Sir, – Since Ireland differs from many comparable countries by apparently running public and private healthcare systems in parallel, it is tempting to believe that the two can be readily compared. Indeed, given that about half the population hold private insurance, superficially the scenario resembles a carefully matched experimental protocol rather than a hotchpotch that results from generations of refusal to make decisions or intervene. Had I not spent much of my life working in Irish hospitals, I would be in agreement with Mark Mohan (Letters, July 25th), who elegantly argues that the public side of our system “underdelivers overwhelmingly”, while the private side performs relatively well. To fairly assess the situation, one has to look at what the two components cover. This serves not only to understand the current reality but also to offer guidance on possible progress toward improvement.
The private system broadly is set up to cater for elective, scheduled and highly predictable procedures. There is no onus on private operators to provide any particular service, nor at any particular, let alone antisocial, time. And if conditions of provision change, such as if the risk of litigation grows prohibitive or demand changes, like any other private business, they can stop, and redirect their efforts. Identifying well-reimbursed procedures that can be scheduled during office hours is crucial.
Conversely, the public system has to provide 24/7 services to all on the island, covering the rarest events and cannot refuse anyone. Private obstetric hospitals have essentially been eliminated by the risk and results of litigation during recent decades. Trauma services, dealing with winter surges, and the enormous but unpredictable consequences of alcohol consumption are left by default to the public system. Intensive care is highly expensive, unpredictable and thus remains almost entirely a public hospital specialty.
Where one can compare scheduled care in public and private centres, lessons can be learned. Specialised public orthopedic hospitals, or those focusing on ophthalmology, or ear, nose and throat work perform quite efficiently. Not having to cope with influxes of patients from emergency departments is hugely beneficial to scheduling.
Conversely, our obstetric hospitals are predicated on the fact that they will have to offer essentially the same level of service round the clock, as the true rhythms of biology are not dictated by office hours. They are regarded as excellent internationally, in many cases despite very poor infrastructure. But enormous amounts of resources are wasted on the no-man’s-land between these extremes–- hospitals that are not that busy out of hours, but must remain open nonetheless. They frequently have small numbers of rather anxious staff within them, hoping that little will happen and knowing they are unfit to cope if anything much does. This accounts for very poor returns on invested resources. The motives for maintaining such arrangements are usually political and very local.
The coupling of emergency with elective services on the same site is also a situation that forces unacceptable trade-offs. Having your cardiac or brain surgery deferred because someone had a car crash, or fell over while drunk ought never happen but remains common. Frequently the same doctors work in public and private hospitals, but they arrive at work in the latter type knowing with considerable certainty what their day will hold. We need more elective public hospitals, places where cases can be scheduled reliably in the confidence of completion. As it is, with anything inherently predictable being directed to the private sector – covered by insurance companies or the State – the public sector is left with high-risk, litigious and complex emergencies and trauma to deal with. It is believed to care for about half of patients but actually receives 100 per cent of complex emergency work. It is doomed to look inferior as long as this method of case selection applies. – Yours, etc,
BRIAN O’BRIEN,
Kinsale,
Co Cork.
Sir, – The recent report from the ESRI, “Projections for Workforce Requirements for Public Acute Hospitals in Ireland 2019-2035″, is a very important contribution to future healthcare planning at national and regional level. The report clearly identifies the two key factors driving future healthcare demands; population growth and ageing.
However, I do have one major concern regarding the report. The report’s projections are based on a central population scenario of 5.44 million by 2035. The report also refers to a low population scenario of 5.3 million and a high population scenario of 5.8 million by 2035. I believe there is compelling evidence that the high-population scenario is the more likely outcome.
The report appears to have been completed before the CSO 2022 census figures became available and of course the influx of Ukrainians and other international refugees are now adding a new upward dynamic to the overall population.
Census 2022 shows a population of 5.12 million. This is an increase of 361,671 since the 2016 census. This is equivalent to an average annual increase of just over 60,000 in that six-year period. The longer-term trend is also interesting. In 2002, the population was 3.91 million. In the 20 year period from census 2002 to census 2022 the population has increased by 1.2 million. This is also equivalent to an annual average increase of 60,000 over the 20 year timeframe. It is a reasonable assumption to make that the current population growth trends will continue into the future, and may even accelerate. If the current growth trend continues, it means that the population is likely to reach 5.4 million not by 2035, as the report suggests, but by the time of the next census in 2027. If current population growth trends continue the population of is likely to reach 5.9 million by 2035, higher even than the reports high population scenario of 5.8 million.
Ukrainians fleeing from war and the rise in the number of international refugees, added to the natural rise in population, is likely to see the population grow by more than 100,000 in 2022 alone. This very rapid rise is putting increased demand on healthcare, education and social services. A hard clampdown by British authorities on illegal migration is also contributing to increased migration to Ireland.
Taking all the above factors into account, I believe the ESRI central population scenario of 5.4 million by 2035 is a serious underestimate. A population close to six million by 2035 is the more likely outcome. We need to plan our healthcare system for a population of that size. Continuing high levels of investment in infrastructure and personnel will be required to meet the growing demand. – Yours, etc,
COLM BURKE TD,
Cork North Central,
(Fine Gael
Health Spokesman),
Blackpool,
Cork.