Fixing the health crisis without massively increasing tax or borrowing

golfwallah

After all the negative news from court cases to growing waiting lists to public pronouncements about absence of a clear national plan, it’s good to hear a few positives of late.

Firstly there’s Minister Varadkar’s announcement about savings on medical cards (without any diminution in entitlements), then progress to avert / defer the nurses strike and now there is good news about IT initiatives under way to improve patient records.

OK money will continue to be tight – but there are signs of light at the end of the tunnel, improvements in management so as to get better value for money out of the public health money pit.

Following personal experience of inefficiencies in paper based records in a large public hospital last year, I am particularly gratified to hear of progress on the Individual Health Identifier and the next step towards an electronic health record for every person in the country. This will certainly help to improve the level of service as demand increases and medical knowledge improves way ahead of growth in available budget. It’s interesting that we are in a position to learn from the mistakes made in other countries. This article in siliconrepublic covers the subject pretty well, including how these initiatives are being clinically led and explains how a public consultation process is in train to see how people would like to see these new records implemented (in terms of privacy issues, etc.).

golfwallah

There's been very little public debate about the use of IT to help the process of modernising our health system. Given the potential for budgetary savings, it's an area crying out for action. The downside is that the debate could be divisive. It will compare the benefits of more informed patient care and strategic decision making against the costs in terms data protection of confidential individual healthcare information.

I guess the absence of public debate is down to avoiding a big political row on the eve of the forthcoming general election. Hopefully, the debate will get more of a public airing after the election so that people can become more informed about the issues involved, the pros, cons, etc.

Here's some more information on the topic for those interested:
http://www.ehealthireland.ie/Strategic-Programmes/Individual-Health-Identifier-IHI-/

http://www.irishtimes.com/news/health/new-health-identification-number-for-every-individual-1.2135560

FreudianSlippers

In my opinion, the only way to fix the health crisis is to hand over the running and staffing of hospitals to the private sector. The Department should be negotiating deals with companies to ensure maximum efficiency and increasing standards on a tightly controlled budget. The government itself is far too bloated, inefficient and wasteful to run hospitals themselves from the ground up.

BoJack Horseman

FreudianSlippers wrote: »

In my opinion, the only way to fix the health crisis is to hand over the running and staffing of hospitals to the private sector. The Department should be negotiating deals with companies to ensure maximum efficiency and increasing standards on a tightly controlled budget. The government itself is far too bloated, inefficient and wasteful to run hospitals themselves from the ground up.

According to the HSE, 7.8% of their expenditure is on admin/management/corporate services..... and 2.7% of staff numbers employed therein.

I don't know how a private healthcare company stacks up against that, like Beacon Medical Group or somthing like that, however the above amount of overhead must surely compare well.

I agree that the private sector should play a much more active role, there is far too little private sector capacity in the hospital sector.... however a state provider (HSE or otherwise) will always be needed.

FreudianSlippers

BoJack Horseman wrote: »

According to the HSE, 7.8% of their expenditure is on admin/management/corporate services..... and 2.7% of staff numbers employed therein.

I don't know how a private healthcare company stacks up against that, like Beacon Medical Group or somthing like that, however the above amount of overhead must surely compare well.

I agree that the private sector should play a much more active role, there is far too little private sector capacity in the hospital sector.... however a state provider (HSE or otherwise) will always be needed.

I'm not suggesting the State shouldn't necessarily pay. They should allow the running of the hospitals to be done by the private sector though.

BoJack Horseman

FreudianSlippers wrote: »

They should allow the running of the hospitals to be done by the private sector though.

Why?

(and remember, that in this service, the unions call the shots).

What would a private tender deliver, given the above, that the recently streamlined HSE not?

FreudianSlippers

BoJack Horseman wrote: »

Why?

(and remember, that in this service, the unions call the shots).

What would a private tender deliver, given the above, that the recently streamlined HSE not?

I don't want to mention the war, but isn't it the same as the theory behind Irish Water. Ultimately phasing out the dead weight and undermining the power of the unions?

BoJack Horseman

FreudianSlippers wrote: »

I don't want to mention the war, but isn't it the same as the theory behind Irish Water. Ultimately phasing out the dead weight and undermining the power of the unions?

That's my point..... that didn't happen at all due to union embargo...

So, as I asked, what would giving control of the hospital sector to companies do with SIPTU calling the shots.

FreudianSlippers

BoJack Horseman wrote: »

That's my point..... that didn't happen at all due to union embargo...

So, as I asked, what would giving control of the hospital sector to companies do with SIPTU calling the shots.

Sorry - I've twice typed out a mid-sized reply and twice the site has been FUBAR! I give up but if the mood strikes me tomorrow I might try again

gctest50

golfwallah wrote: »

There's been very little public debate about the use of IT to help the process of modernising our health system. Given the potential for budgetary savings,.......

One main way IT in healthcare would help (& reduce costs ) is the records would be less prone to being altered after significant event ( if it's set up properly timestamps,offsite etc etc etc)

Once that little get-out-of-jail-free card is more or less removed, people tend to be a tiny bit more careful

( if your doctor has never, ever made a mistake with anyone - run, run away, aliens!)

All really caused by insane working hours

http://www.irishtimes.com/business/doctors-not-compliant-with-working-hour-limits-until-2017-1.2157898

which all leads to payouts :

Responding to a parliamentary question, the Minister for Health outlined that more than €197 has been paid out in the past three years for claims against the HSE.
The Medical Indepenent details that this consists of:

• €64 million in 2011.
• €47 million in 2012.
• €85 million in 2013.

and all that needs much admin and more

BoJack Horseman wrote: »

According to the HSE, 7.8% of their expenditure is on admin/management/corporate services..... and 2.7% of staff numbers employed therein..........

golfwallah

gctest50 wrote: »

One main way IT in healthcare would help (& reduce costs ) is the records would be less prone to being altered after significant event ( if it's set up properly timestamps,offsite etc etc etc)

Once that little get-out-of-jail-free card is more or less removed, people tend to be a tiny bit more careful

( if your doctor has never, ever made a mistake with anyone - run, run away, aliens!)

All really caused by insane working hours




which all leads to payouts :



and all that needs much admin and more

There's really no need for the "insane working hours" that are a feature of our paper based, sub-optimal health information system. All stakeholders need to work together to bring about a more information based system / process that belongs more to the modern age than our Dickensian paper based systems. The situation "as is" is one in which all practitioner and hospital records are kept in separate silos that are virtually useless as an aid to an evidence based medical information system.

It's not more and more admin that is required but rather more effective, evidence based and secure information systems to support front line health practitioners to deliver more effective health care.

It's also critical that the medical practitioners are the system sponsors / owners, supported in system delivery by relevant IT and other functional experts.

Here's an example of what can and has been done in the VISTA system in the US (for veterans):
http://www.ehealth.va.gov/engine/swf/player.swf?url=/EHEALTH/videos/VA_Vista_OPEN_CAP368.flv&volume=100

gctest50

golfwallah wrote: »

Here's an example of what can and has been done in.........

That's over there though and i'm sure they have a lovely system for HR and payments and things

The fear that it would upset things means it would end up like PPARS

THE PPARS (personnel, payroll and related systems) computer system used by the HSE was a disaster.



Professor Brendan Drumm called a halt to its national rollout in 2005 as costs ballooned from an initial estimate of €9m. It has cost well in excess of €220m to date and is able to do just a fraction of the work intended.

It was hoped it would provide detailed information on its 136,000 staff for human resources as well as draw up rotas. However, it is only capable of paying 30,000 staff and storing information on 70,000.




http://www.independent.ie/irish-news/ppars-fiasco-as-costs-hit-220m-26567284.html

golfwallah

BoJack Horseman wrote: »

Why?

(and remember, that in this service, the unions call the shots).

What would a private tender deliver, given the above, that the recently streamlined HSE not?

gctest50 wrote: »

That's over there though and i'm sure they have a lovely system for HR and payments and things

The fear that it would upset things means it would end up like PPARS

Why blame the unions when unions are just doing what unions do, i.e. represent their members? And do we seriously think that, in Ireland, from the example of poor specification, design and implementation of a system like PPARS, we are permanently rendered incapable of bringing into reality a modern, fit for purpose health information system?

No – these issues are down to poor management and poor leadership or a combination of both. Blaming the unions, poor decision making or whatever are just excuses for not delivering results.

And, yes, it’s hard to manage situations, like the current state of industrial relations in which management either don’t or are not allowed to manage (by their political masters) – but it’s not impossible! It’s also hard to specify, design and implement an effective management information system – but also, it is not impossible.

It has been said that there's no such thing as bad employees, only bad managers – and this adage certainly meets with my experience over the years.

The same applies to leadership – just look at the difference between Churchill, who embraced change, inspired others and led his people through an almost impossible situation, and Chamberlain, who was a good man who just wanted to give people what they wanted most (peace). What we need is leadership, good management and the courage to do what it takes - from the political through to senior executive levels!

See also this article on the subject.

micosoft

BoJack Horseman wrote: »

According to the HSE, 7.8% of their expenditure is on admin/management/corporate services..... and 2.7% of staff numbers employed therein.

I don't know how a private healthcare company stacks up against that, like Beacon Medical Group or somthing like that, however the above amount of overhead must surely compare well.

I agree that the private sector should play a much more active role, there is far too little private sector capacity in the hospital sector.... however a state provider (HSE or otherwise) will always be needed.

I have to agree with this. Far too much "received wisdom" around the health service and unhelpful terms like front line health workers as if the front line don't need a long chain of supports.

It was interesting to hear a consultant this week complain that not all Nurses for example were being helpful and certainly not the INO with regard to the ER overcrowding.

I agree that we need a mix of models - neither of the extremes work. If you look at the fundamental problem it's not that private sector is better then public sector. It's that flexibility and terms and conditions of employment are so entrenched in the Public Health Care system here. And that's hard to fix as the INO threat of strike shows...

micosoft

golfwallah wrote: »

Why blame the unions when unions are just doing what unions do, i.e. represent their members?

In most functioning organisations Unions understand they need to work in partnership with Management, not opposition. They get away with it in the HSE because unlike a private company it can't go bust. Nontheless I can't accept a Union's role is to focus on their terms at the expense of the organisation and mission. It's highly dysfunctional and reminiscent of 1970's UK unions as opposed to Continental Model where Unions want to be part of the solution for a well run organisation (for the most part/broad brush strokes etc).

golfwallah wrote: »

And do we seriously think that, in Ireland, from the example of poor specification, design and implementation of a system like PPARS, we are permanently rendered incapable of bringing into reality a modern, fit for purpose health information system?

The system chosen to run HR in the HSE runs happily in many other state and private sector companies. The challenge was implementing a HR system without consolidating terms and conditions across the HSE. That was setting up the implementation for failure. Ultimately the lack of will to force through standardised terms and conditions led to the project failure. No arguably they shouldn't have even started it until this was ironed out but then the complaints against management would have been they are not on top of staffing. A hobsons choice.

This is also a bugbear of mine. The reason there is a perception that their are more project failures in the public sector is that they are far far far more likely to be reported on then a private sector company where they can easily brush it under the carpet. I'm mainly worked in the private sector (and still do) and find this old trope simply not true.

golfwallah wrote: »

No – these issues are down to poor management and poor leadership or a combination of both. Blaming the unions, poor decision making or whatever are just excuses for not delivering results.

But management and leadership have consistently gotten both of their hands tied behind their backs because instead of normal shareholders they are beholden to politicians. Who hate things like strikes. Therefore they have to ask for changes and if the Union says no... well that's more or less the end of the story. The reason in my mind to privitise is not so much because the private sector is better but that it would depoliticize the service. No reason other then lack of political willpower to do this in the context of a public system.

golfwallah wrote: »

And, yes, it’s hard to manage situations, like the current state of industrial relations in which management either don’t or are not allowed to manage (by their political masters) – but it’s not impossible! It’s also hard to specify, design and implement an effective management information system – but also, it is not impossible.

It has been said that there's no such thing as bad employees, only bad managers – and this adage certainly meets with my experience over the years.

Let the managers manage and then criticize them!

golfwallah wrote: »

The same applies to leadership – just look at the difference between Churchill, who embraced change, inspired others and led his people through an almost impossible situation, and Chamberlain, who was a good man who just wanted to give people what they wanted most (peace). What we need is leadership, good management and the courage to do what it takes - from the political through to senior executive levels!

See also this article on the subject.

Big difference between a War of survival and ongoing running of the Health Service. We don't need a hero to save the Health System. We just need to put in an appropriate system with the right levers to get people to behave in a high performing way and the support to face down those who don't want change even if that means front line workers out on the streets.

jimmycrackcorm

The health system can only be fixed by scrapping what we have and rebuilding from afresh with a completely different perspective. Like a Web 2.0 version. My mrs is a nurse and I don't get shocked any longer when she tells me stories about how patients have died because the "rules" say they can't give life saving treatment because they need to get hold of the one doctor available that's not actually available.

ressem

jimmycrackcorm wrote: »

The health system can only be fixed by scrapping what we have and rebuilding from afresh with a completely different perspective. Like a Web 2.0 version. My mrs is a nurse and I don't get shocked any longer when she tells me stories about how patients have died because the "rules" say they can't give life saving treatment because they need to get hold of the one doctor available that's not actually available.

The "clean slate" / "bulldoze and start again" view is always attractive but very often fails badly when implemented on a large institution.

Accurate information needs to be kept available, if not at fingertips, then within a few meters to decision-making front line staff.
Nurses shouldn't be forced to consume half an hour to phone around wards for space, or to locate a doctor, or access an x-ray queue.
(They were meant to be trialing that MedXNote app created by a start-up to replace pagers, in Blackrock and St James)

Part of this is management failure, other is people being obstructionist. Functionally it should be a solved problem to be imported from other hospitals, piloted on a quieter hospital in Ireland to clean up any country-specific nuances.

They should be a couple of years into this 7 year plan.
http://www.ehealthireland.ie/Knowledge-Information-Plan/eHealth-Strategy-for-Ireland.pdf
What's working, what's not being achieved?

ressem

It looks as though the EU is driving a common inter-operable Electronic health record and electronic medical record;
http://www.eurorec.org/RD/eStandards.cfm
http://himss.eu/emram
Apparently Galway Clinic is one of the hospitals demonstrated as showing best practice in health IT implementation, stage 6 out of 7
http://himss.eu/emram-stages.
( the public service spends something like 0.8% of budget on IT, compared to substantially more by private hospitals, understandably. )

so they might avoid the situation that's in the US with EPIC managing the records of 170 million americans but having GPs, and users of the competing systems complaining that they cannot access / interoperate with those records.
http://www.motherjones.com/politics/2015/10/epic-systems-judith-faulkner-hitech-ehr-interoperability

As Richard Corbridge points out in the OP's referenced interview, there are substantial savings possible from being a follower. And his group's approach of providing the electronic records first to Epilepsy sufferers, who have most to gain is sound.
The suggestion is made that a 'cancer cure' will resemble the modern epilepsy diagnosis; highly particular to individuals, involve a few genome scans to identify the most problematic / target-able mutations out of 15,000+ in the affected cells.