SECOND OPINION:HSE might be forced to plan for health rather than disease, writes JACKY JONES
I MUST BE one of the few people in Ireland who think that cutting more than €700 million from the health budget for 2011, with more cuts to follow in 2012 and 2013, might turn out to be a good thing. The reason I say this is because cuts of this magnitude might finally bring about changes in the way health services are planned and detailed every year in the HSE National Service Plan (NSP).
In fact, no plan exists for Irish health services; instead we have a plan for treating more and more disease. This almost exclusive focus on diseases is a very expensive way of doing business. No country in the world, including Canada and the UK, has managed to reduce health expenditure by planning for disease and not health.
The annual HSE NSP, which is submitted to the Minister for Health, contains details of services which will be delivered to the public in the coming year. Every year for as long as I can remember – 35 years – success is seen as doing more of everything and, in particular, delivering more treatment programmes. Indeed, “we are exceeding all targets” is part of the rhetoric frequently used by health managers when trying to explain why hospitals and community services are yet again overspent. The notion that it would be better if fewer people needed HSE services does not seem to be part of the mindset of service planners. Surely fewer people requiring health services means health planning is succeeding. Let me give you some examples.
In 2007, the number of clients receiving methadone treatment was 6,800; the target for 2010 has increased to 8,775. One way of interpreting these figures is to presume that more people are availing of treatment. Another way of looking at it is that this increase highlights a failure of prevention strategies. In 2007, there were 530,000 long-term illness claims. The target for 2010 is 1,084,000: the number of claims has doubled in three years! The number of prescriptions for 2009 was 16.2 million; the expected target for 2010 is 18.4 million. The total number of children in care in 2009 was 5,334; the expected target for 2010 is 5,700. So more children are expected to need residential and foster care this year than last year. Again this can be seen as a positive thing if we are viewing the figures from the perspective of “treatment”, but as a failure if we are viewing the figures from a prevention, family support service point of view.
The incidence of type 2 diabetes is increasing in Ireland and this is closely related to obesity. A new performance indicator for 2010 is the number of patients taking part in a structured programme of diabetes care. It is likely that HSE success will be measured as this number increases year-on-year.
Bariatric surgery, which limits the amount of food someone can eat, is now being carried out in more hospitals as a “treatment” for obesity. Every year, the service plan includes more of these operations and this is seen as success. Type 2 diabetes and obesity can be prevented and, while bariatric surgery may help individual patients who have life threatening weight problems, it will not do anything to ease Ireland’s overall obesity problem. In fact, the availability of bariatric surgery will make the problem of obesity worse because precious funds will be spent on expensive surgery that could be spent on preventing obesity.
No one seems to be calling a halt to this madness and saying let’s plan for fewer diabetics, fewer drug addicts, less heart disease, fewer children needing care. This would involve exploring what additional prevention and health promotion programmes we need in order to ensure that fewer people need disease services. Currently the HSE spends less than 0.2 per cent of its overall budget on health promotion, even though the World Health Organisation recommends that 10 per cent of all health spending should be in this area.
We have to stop people falling into the river in the first place and not spend billions saving lives downstream. Even mid-stream programmes such as methadone treatment – which can be equated to teaching people how to swim – is not a long-term solution to health funding problems.
Cutting the budget by a massive €700 million-plus in 2011 might start the process of planning for health – because we just can’t afford to go on as we are. An analysis of the 2011 NSP will show whether the HSE is now planning for health and not disease or if prevention programmes have been cut instead.
Jacky Jones has recently retired as a regional manager of health promotion with the HSE