Acute hospitals are bursting at the seams. No one, including all previous ministers for health, has been able to eliminate the long queues for treatment. Official reports published over the past 15 years show the numbers of people using hospital services have increased greatly, despite Government policy to treat more people at primary care level.
The Health Service Executive’s National Service Plan for 2015 says: “Over the last number of years work has been underway to realise the vision for primary care services whereby the health of the population is managed, as far as possible, within a primary care setting with patients rarely requiring admission to a hospital.”
This vision is not being realised.
Ten years ago, a report from the Economic and Social Research Institute, Activity in Acute Public Hospitals in Ireland 2005, concluded "the level of activity supported by the acute hospital experienced stronger growth than the population. There were 246 discharges [day-patients and inpatients] for every 1,000 people, a 10 per cent increase on 2001, when there were 223 discharges per 1,000."
The latest report on hospital activity, published in December and available from the Healthcare Pricing Office (HPO), shows that the number of discharges in 2013 was 345 per 1,000 people, 55 per cent more than in 2001, a total of one and a half million patients. More than one million people were treated by emergency departments in 2014. This year, the HSE’s acute hospitals will provide appointments to more than three million outpatients, half a million more than 2006. As of January 2015, 395,720 were waiting for an outpatient appointment. These are staggering figures. It seems that nearly everyone is using hospital services. Are we any healthier as a result?
Population health
No one knows whether hospitals actually improve population health. The general consensus is people are living longer but are more likely to develop chronic diseases due to obesity, being overweight and lack of physical activity. The HPO reports reveal nothing about outcomes or whether patients are better or worse following treatment. Each admission is counted, not each person, so there is no way of calculating how many people are readmitted, or about the continuum of care. The reports tell us nothing about whether the services provide value for money.
One solution to hospital queues is to change the model of care. A majority of those availing of acute hospital services have chronic diseases, such as diabetes, psoriasis, emphysema and haemorrhoids, and the prevailing paternalistic model is not the most effective one for treating chronic disease. Angela Coulter, from the Health Services Research Unit at Oxford University, argues that paternalistic styles “create dependency, discourage self-care, ignore [patients’] preferences, undermine confidence, and do not encourage healthy behaviours”. She estimates that most people with chronic disease get at most two hours of professional care per year whereas self-care is 8,758 hours per year; this is best provided at home with support from primary care teams.
The meaning of hospitals
The meaning of hospitals has changed dramatically in the past 100 years. Originally they were set up to provide services to society’s poor. The rich were treated at home. The opposite is now the case. Citizens believe hospitals can solve their health problems, and that the GP won’t. Everyone wants an expert, therapist, counsellor or consultant. Instant waiting lists would materialise if the HSE provided a counsellor to every GP practice in the country to help patients with psychological issues. What happened to self-efficacy: “I don’t necessarily need an expert to tell me what to do.” What happened to self-care: staying in bed for a couple of days, drinking plenty of fluids and allowing the body to heal itself?
The current model of hospital services is unsustainable and will collapse sooner rather than later. Hospitals must orientate themselves away from patient compliance towards citizen empowerment. They need to stop counting patients, beds and discharges, and start measuring outcomes and value for money. They need to move to continuums of care linked to self-care.
The new National Healthcare Quality Reporting System is a step in the right direction. The first annual report published by the Department of Health this month lists some outcomes, including five-year cancer survival rates. It is not enough. We need a debate about what hospitals are for in the 21st century. And the sooner people are empowered to look after their health, the better.
drjackyjones@gmail.com Dr Jacky Jones is a former HSE regional manager of health promotion and a member of the Healthy Ireland Council.