For years we have been hearing about long waiting lists for public-hospital treatment in Ireland. However, the recent RTÉ Investigates programme Living on the List brought home in graphic detail the human stories behind these waiting lists. But why do we have these waiting lists and what needs to be done to ensure they are reduced?
The Irish health system has many good points, and these need to be acknowledged. Front-line staff provide high-quality service, with which most patients are very happy. However, accessing the public-hospital system is problematic, and there are a number of reasons for this.
The first is that the system does not have the capacity it needs to deal with the demand for services. Ireland’s public-health system suffered from severe cutbacks in the 1980s and early 1990s, during which thousands of hospital beds were closed. We still have not built this capacity back up again, meaning we now have fewer beds than we did in 1980, despite an increase of a third in the population since then and a two-thirds increase in the over-65 population, which is disproportionately likely to require hospitalisation.
While we are making more use of day-case rather than inpatient procedures, and while we are trying to keep people out of hospitals by improving the primary care system, it is quite clear from the waiting-list figures that we need more hospital beds.
Capacity problem
To put this into perspective, OECD figures show we have 2.8 hospital beds per 1,000 population, compared with an OECD average of 4.8. If we were to bring our bed numbers per 1,000 up to the OECD average then we would need more than 9,000 additional hospital beds. While we may not need quite that many – our population is younger than the OECD average, although it is growing and ageing – it indicates the scale of the capacity problem.
We also have relatively fewer doctors per 1,000 population (2.7 compared with an OECD average of 3.3) and a lower proportion of doctors in Ireland are specialists than the international average. Again, if we were to bring our numbers up to the OECD average we would need to recruit more than 2,800 additional doctors.
The argument has been made recently that we are spending €14 billion on our health service and that our spending as a proportion of GDP is towards the higher end of the international comparisons. However, in addition to not fully recovering from the cutbacks in the 1980s and 1990s, we experienced a significant cutback in public-health expenditure as a result of the fiscal difficulties the country suffered between 2008 and 2014. During this time, the Health Service Executive’s budget and staff numbers were cut, despite the fact that demand for public health services continued to rise. Therefore, any relative overspend now needs to be viewed in the context of previous underspending.
Furthermore, because of capacity constraints, which lead to longer waiting lists, patients' conditions have, in many cases, deteriorated by the time they are treated (and we saw examples of this in the RTÉ Investigates programme), meaning they need more complex – and therefore costlier – interventions. In this context, €14 billion does not go as far when people are being seen at a later stage of illness than it would if they were seen earlier.
So what can be done to deal with the waiting-list issues? Obviously, increasing capacity will be necessary, but this will take significant time and money – the ongoing story of the national children’s hospital is testament to that.
In the short term, the National Treatment Purchase Fund will be given additional money to have patients who have been waiting long periods on public lists treated privately. As an immediate response to a crisis, this is a pragmatic approach, but it should not be relied upon in the long term. It also highlights another, more fundamental, issue that needs to be dealt with, which is the intertwining of public and private funding and delivery of healthcare in Ireland.
Overlap
It is not unusual to have public and private healthcare systems operating alongside each other, but where Ireland is unusual is in the degree of overlap between the two.
Recent figures show that, in 2015, more than 19 per cent of inpatient discharges from public hospitals were of private patients. While the use of public hospitals by private patients is a long-standing feature of the system, it makes little sense to have private patients being treated in public hospitals while public patients are being treated in private hospitals, which have spare capacity, because they cannot access those same public hospitals in a timely fashion.
However, moving the treatment of private patients away from public hospitals would require contract renegotiations with consultants, as well as additional public funding to replace the private income currently being received by public hospitals and to pay for the treatment of additional public patients instead.
The Minister for Health, Simon Harris, has said the problems cannot be boiled down simply to money, and there is some truth in this. However, it is equally true to say the kind of serious reform we need in order to ensure we are not still talking about waiting lists in years to come will not be achievable without significant additional resources. We need to accept this and move on to having a mature discussion about how to generate these resources.
Brian Turner is a health economist at UCC