SECOND OPINION:Lack of funding means demand-led planning not working, writes JACKY JONES
IRELAND IS facing challenging times over the next 10 years if forecasts of the numbers of people who will be living with chronic health conditions by 2020 are correct. Four recent reports published by the Institute of Public Health (IPH) describe the increasing prevalence of hypertension, diabetes, chronic airflow obstruction (CAO) and heart disease (CHD). The IPH used the Survey of Lifestyle, Attitudes and Nutrition (Slán) to estimate the chances of developing chronic health conditions associated with a variety of social, biological and behavioural risk factors.
All chronic health conditions are connected, and have common risk factors such as smoking, physical inactivity, poverty and obesity.
The reports estimate that the number of adults with hypertension will increase from the present 950,000 to 1.2 million by 2020, representing a 28 per cent rise. The number of adults with diabetes is expected to rise by 30 per cent, from 135,000 to 175,000. The number of adults with CAO will rise from 82,000 to 101,000, a 23 per cent increase.
Although heart disease treatment has improved in recent years, by 2020 the number of adults with CHD is expected to rise by 31 per cent, from 79,000 to 103,000. The estimates assume that levels of social, biological and behavioural risk factors do not change: that poverty does not get worse, that the same numbers continue to smoke, and there is no increase in obesity levels.
The recession is a new risk factor. High unemployment rates mean that the percentage of the population with chronic conditions by 2020 will be greater than predicted. The Slán data shows “the influence of social and economic factors on levels of reported psychological distress is very evident”.
Unemployed people are more than twice as likely to be depressed. People with depression are more likely to smoke, eat less healthily and take less exercise, leading to a vicious cycle of more ill health and more depression.
Forecasts of population changes are often used to plan the development of public services. This is known as “demand-led planning” and is the most common methodology used in Ireland. Demand-led planning means the vision for future services is based on estimated needs and not available resources. In the health services, this translates into more health professionals and more clinics.
Demand-led health planning doesn’t work because there is never enough funding to cater for present needs never mind future needs and cuts inevitably lead to beds in corridors and long waiting lists.
The 2011 HSE Annual Report shows nearly 19 million GMS prescriptions were filled last year, 1.3 million more than 2010. The National Diabetes Programme is being implemented only this year and will inevitably be affected by the cuts. Stroke units were expected to be developed in nine target sites in 2011 and only six are operational. How is the HSE expected to cope with at least a third more people with chronic conditions? An impossible task unless it changes its approach to planning.
Henk van der Kamp from the School of Spatial Planning in the Dublin Institute of Technology might have the answer. He argues that demand-led planning methodologies that work from the present to the future have failed and proposes a supply-based approach that works from the future back to the present.
This involves describing and analysing the future as if it has already happened, which produces a clearer picture of what must happen now. The “assumed-future” method triggers innovative solutions and is more sustainable because the description of an assumed future is based on available resources, not demand.
Van der Kamp’s theory applied to health planning involves analysing the estimates produced by the IPH for 2020 and then assuming a different, better future. Suppose 2020 Ireland succeeded in halving the numbers of people with chronic diseases. The backward planning method asks, how did that happen? What worked?
You can be sure fewer people with chronic conditions means healthy public policies have been pursued, at least three-quarters of all health services are supplied by primary care teams, the menu of hospital services is considerably reduced, obesity is no longer driven by the food and drink industries, cigarettes are sold in plain packaging, and smoking is not allowed other than in your own back yard.
Dr Jacky Jones is a former regional manager of health promotion with the HSE