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Hospitals slowly squeezed to death through neglect and lack of investment – Mitchell Speech by Fine Gael Health Spokesperson, Olivia Mitchell TD, at the Fine Gael National Conference, Galway, on Saturday 29th November 2003. I want to begin by thanking our contributors for giving us some very thought provoking and varying views on different aspects of the health service. And it is the vastness and the multifaceted nature of the health service which makes it so problematic – which makes it so difficult to propose the kind of holistic health model that meets all of our aspirations in terms of what we expect from a health service, and which at the same time is cost effective. Seeing the bigger picture is the real challenge in a sector that is increasingly specialised where everyone is an expert in their own area, but no one has the ability to stand back and get the ‘birds eye view’. The result of that is that the debate tends to focus, at any time, solely on one aspect of the service or it degenerates into a sort of blame game where some other group is always at the root of the problem. And it is not just the professionals who have strong points of view. You just have turn on talk radio any day to hear who is to blame for the sorry state of the health service. The consultants, of course, are favourite hate figures, followed closely by that dreadfully selfish creature ‘the private patient’. As for the poor health boards, no one has a good word to say for them. The GPs and the pharmacists are all ripping us off and either there are not enough medical cards or there are too many and they are all spongers anyhow. And so on and so on. Of course, there are fragments of truth in all these points of view, but I am afraid they all miss the bigger picture. Including the health professions, who often view the health service from their own perspectives. They tend to be as sectoral, as territorial and as competitive as any other group in society. They are also highly politicised and when they want to be are extremely articulate and highly motivated vested interests. They would deny that their lobbying is in anything other than in the interests of their patients. And of course it usually is, but often only in the very immediate and narrow sense. In short, our health service is fragmented, disparate and disjointed. Accountability is dissipated, information is either non-existent or difficult to access. Regions, hospitals, managers and health professionals are all competing with each other in the desperate scramble for scarce resources and continuing influence. In the last number of years the Government poured money into this mishmash, while at the same time they allowed the underlying problems to fester away, so that now we have a service which is creaking at every seam and screaming for reform. And reform is not just an option, it is essential. We simply cannot sustain even the health service we have now, the one with which there is wide spread dissatisfaction, if we continue with the same structures and delivery method as before. And it gets worse than that. There are further problems coming down the road at us which will exert inexorable pressure on costs. Better and consequently more expensive drugs, technological improvements resulting in more sophisticated and more expensive diagnostic and treatment methods. Where before a check up was with our GP and his stethoscope, now we want a full body scan on a €1M machine. As a result of better medicine we will live longer, but there will be higher maintenance costs associated with keeping sick people alive and functioning. And of course the biggest time bomb of them all is the fact that the population as a whole is getting older. Its worth remembering that our demographic profile will never again be less demanding in terms of cost than it has been for the last few years. Our population bulge, our twenty somethings, are the least costly in terms of their health demands and we have had a very low dependency ratio at both ends of the spectrum. But that is changing and the change will be rapid and dramatic. Despite the population age spread being very very favourable for the past few years, out of every euro the Government spends, 25cent of it is spent on health. If one Government department is taking 25% of the spend, then that leaves a big hole in what is left to the other 14 Government departments. Every taxpayer, on average, is contributing €6,800 to pay for the public health service. That makes it absolutely imperative that every penny spent is spent to good effect. There must be systems in place to ensure that we know exactly where the money is needed and how it should be spent. Too much money has been wasted in our health services because of a lack of basic information, the underestimation of the extension of the medical card to the over 70s by millions of euros is one example. Our health services cannot afford these mistakes. There is an urgent need for a significant investment in information technology. We must also be looking at the long-term effects of that spending. One cost effective area which has been largely ignored by Government is the area of preventive medicine. We spend a significant amount of time and money treating ill patients when the focus should be on preventing these illnesses and diseases in the first place. Prevention is better than a cure. This makes sense from a public health and from a public expenditure perspective. Preventive medicine can only be achieved by developing primary care facilities, improving access to primary care, introducing more health screening programmes and by intensifying health promotion initiatives. There is of course wide spread recognition of the need for reform and the Minister makes much of his reforming zeal and his intention to revolutionise the health service. Unfortunately, both these reports and any sign of reforming zeal in the Minister came rather late in the day and much too late in the life cycle of the Celtic Tiger. But in any event, many of the reforms talked about are rather timid in nature and I genuinely do not believe they go half far enough. I have referred to the changes proposed as changes in the system rather than the systems change that is really needed. It is true that there will be some savings by getting rid of health boards, but I suspect the savings will be of a once off nature and certainly not giving the kind of sustained downward pressure on costs that is needed in the long run. The administration of health is now to be centralised under a new body called the Health Service Executive. Ironically, the last major reform of the health structures was a recommendation to move in precisely the opposite direction. While there are undoubtedly some decisions which need to be made centrally, it hardly seems likely that a return to soviet like central administration and decision-making is going to bring us enormous efficiencies. On the contrary it seems more likely that in a big monolithic organisation that new inefficiencies will quickly establish themselves. I believe its time for the State to start withdrawing from the position of provider of all services and to begin to examine the possibilities for the increased use of market oriented solutions in the health sector. In short we need some competition in health care provision. Many would argue that health is not a product like any other and is too important to be left to the vagaries of the market. However, I would contend that precisely because health is different and is such an important product that it cannot be left to a single provider. It is undoubtedly the State’s function to develop our health policy, to regulate health provision and to ensure that healthcare is provided, but there is no philosophical justification which suggests that only the State can run hospitals. Only with the introduction of competition can we capture for patients the benefits of the market and ensure that the health services benefit from innovation, from financial and operational efficiencies, the use of technologies, the incentives to control costs, and all of the other dynamic benefits that operate automatically in a system in which competition flourishes. Ideally hospitals would tender to provide services as would laboratories and x-ray departments. Obviously, hospitals would have to be set up at arms length from Government and could, if they did not perform, potentially lose the contract to provide services. I do not envisage that the State would overnight withdraw from the provision of healthcare, but I think it is a direction in which the health service must begin to move. For the moment the Government is both the provider of all services, the employer of all personnel, the price setter, the price taker as the owner of the hospitals and even more bizarrely sets the price of private health insurance. Within this system, no matter how well meaning management, administrators and health professionals are, there are simply no inbuilt incentives to provide value for money, to innovate, to respond to the changing demands of the population and consequently, we pay more than we need to for less than we deserve. I want now to say a few things about Hanly in response to Professor Loftus and also in response to the wide spread concern which has been expressed about its implications. I want first to refer to the aspect of Hanly which has attracted most opprobrium – the reduction in A & E services, currently located in approximately 40 hospitals to approximately 12 hospitals. The rationale of course being that the quality of service that can be given in a regional centre with teams of multidisciplinary consultants, with state of the art diagnostic and treatment facilities would be infinitely better. And of course they would be better. But there are two things to say about that. The first being that for most A & E visits patients do not either want or need 50 consultants nor do they need state of the art equipment. What they want for the most part is simply the comfort, certainty and reassurance of being able to see a doctor. And if you are lucky enough to live within a reasonable orbit of your regional hospital then you will see a doctor. In fact, you will be spoiled for choice of doctors. But if you live 30, 40 or even 50 miles away the chances are you will not have that certainty. And its not merely because we doubt the commitment or ability to fund and put in place better roads, better equipment and more ambulances with fully trained staff, a better resourced and equipped GP service, all of the things promised are needed to guarantee access. Of course we are sceptical about those thing coming, but even if they did, we are sceptical that they would fully compensate for the loss of the local service. And the reason I say that is I genuinely believe that distance will actually influence change the way people will behave and react in a medical emergency. If you have a child who gets sick in the middle of the night, and to the lay person it is very difficult to distinguish a real emergency from yet another run of the mill childhood illness, but if you live 5 or even 10 miles from the hospital you will get out the car or call an ambulance. More than likely it is nothing serious, but you need the comfort of knowing. But if you are an hour or an hour and half’s drive away you are far more likely to hesitate, to wonder about taking the child out of bed for a long drive in the middle of the night, to question bringing an ambulance 40 or 50 miles and then possibly facing the prospect of getting a taxi back home. You will probably decide to stay put until the morning. That hesitation may be fatal. By morning the child may have advanced meningitis That is an extreme example, but not I think an unlikely scenario and one I could multiply many times. So while the majority would undoubtedly get top class treatment in the regional hospital, a sizeable majority could lose out and rightly no one is willing to sacrifice their families in order to participate in an untried health experiment. This is the message going to the Minister from Ennis and Nenagh and all of the other hospitals around the country and the Minister ignores what they are saying at his peril. In persisting in the view that Hanly is an immutable Holy Grail he is demonstrating a huge arrogance and jeopardising the positive aspects of Hanly. The public do not want or expect brain surgery in every hospital. They have never had it and do not want it. What they do want though, and what it is not beyond the Minister’s ingenuity to provide, is some form of medical cover on a 24-hour basis. With the thousands of new consultants promised it must be possible to roster a continuous medical presence in the majority of hospitals. There is much of Hanly which has merit. But there is a huge scepticism about both the availability of funding and about the capacity of the system to deliver change on that scale. People see what happened to Monaghan hospital and what is happening elsewhere as hospitals are being slowly squeezed to death through neglect and lack of investment. They believe it will be the same with Hanly. They believe that they will get the cost saving measures of the package, but they will wait and wait for the enhanced services. It is our job to ensure that does not happen. The reform investment programme must start and start now and plans to remove 24 hour A&E on-site services from the majority of hospitals must be shredded, permanently.