Dara Gantly

Dara Gantly looks at how IT is finally being utilised to deliver much-needed reforms in the health service.

The message from the Minister for Health was clear at the recent briefing on the work of the Special Delivery Unit (SDU): “Reform does work and delivers for patients”.

After an in-depth analysis, brimming to capacity with numbers on trolleys and waiting lists, the Minister hinted at what was really behind this ‘big news story’. “Analysis and information is how you make change. And it has empowered the system. I think this has been huge… hospitals are now regaining the sense that they do actually have control over this.”

So how exactly have the health authorities achieved a reduction by 27 per cent in the numbers waiting on trolleys, given that the budget had been cut and will be again? One vital element seems to have been a realisation that IT can help improve the information available to hospitals, which in turn can improve patient flow.

Fundamentally, the task of improving waiting lists and waiting times comes down to capacity management: Has the system got the senior decision makers on the floor to discharge patients home, to residential care facilities, or back into the community with the support of home care packages? But even before that, the system has to know what capacity is available and what surges are ahead. And that’s where IT — such as the email system that can examine what the trolley rate pressure is like three times a day, introduced by the SDU in December — comes into its own.

Indeed, it has been an exciting start to 2012 for health IT nerds. The National Cancer Control Programme (NCCP) has set a target of doubling the number of GPs referring patients online to the eight designated cancer centres this year. A collaboration between the NCCP, ICGP, GPIT Group and the HSE ICT Directorate, the new referral system for breast, lung and prostate cancer aims to eliminate the use of GP letters and faxes, increase efficiency and provide more rapid access for urgent cases that need to be seen within two weeks of referral. It should ensure that — regardless of where a patient lives — the referral pathway they follow is of the same quality and standard, and should eliminate a repeat of the Tallaght referrals debacle.

And in this week’s issue of IMT, we hear that five more hospitals in the North East will shortly become part of the National Integrated Medical Imaging System (NIMIS), joining Sligo General, Waterford Regional, the Mater and Beaumont Hospitals. Beaumont’s turnaround-time for reports has decreased to less than 18 hours, and consultants in the regional hospitals are now able to quickly receive a second opinion from a Beaumont consultant, which becomes part of the patient’s record within minutes.

'It seems that behind many of the emerging success stories from our embattled health service are innovative IT systems that allow doctors, nurses and administrators to work better, faster and smarter'

And last Friday we had the official launch of the Caredoc Community Intervention Team (CIT) service, which has already carried out approximately 700 patient care interventions since it was established in the Carlow/Kilkenny region in mid-September.

Behind this service is also a highly intelligent IT system, where the clinical records of the CIT patients are managed via an electronic patient record system provided through a database linked to the Caredoc out-of-hours IT platform.  The CIT nurses can also record their treatments on an electronic hand-held device, which automatically updates the patient record and forwards this information through electronic messaging to the patient’s own GP’s software package.

It seems that behind many of the emerging success stories from our embattled health service are innovative IT systems that allow doctors, nurses and administrators to work better, faster and smarter. ‘Better, faster, smarter’… I must listen out for that one from the Minister next time around. What is it they say — ‘The geeks shall inherit the earth’?

Dara Gantly

Are the long-promised plans to move towards chronic disease management in primary care in a chronic condition, asks Dara Gantly.

In last week’s Editorial, we heard about how the HSE plans to minimise the impact on services of a €750 million reduction in its budget by fast-tracking new, innovative and more efficient ways of using reduced resources.

The Executive has suggested that by moving to new models of care which, as the Minister for Health Dr James Reilly has stressed, must treat patients at the ‘lowest level of complexity’ and provide quality services at the least possible cost, the health services can keep the inevitable and unavoidable cuts in services to a minimum. In many cases, and particularly with chronic diseases, this ‘lowest level of complexity’ means primary care.

A perfect example of such innovation would be to put in train long-hatched plans for the management of such chronic diseases as stroke, acute coronary syndrome, heart failure, COPD, asthma and diabetes in primary care. But what did the HSE give us? An uncosted pledge to develop an overall ‘chronic disease watch’ model of care, with initial focus in 2012 on the diabetes programme.

Readers will be familiar with Heartwatch — the first such programme in general practice, which saw 470 GPs involved, 11,000 patients treated, and 81 deaths prevented or postponed due to treatment in the first two years of the programme. The big problem with it was that it was only ever brought out to 20 per cent of GPs and never rolled out nationally. But the template worked, and can do so in other disease areas as long as it is GP-supervised but practice nurse-delivered.

Dr Barry White, HSE National Director for Clinical Strategy and Programmes, accepts that we have to improve chronic disease management in primary care. While it may not necessarily give us a decreased demand on hospital services in 2012, it is very important for the overall health of the population and will have longer-term benefits.

Speaking at the launch of the 2012 Service Plan, Dr White noted that the HSE had identified diabetes as the most important area within that context, where patients have the highest risk of cardiovascular complications. He said the Executive was “very keen to start the implementation of chronic disease management in diabetes in 2012”, albeit there was quite a lot of work to be done in terms of working through the funding stream and having discussions with GP representative bodies. The Service Plan has set the target of Q4 for commencement of the phased roll-out of the programme for diabetes, which means the danger of it being pushed into 2013 is all too real.

An immediate action the health authorities could take would be to prioritise legislation for a unique patient identifier and assist every GP in the country to create a register of their patients with the six major chronic diseases

Minister for Primary Care Róisín Shortall believes that implementing primary care programmes for chronic diseases are “overdue reforms” that will deliver significant health gains and savings on expensive hospital care. She has committed the Government to establishing the first phase of the diabetes chronic care programme in primary care this year, with the scheme extending in the years ahead and expanding into other disease areas. But do we really need more pilots?

Back in 2006, a three-year shared-care, IT interactive, collaborative heart-failure management pilot, involving St Vincent’s University Hospital and 50 GP practices, covering a patient population of approximately 200,000, commenced with funding from the HSE. Spearheaded by Prof Ken McDonald, this integrated programme decreased hospital admissions by 4,000 per year. In that small area in South Dublin, this is the equivalent of building a small-to-medium sized hospital, at a cost of €27 million!

An immediate action the health authorities could take would be to prioritise legislation for a unique patient identifier and assist every GP in the country to create a register of their patients with the six major chronic diseases. This will be an essential element of any programme and should be a ‘first step’.
We have heard a lot of ‘talk’ over the great pace of change around the whole area of chronic disease management since the new Government took office.

We got a junior Minister for Primary Care for the first time in the history of this State, and the Minister himself is a GP, fully aware of the potential role primary care can play in the reform process. But we have yet to see much of the ‘walk’.

Moves may well be afoot for reform of our chaotic healthcare model, but the strides we are taking remain stubbornly small.

Dara Gantly

Dara Gantly looks at the likelihood the HSE will achieve the ambitious targets outlined in its Service Plan for 2012.

If the publication of the HSE’s Service Plan was an episode of Sesame Street, it would have been brought to you by the number 750 million, the letters W-T-E, and the word ‘challenging’ (used by CEO Cathal Magee on too many occasions to count, even for the Count!).

The 750 million, of course, refers to the amount in euro of the cost reduction for 2012 in the health budget; WTE stands for whole time equivalents, 2,816 of whom (or 3,313 staff) will be leaving the health service, mainly by the end of February; and ‘challenging’, well, could refer to just about anything.

Leaving the actual measures aside for a second, even drawing up the document to take account of what Magee described as the “change of direction” demanded by the Minister for Health following the draft plan must have been a mammoth challenge. I make it just three-and-a-half weeks between when the draft was available and the final report, which perhaps explains the many gaps contained within it. The Plan will also have to be ‘revised’ when the full impact of the staff leaving at the end of the February 29 ‘grace period’ is known.

I guess the ‘Big Bird’ in the room that nobody wanted examined in too great detail was how the HSE will be able to offset these cuts by increased efficiencies. Dr James Reilly had made it clear before Christmas that while the scale of the financial challenge facing the HSE meant there would be an “inevitable and unavoidable” reduction in services, it should not be a “straight-line reduction” — so a 7.8 per cent cost reduction for our hospitals should not translate into a 7.8 per cent cut in services.

He wanted a commitment from the HSE to minimise the impact by fast-tracking new, innovative and more efficient ways of using reduced resources, and moving to new models of care. He got his pledge — but can they stick to it?

Of the 7.8 per cent reduction in the acute hospital budget, the HSE CEO believes about 6 per cent has a direct service delivery impact. He believes the implementation and the fast-tracking of the new models of care and the clinical programmes will deal with 3 per cent, leaving a net impact of 3 per cent on activity. This 3 per cent is the “maximum reduction” envisaged, according to Dr Barry White, National Director for Clinical Strategy and Programmes, and some work remains on interpreting this at individual sites.

'If the publication of the HSE’s Service Plan was an episode of Sesame Street, it would have been brought to you by the number 750 million, the letters W-T-E, and the word ‘challenging’ (used by CEO Cathal Magee on too many occasions to count, even for the Count!)'

While the HSE broke even in 2011 — with the assistance of supplementary funding in December of €148m — hospitals did not, leaving the likes of Limerick, Galway, Tallaght and Drogheda, who had significant run-rate deficits, come into 2012 with not only a reduced allocation, but with that legacy deficit. The Casemix figures released on the same day as the Service Plan would have made grim reading for many of our most struggling hospitals, particularly those in the North East.

On top of this conjuring trick, the HSE is also tasked with achieving the target of less than nine-month waits for elective procedures and the six-hour target for patient experience time (PET) in emergency departments (EDs). According to the latest available Performance Report for October 2011, patients waited on average 6.4 hours in EDs from time of arrival to time of leaving the department. Yet the average time for patients who required admission was 10.2 hours, with only 45.3 per cent of patients admitted within six hours of their registration in an ED; just 17 hospitals routinely returning all patient data.

How on earth can this be achieved? Well, by better use of beds so that the impact on activity is minimised, the HSE believes. But what was that about reduced bed capacity in 2012? “It is too early to say at this point what the reduction in bed capacity will be across the acute system,” said Cathal Magee. It was also too early to provide details on outpatients, targets for which will be determined in the first quarter of 2012.

Dr White summed up the task ahead pretty well: “If we can get to the situation — and this is what makes it really difficult — whereby we can actually decrease our average length of stay, that is the only way we can do it.”

I don’t want to appear like Oscar the Grouch, but that’s a big ask given the circumstances.

Dara Gantly

Dara Gantly looks at what we might learn from the latest overhaul of the health service in Northern Ireland.

The long-awaited health review is out, and with it the biggest change in the health service in 40 years. It will see a halving of acute hospitals, a radical overhaul of elderly care, and a new emphasis on giving GPs a wider role in treatment and diagnosis. Familiar stuff; but the health service in question is north of the boarder and the report, ‘Transforming your Care’, was carried out by a team led by NI Health and Social Care Board CEO John Compton.

Released just before Christmas, the Compton review suggested that the current 10 NI hospitals with emergency departments and emergency surgery could be reduced to as few as five over the next five years, with the three main Belfast hospitals — the Mater, City and Royal Victoria — merging.

More sick and elderly should, in future, be cared for in their own homes, and with Stg£83 million (€99.6m) being transferred from hospitals to GPs and other services, the changes will see the 350-plus GP practices — which should form up into 17 federations — providing many more patient services, including day patient procedures, to ease hospital waiting lists.  Again, we could so easily be discussing reforms at our own end of the M1.

Apart of the benefits of knowing what plans are afoot across the border, and learning from our nearest neighbours, the Compton review directly stated that there should be greater co-operation between the health services North and South, particularly for patients living in the border areas. NI Health Minister Edwin Poots went further when he suggested a cross-border service within the next five years, where the Government in the Republic could buy services in Northern Ireland, thus enabling the North to sustain its hospitals in the border region. An unusual move, one might think, from a Unionist minister, and certainly a sea change from the attitude of his predecessor Michael McGimpsey. But these are unusual times.

You may recall that the Health Ministers in Northern Ireland and the Republic commissioned a major report several years back in the area of cross-border/all-island co-operation. This was a joint study led by the Department of Health and the NI Department of Health, Social Services and Public Safety (DHSSPS). The North-South Feasibility Study — as it was called — was submitted to both Minister McGimpsey and Minister Mary Harney in January 2009. But it was left lying on a shelf for nearly three years.

Why? Well, politics of course. While the South was seeking its publication, Minister McGimpsey felt, in the current financial climate, it was “not the right time to create any new or additional administrative or bureaucratic structures around co-operation in the health and social care sector”. But with the Compton review, the time suddenly became right, and the North-South Feasibility Study was finally released last month — the day before the Budget!

The Compton review also noted that an area of similar population size to Northern Ireland — 1.8 million — in Britain would typically be served by four acute care facilities. If you do the same maths, that would leave just 10 acute facilities in the Republic

A good day to bury bad news, expect that the report has a lot of good, common sense news hidden within its 64 pages: increased co-operation in the delivery of acute, primary and community care; joint procurement; joint paediatric and congenital cardiac services; additional radiotherapy provision in the North West; collaboration on chronic and lifestyle diseases such as obesity; the development of transplantation services; and joint brain injury services.

For such highly-specialised services, the population based in either jurisdiction may not be sufficient to sustain a team of appropriately-trained, skilled clinicians and the longer-term sustainability of a high-quality service may only be possible if considered on an all-island basis. Thus, combining resources for the provision of such services on a North-South basis makes sense.

However, the Compton review also noted that an area of similar population size to Northern Ireland — 1.8 million — in Britain would typically be served by four acute care facilities. If you do the same maths, that would leave just 10 acute facilities in the Republic.

With a combined population North and South of less than the city of London, one could legitimately ask, do we really need two distinct health services and employ 180,000 health staff across the HSE and the DHSSPS?

Interestingly, NI Health Minister Poots does not believe the potential reduction in acute hospitals is the most significant element of the Compton report; rather, it is the shift from hospital secondary care to the primary community sector. Our own Minister for Health would probably agree. But the voters of Newry and Coleraine — and Roscommon and Navan — would not.

Dara Gantly

It has been a difficult start to the year for the health insurance sector, after a long and tumultuous month and an even longer 2011, punctuated as it was by numerous premium increases. Not that the rest of 2012 is going to be any easier for either insurer or insured.

The Minister for Health surprised many last week by increasing the Government’s health insurance levy by 40 per cent, from €205 to €285 for an adult and from €66 to €95 for a child. Just a few weeks previously, Dr James Reilly reacted angrily to the suggestion by Vhi Healthcare that plans in the Budget to alter charges for private beds in public hospitals would double what it pays for customers attending public hospitals. If the insurer was to continue to cover all public hospitals, it would result in a premium increase of at least 50 per cent, Vhi warned.

Responding in turn, Minister Reilly said such talk of 50 per cent price hikes was “utterly unreasonably and not acceptable” to the sole shareholder of Vhi — the State. He said the increase in charges from such a move on private beds in public hospital would be less than 4 per cent, so any resulting increases should be closer to this mark.

Back in December — and again last week when he defended the insurance levy increase as being necessary to safeguard “intergenerational solidarity” — Minister Reilly reiterated that health insurers needed to look at their costs before passing on more increases to subscribers. While this additional scrutiny is likely to see consultants’ fees targeted (in particular, the so-called ‘€1 million’ earners), he also wants discounting of consultant fees if they are carrying out procedures in hospitals that should be able to be carried out in primary care.

He also wants the private sector to mirror the successes of the clinical programmes in the public sector, where, for instance, a ‘money-follows-the-patient’ initiative in orthopaedic surgery involving same-day admission has led to €6 million in savings.

But policy holders are unlikely to escape unscathed, as part of this cost review will no doubt include an audit of procedures to see if they are, in fact, necessary. If you recall, back in March 2009 a senior HSE official said the challenges facing the HSE then were akin to “war-time challenges”, with the likelihood that certain services would have to be rationed. Of course, things have only gotten worse for the HSE and ‘rationing’ is back on the agenda.

But is rationing also going to become a concern for private patients?

In England, one in three primary care trusts have reduced access to treatment for ‘non-urgent’ operations. Examples of rationing there include knee operations only being allowed to go ahead where patients are in severe pain, overweight patients being made to lose weight prior to procedures, and cataract patients being denied treatment until their sight problems seriously affect their ability to work.

'What’s also certain is that the number of people covered by private health insurance — which fell by 53,000 in the first nine months of last year — will continue to decline in the face of even more increased premiums in 2012, thus putting additional pressure on an already-stretched public service'

We are still awaiting the HSE Service Plan, but should expect the worst. Yet are we also about to see ‘low-priority’ treatments such as varicose vein surgery now come under the private health insurer knife? Will the move on private bed charges in public hospitals result in health insurance companies reconsidering their cover for all public hospitals in the future?  Does the Government’s intention to introduce legislation to allow public hospitals to raise charges in respect of all private patients in public hospitals eliminate the right of every citizen to avail of free public healthcare, as some have suggested?

I said it had been a long month for the health insurance sector. The buy-out of Quinn Healthcare by the company’s senior management team did bring a degree of “certainty”, as the Minister stated. But it also scuppered any possible plans for the State to purchase the company and merge it with Vhi ahead of the introduction of universal health insurance. What’s also certain is that the number of people covered by private health insurance — which fell by 53,000 in the first nine months of last year — will continue to decline in the face of even more increased premiums in 2012, thus putting additional pressure on an already-stretched public service.

The European Commission, meanwhile, is also certain to have more to say about Vhi’s continued flouting of EU directives, and the suggestion that the insurer will not become authorised by the Central Bank until the end of 2013 — all of which puts whatever plans the Government might have into perspective.

It seems there will be few winners following all the likely changes in the private health insurance market  in 2012 — certainly not the 2,174,000 people (and falling) still with private health insurance plans, nor the millions more (and growing) relying on our public system. To quote the famous (?) thinker Mike Tyson, “Everyone has a plan… ’til they get punched in the mouth!” Expect to be hit again — and hard.

Dara Gantly

Will the New Year see yet another ‘new’ health service administration emerge, asks Dara Gantly.

It seems one of the Minister for Health’s New Year resolutions is to implement more of the far-reaching health reforms promised in last year’s programme for government, and it appears he just couldn’t wait until January 1 to tell us of his plans. Just five days before Christmas, Dr James Reilly announced that there would be no more room for the old HSE in the Dr Steevens’ Inn. Instead, on December 20 the Government approved the drafting of legislation which, once implemented, will replace the current Board/CEO structure of the Executive with a Directorate. Please, no mention of deck chairs just yet!

Seven areas in total will be the subject of one of these news Directorships, which are seen as a necessary ‘initial step’ towards universal health insurance (UHI). Seven key individuals will be appointed as Directors for: Hospital Care; Primary Care; Mental Health; Children and Family Services; Social Care; Public Health; and Corporate/Shared Services. One of the seven will be appointed as the Director General, and it is envisaged existing HSE Directors or others identified by internal competition will be appointed to these new posts.

So in terms of personnel, perhaps not much of a change, although on the same day as the Minister’s news, Dr Frank Dolphin announced that he was stepping down as the Chairman of the Interim Board of the HSE, to be replaced by DoH Secretary General Michael Scanlan. The legislation to give effect to these changes will be given, according to the DoH, a “clear priority”. Not quite the Epiphany, then.

Nearly seven years previously to the day (December 23, 2004) the then Tánaiste and Minister for Health Mary Harney signed the relevant orders bringing the Health Service Executive into operation, with effect from January 1, 2005. At the time, she said the establishment of the HSE was a “significant milestone in the development of the Irish health services”. For today’s Minister, the Executive was, from the very outset, rather a millstone he was unwilling to carry around his neck.

“The purpose of the very significant restructuring which this represents is to enable the health services to develop to provide more effectively and efficiently for the needs of patients. To realise this potential, it will require the full commitment, energy and professionalism of all staff throughout the health services.” Forgive my mischievousness: the remark is by Mary Harney from December 2004 not Dr Reilly in January 2012.

So what has Minister Reilly said? Well, nothing he hasn’t flagged already, as the backdrop to all this is the introduction of UHI and the implementation of a ‘money follows the patient’ system. It’s his ‘big idea’, and a big enough one that demands little deviation.

Yet his ‘big announcement’ on December 20 had more than a whiff of publicity rather than the festive fragrance of frankincense. And one has to ask, will the HSE by any other name smell just as sweet?

Few would argue that the Minister needed to round off the year with some positive and proactive news on his radical health reforms. For apart from the resignations of the old Board of the HSE at the end of April and the appointment of Dr Martin Connor to head the new Special Delivery Unit (SDU) at the start of June, 2011 was largely another year of fire-fighting at the coal face of the health service. And while the SDU was technically delivered within the first 100 days of the Government’s term, as pledged, whether it has “assisted the Minister in reducing waiting lists and introducing a major upgrade in the IT capabilities of the health system” will take longer to appraise.

We do need reform of the health service; what we don’t need is another seven-year experiment that is reversed as soon as the political wind changes direction.

A resolution to stick to, I think.

Dara Gantly

Dara Gantly wonders whether the two ‘wise men’ from the east will come bearing gifts for hospitals in the West and Mid-West.

Our story starts with some distinguished foreigners ‘from the east’ observing a star at its rising before setting forth on a journey West. So it was — or will be — for Bill Maher, Acting CEO of St Vincent’s University Hospital, and Ann Doherty, former head of the National Hospitals Office, the Minister for Health’s chosen ‘wise men’ who will become the new CEOs of two groups of hospitals in the West and Mid West in the New Year.

Maher was named last week as CEO of the Galway/Roscommon Hospital Group, which now includes GUH, Merlin Park, Portiuncula, Ballinasloe and Roscommon Hospitals, while Doherty will transfer from the National Cancer Control Programme in early January to become CEO of the Mid-Western Hospitals Group. This will mean the MWRH, Dooradoyle, Ennis and Nenagh, together with the Orthopaedic Hospital at Croom and the funding arrangements for St John’s Hospital, Limerick, are to be placed within a single management structure led by a single CEO. In both cases, the hospital groups will have a single clinical governance model, one budget and one employment ceiling.

With record numbers on trolleys in Galway just a few weeks ago, and the new full capacity protocol seemingly only achieving a certain success, something radical was needed, and the Special Delivery Unit gladly obliged by coming up with what Minister Dr James Reilly described as an “appropriate solution”. But is it new management or a new system that is really required?

In a recent letter to Irish Medical Times (04.11.11, http://bit.ly/sHn7dD), the Medical Board of GUH pointed out that the hospital had reduced expenditure by over €35 million over the past two years, staff levels had fallen by 270 yet activity had been maintained, with the highest level of inpatient discharges in the country. Overall, GUH is the busiest single hospital site in the country, seeing more inpatients, outpatients and emergencies than any other hospital. All of which was resulting in significant pressure on the facility, with problems particularly in the emergency department.

Speaking on RTÉ radio last Friday, Minister Reilly praised the excellent efforts of Dr David O’Keeffe, Clinical Director and also acting CEO in Galway.

However, he said Dr O’Keeffe had been asked to do “the impossible” in trying to do these two jobs.

So what’s Dr Reilly’s epiphany, if you’ll excuse me getting ahead of myself? He wants the new CEOs to maximise the capacity of the hospitals to ensure the swift exchange of services out to the perimeter or periphery where it can be delivered at lower cost and at much greater convenience to patients.

But the Minister paints a more vivid picture: “I have said in the past, this idea of attending large hospitals like Galway or Limerick for varicose vein ligation, hernia repair or gallbladders is akin to taking a 10-year-old Volkswagen into the Ferrari testing centre. Sure, they’ll do a great job, but it is not the best use of resources.” The Minister certainly knows his cars.

But have we not heard this Christmas story before? Prof Brendan Drumm, the ghost of Christmas past, told us all some years ago about a resource allocation model where money ‘follows the patient’, and all about Integrated Service Areas (ISAs) and Regional Directors of Operation with overall budgetary control. Is this new set-up such a radical departure from that?

Will the Minister’s new ‘Magi’ be able to work their magic in the West and Mid-West? The CEOs are going to face a massive challenge, but at least they have been given three years to get the structures bedded down. Whether the announced changes do indeed prove to be a ‘good day for the West’ will be a story for another day.

Happy Christmas and see you in 2012.

Dara Gantly

Dara Gantly on the kites and clues ahead of the budget that indicate which way the wind might blow for our health service.

When the Minster for Health vowed to scrap the 50 cent prescription charge just a week into his new job, we didn’t think this would mean it would be removed, only to be immediately replaced by a charge potentially four times that amount.

But that’s what was reportedly discussed as a possible option by the Minister at a Fine Gael parliamentary party meeting last week and later in a briefing to Labour Party TDs and Senators, with all the sieve-like security that implies.

Whether the move — along with a €50 annual charge for a medical card, the closing of 40 community nursing homes and the introduction of co-payments for home care packages — was expert kite-flying on the part of the Minister or not, we will find out next week. Nevertheless, it is worth noting right now exactly what Dr James Reilly said back in March, in his first television interview after taking over at Hawkins House.

“I obviously have to talk internally with our finance people to see how soon we can do that [scrap the 50c charge], but that is something I have certainly undertaken to do and something that I believe was not a wise policy decision to take in the first place, because if you put any barrier between patients and their prescriptions you are likely to get less compliance.”

Junior Minister Deputy Róisín Shortall stated in the Dáil in June that it was still the Minister’s intention, subject to Government approval, to introduce legislation to abolish prescription charges for medical card holders. Then, in a written response to a Dáil question replied to last week, within just hours of his briefing to backbenchers, the Minister repeated this pledge, verbatim. What could be going on, you may ask, as another sail-like object floats over your head.

On one level an ‘unwise’ policy less than nine months ago — which if increased further would, by implication, have an even greater impact on compliance — has not only become no longer ill-advised, risky or stupid, but could become a handy revenue-raiser for the Government, if the charge was increased to €2 per item. In fact, €100 million could be generated annually.

At least Mary Harney seemed to honestly believe that the prescription charge would discourage the overuse of medication. It is too late for Minister Reilly to use that line; this has knocked the wind out of that particular sail.

But ‘we are where we are’, no longer ‘going forward’, but backwards — and at some speed — to the health cuts of the 1980s. So where might other increased charges appear?

In last year’s budget there were no hikes in the emergency department charge, the statutory day and inpatient charges, or the monthly threshold for the Drug Payment Scheme. So we can probably expect no escape there in the Estimates.

Most savings, however, are probably going to come in the areas of the new ‘old reliables’: drug costs, professional fees, procurement and administrative savings. Yet it seems almost inevitable that services will experience cuts or temporary closures.

Last year’s budget attempted to make reductions in a way that minimised the impact on services to patients and continued to protect, as far as possible, the most vulnerable. A €50 charge on a medical card would have certainly put paid to that by placing the burden on the sickest, poorest and most vulnerable.

All of which puts Minister of State Shortall’s announcement of just two weeks ago that free GP care for all would be brought in by 2015 — beginning with the scrapping of fees for the 56,000 registered as having long-term illnesses by next March — into perspective.

Quite a lot of scrapping, no doubt, in every sense of the word.

Dara Gantly

Dara Gantly on the latest ambitious targets to cut CVD rates.

It is described as an “alarming report”, which paints a “new dramatic picture” following the emergence of “disturbing evidence” throughout Europe. No, not the leak of yet more confidential Irish budgetary matters in the Bundestag, but the latest report on the impact of diet and physical activity on coronary heart disease and stroke, which was due to be released in Brussels this Wednesday (November 23).

Emotive language, you’ll agree, which is more often associated with members of my own lowly profession. The fact that these words are from the European Heart Network — the Brussels-based alliance of EU heart foundations, including the Irish Heart Foundation — and backed by the European Commission indicates just how seriously they want us to take the document.

The report, ‘Diet, Physical Activity and Cardiovascular Disease Prevention in Europe’, does indeed point to worsening trends across the board, with Ireland among the worst-hit countries. The result of two years of collaborative research, the report presents the most comprehensive review to date of the latest evidence on the relationships between cardiovascular health and what we eat or how active we are.

You’ll be aware of some of the shocking statistics: 12,000 Europeans die every day due to heart attacks, strokes and other forms of CVD; and the cost of disease in the EU is estimated at €192 billion, which is more than the entire EU budget. And with the dramatic rise in obesity and type 2 diabetes, together with an ageing population, the whole of Europe is indeed sitting on a ‘ticking time bomb’. Now they’ve me at it too.

The experts believe a tough legislative approach, combined with more ambitious targets on population nutrition and physical activity goals, is required.

In terms of what governments can do, some measures sound familiar, others less so. They want an EU-wide ban on industrially-produced trans fats in food; mandatory nutritional labelling in the form of a ‘sign-posting’ scheme; control of advertising unhealthy foods to children and a ban during all daytime broadcasting; the combined use of taxes and subsidies to promote healthier eating; and the removal of financial barriers to sports and leisure facilities, among other measures.

'What struck me more, however, was the long list of population goals set out in the report, including the ambitious longer-term goal for people to consume 600g of fruit and veg a day (that’s peeled and prepared), less than 4g of salt, and no sugar-sweetened drinks whatsoever'

What might dominate headlines in this country — particularly after the Broadcasting Authority of Ireland’s ‘Cheesegate’ controversy — is the call for changes in the EU Common Agricultural Policy (CAP) that would see market intervention for butter being phased out. I think IFA National Dairy Committee Chairman Kevin Kiersey might be back on RTÉ for a rematch.

What struck me more, however, was the long list of population goals set out in the report, including the ambitious longer-term goal for people to consume 600g of fruit and veg a day (that’s peeled and prepared), less than 4g of salt, and no sugar-sweetened drinks whatsoever.

An immediate exercise target is for 150 minutes of moderate-intensity endurance or aerobic activity per week — like quite brisk walking — in addition (my italics) to one hour of moderate activity on most days. But in the longer term, we should be aiming for at least 60 minutes a day of moderate-intensity physical activity in order to obtain additional health benefits, and we should be aiming for an average BMI of 21 in adults.

So how are we going to fit all this in? Well, what they call ‘active travel’ (like walking to our train station) can build physical activity easily into our daily routines, but the State can give us a head start by subsidising the use of leisure facilities, providing vouchers, and ensuring our local environment is safe and attractive to exercise in.

Although Europe-wide legislation will take time to enact,  “for governments the time to act is now”, according to Susanne Løgstrup, Director of the European Heart Network. But while we’re all waiting, I’m going to try some small changes, like going back to my morning run and having an extra drink of water before heading out to the shops… for a Coke.  As a former Minister for Health once told me, targets are important to aim for — even when you always miss them.

Dara Gantly

Dara Gantly wonders if the Government is playing the lottery with our health infrastructure needs

Welcome to tonight’s Lotto draw, which as always is independently observed by the DoH. Firstly, congratulations to the Central Mental Hospital (CMH), which may have won last week’s jackpot with the confirmation that the Government’s new five-year capital investment programme includes the much-needed replacement of the Dundrum facility. The hospital bought its ticket some 16 years ago and has have been playing since 1850 (the year from which the current facilities date). Minister Kathleen Lynch expects the new facility to be operational by 2016.

Back to tonight’s draw, and the new children’s hospital is playing for a jackpot of €650 million. So best of luck and off we go. And the first number out this Saturday is 445 (the number of beds envisaged in the hospital, which will also have 13 operating theatres); followed by number 2013 (the year construction on the project will hopefully start). Next we have 200 million (the amount in euro that was due to come from different sources including charitable donations, although Minister Dr James Reilly now says the development will not be contingent upon charitable donations). This is followed by 26,688 (the number of inpatient discharges envisaged in 2015; this should rise to 27,542 by 2021).

Next we have 2 (the number of Chairmen recently lost by the National Paediatric Hospital Development Board — its previous CEO also left for Tallaght Hospital). And now we have 55,700 (the number of urgent cases planned for the Ambulatory and Urgent Care Centre, to be located at Tallaght Hospital, in 2021, representing 45 per cent of all emergency attendances between the two sites). And finally tonight, our bonus number is 20 million — the amount in euro that could be saved in building costs due to the current competitiveness of the construction industry; a small silver lining to our dark economic cloud.

What the likelihood is of these numbers ever coming up remains to be seen, but the Government seems confident that a jackpot windfall from the sale of the National Lottery licence early next year will secure the hospital’s future. Indeed, Minister for Public Expenditure Brendan Howlin is “absolutely confident” the money will be secured — which suggests interest has already been expressed in a possible tender.

Would this sale generate enough money? Last year, the National Lottery generated €772 million in sales and €243.7 million was raised to fund good causes, bringing the total amount of funding raised to over €3.6 billion since 1987. So if, like in the UK, the Government was to run a competition for a 10-year licence, one would imagine this is doable. For every pound spent on the National Lottery in the UK, Camelot pays 50p into the prize fund, 28p to good causes, and 12p to the government — so 12 per cent of €722 million is €86.6 million, which means the €650 million required could be generated over seven-and-a-half years, and it would be well covered if the licence was issued for 25 years, as has been mooted by some.

On hearing that in the years 2012-2016 an investment of €1,950 million, or €390 million per year, will be made in health infrastructure, many no doubt were relieved that Health survived the capital machete much better than Transport or the Prison Service. Sighs of relief also probably emanated from those involved with the National Project for Radiation Oncology, the Clinical Research Facility at UCHG, and the replacement blood transfusion facility in Cork.

Good news too for IT contractors, as the Minister signalled a major upgrade in ICT capabilities for Health, and hopefully also for the beleaguered primary care strategy, with news that a new plan due for the construction of primary care centres based on a mixed Exchequer and private-funding approach is imminent, with State funding targeted at disadvantaged areas. And about time too.

So perhaps Health’s lucky numbers have come up this time around. From all of us here at the Lotto draw, slán agus beannacht leat.