I assume this is A&E) is all public system, at least as far as anything serious is concerned, so not much in the way of "queue-jumping", here. The queue-jumping argument is much more relevant for elective procedures, and where consultant referrals are concerned.

No real argument about the quality of public v private care: it's all about speed of access. Part of the problem is that in our system, tax-funded hospitals by and large get resources which are not directly dependent on "output" (sorry to use such an industrial term), whereas private facilities depend directly on "output" for their income. The incentive problem is obvious, and even if you throw more money at the public system the incentive problem will still be there.

BTW if one were to nationalise all health facilities and forbid private treatment, some people would simply go abroad. More inequality. Or do you want to forbid foreign travel for medical treatment? We had a referendum on that a few years back!

Traumadoc

Economics101 wrote: »

I would hesitate to call it queue-jumping, because privately insured patients bring more resources into the system as a whole (public+private).

As for "nationalise all health care", that sort of totalitarian leftwing claptrap would never survive a constitutional challenge, never mind European human rights.

It is queue jumping , or as Ryan air would call it " priority boarding"

However you cannot equate healthcare to airline tickets.

Would you be happy for me to get faster health care because I pay more income tax ?

Morally it is repugnant and hopefully with Slaintecare the use of PHI to jump the queues in Public hospitals will end.

As for "Nationalise healthcare" being leftwing claptrap - that is exactly what Nye Bevin did - it was a brilliant success..