How to fix the health service in 10 years

Kurtosis

We have a government, and a new Minister for Health, and so far the talk on this front seems positive with the development of a 10 year cross-party health strategy being proposed. Trying to build a consensus on this (a necessity given the Dail arithmetic) and with a realistic time frame for meaningful change has to be welcomed.

Things that I'd like to see included in it would be:

• Development of community-based diagnostic services which would allow GPs to effectively manage patients without having to refer them to hospital where the waits can be horrendous. One of the Sunday papers mentioned the idea of tax breaks for such equipment had been floated. Allied with this, introduction of practice-based pharmacists to try to optimise medication use/prescribing as part of wider primary care teams.
• Increased support for GPs in areas of deprivation, the variation in disease burden and health outcomes is pretty stark. Doctors cannot provide the same level of care in less affluent areas on the same resources as those in more affluent areas.
• Further movement towards universal health care, some of the statistics on wait time differences for public versus private care publicised in the last few weeks were deeply unsettling. The Dutch style universal health insurance model seems to have been dropped which is probably a good thing, given the rise in costs that have occurred in the Netherlands and we probably don't have the population to support multiple competing insurers. My preference would be a centrally funded single payer model, but that's easier said than done!
• Proper planning of different secondary care services within the hospital groups and reduction in duplication of services. This is a hard sell as generally people want their local hospital to do everything but rationalising this would likely reduce costs and improve outcomes.

So, what would you suggest should be in this 10 year health strategy? (disclosure: I genuinely am not in Hawkins House fishing for ideas :P)

palmcut

A seven day medical week.
An increase in the number of community GPs.
Sort out current "things" before we start adding more bits and pieces.

Drop the word (and thinking) Executive from HSE.

Just use Health service.
To date the HSE has spent too much at the Executive bit and not enough at the Health SERVICE bit.

Kurtosis

palmcut wrote: »

A seven day medical week.
An increase in the number of community GPs.
Sort out current "things" before we start adding more bits and pieces.

Drop the word (and thinking) Executive from HSE.

Just use Health service.
To date the HSE has spent too much at the Executive bit and not enough at the Health SERVICE bit.

I think the change in thinking RE Executive has started, at least at the top anyway. Heard Tony O'Brien speak a couple of years ago and he made a point of emphasising in his introduction that he was the Director General of health service.

It's interesting that you bring up the seven day working, it's a major point of contention at the moment in the NHS and was one of the factors that precipitated that recent junior doctor strike. There's also been a bit of a controversy over whether there is a "weekend effect" on mortality in hospitals, with a number of studies of late arriving at opposite conclusions.

Unz88

I think the soundbite of a 7 day health service is thrown around a lot without really considering what it means. Numerous studies have shown that the "weekend effect" i.e. increase in mortality following acute hospital admission at the weekend doesn't exist. Community pilots of GP practices opening weekends in the UK were found to be pretty inefficient, not cost effective as undersubscribed. Beyond Saturday morning attendances which are already in existence in many places, people just don't want to see their doctor on a weekend.
Even if a 7 day service was shown to be beneficial, the existing 5 day service absolutely needs to go to great lengths before we could even consider stretching our services beyond 5 days. Staffing and resources are so underfunded Monday to Friday, it would be a disaster to spread these thin to create the holy grail that seems to be the 7 day service.

RobFowl

In terms of GP's we are far short of the number needed to provide a 5/7 day service......

Dingle_berry

A strategy on improving good citizenship should be introduced across all government departments. If people fail to show for a public appointment without good reason they should be fined and put to the back of the (triaged) waiting list. Everyone should be registered to vote and fined if they don't show on polling day (like in Australia). Tax benefits for spending time volunteering.

In terms of the HSE itself, it desperately needs major IT modernisation. E charts, national LIS, electronic referrals, voice recognition dictation, etc. Get rid of paper, post and archiving costs. Phase out a chunk of admin staff.

Arbie

Dingle_berry wrote: »

A strategy on improving good citizenship should be introduced across all government departments. If people fail to show for a public appointment without good reason they should be fined and put to the back of the (triaged) waiting list.

I used to think about this when sitting in a Friday afternoon clinic which 50% of patients did not attend. They were timed appointments and we had to stay there until the last patient just in case, so we couldn't even go help out elsewhere.

I mentioned it to a colleague and she countered that the patients who don't attend are probably the ones who most need to attend and if we penalise them they may just opt out altogether. She gave the example of a patient with diabetes and poor control. If they are getting punished for poor attendance and pushed down the queue, they may end up costing more in time and resources when they end up in ED with renal failure, DKA, retinal detachment, etc. They are likely the 10% that require 90% of the care (made up numbers for illustration only!)

It's hard to balance increasing patient responsibility with the risk of unexpected/indirect increase in burden on the system down the road.

Have penalties been tried elsewhere? Any evidence for/against?

echo beach

Arbie wrote: »

I mentioned it to a colleague and she countered that the patients who don't attend are probably the ones who most need to attend and if we penalise them they may just opt out altogether.

That is a very insightful observation. We need to look closer at WHY people don't attend. Did they forget? Did they ever get the appointment? (Sometimes the appointment arrives after the clinic or goes to another person with a similar name). Do they have transport to get there? Are they afraid of being treated like a naughty child because they they didn't comply with treatment for whatever reason? Are the clinics arranged at a time that doesn't suit people?(At one time they held smear clinics at 2pm, the very time many women have to pick up children from school. Now you can book a time with your own GP and I'm sure very few opt for 2pm.)

It would be interesting to compare non-attendance at clinics with that at NCT centres where you can go on-line and make an appointment yourself rather than getting on in the post for a time that may not suit you.

Mrs OBumble

Unz88 wrote: »

Community pilots of GP practices opening weekends in the UK were found to be pretty inefficient, not cost effective as undersubscribed. Beyond Saturday morning attendances which are already in existence in many places, people just don't want to see their doctor on a weekend.

So how come a private weekend clinic is surviving in a town as small as Galway?

http://www.weekenddoc.com/

Corruptedmorals

Non-attendance is a massive problem. In the hospital I work in, every clinic will have 2-5 of them on average, very rare that there would be none. A healthy proportion of them are people who went private and did not take themselves off the waiting list. The HSE policy is you get 2 chances and then you're discharged with a letter to the GP.

What the hospital and several others are doing is validation of the waiting list, everyone on it is contacted either by post or by phone and they need to freepost the letter back in order to stay on the list.

As regards cutting down admin staff...maybe non-frontline but in my own experience (3 hospitals) frontline staff tend to be understaffed or adequately staffed.

E-charts would be amazing. Every week in this hospital procedures and appointments are cancelled after the patient has turned up because the chart cannot be found, it's that bad. Looking for charts is such a huge drain on time.

Speedwell

Priority health care for GPs themselves. Seriously. I would be so lost without the man who understands my body and its issues, and I hope he lives forever.

BrianBoru00

Bring in a dictatorship for 2 years.


Seriously, politics is the problem and as the largest employer in the state, there are so many different interest groups in the HSE that there'll be strikes no matter what changes are made.

A few small suggestions:

#1 €10 charge for GP visits for anyone with a medical card and OAPS.
This won't be brought in because of fear of political retribution for the government (the grey vote more powerful than low waged as evidenced by the ridiculously cynical ploy of not reducing the pension by 10% when everyone else in the country was targeted.) I know myself that I ve brought kids to the GP with high temperature and rash.We weren't overly worried but "hey its free sure we might as well". I was sorry both times as felt there wasn't an issue so haven't done so since. . .

#2 State run / subsidised nursing homes. Too many people are taking up beds (trolleys) in A&E where they could be cared for in a far more respectful way in a well run home (and/or day facility with an in house GP).
This is vital as the population is getting increasingly older and the current problems are going to be exacerbated

Speedwell

Corruptedmorals wrote: »

E-charts would be amazing. Every week in this hospital procedures and appointments are cancelled after the patient has turned up because the chart cannot be found, it's that bad. Looking for charts is such a huge drain on time.

As an IT database and CRM professional, I have often wondered if my fellow IT professionals would be interested in donating a few hours of their time to a great general data conversion and end-user training project to get the Irish health system on its technical feet.

Unz88

BrianBoru00 wrote: »

Bring in a dictatorship for 2 years.


Seriously, politics is the problem and as the largest employer in the state, there are so many different interest groups in the HSE that there'll be strikes no matter what changes are made.

A few small suggestions:

#1 10 charge for GP visits for anyone with a medical card and OAPS.
This won't be brought in because of fear of political retribution for the government (the grey vote more powerful than low waged as evidenced by the ridiculously cynical ploy of not reducing the pension by 10% when everyone else in the country was targeted.) I know myself that I ve brought kids to the GP with high temperature and rash.We weren't overly worried but "hey its free sure we might as well". I was sorry both times as felt there wasn't an issue so haven't done so since. . .

#2 State run / subsidised nursing homes. Too many people are taking up beds (trolleys) in A&E where they could be cared for in a far more respectful way in a well run home (and/or day facility with an in house GP).
This is vital as the population is getting increasingly older and the current problems are going to be exacerbated

Erm, so putting all the older patients into a nursing home is the answer?
Do you realise that when older people attend A+E there is usually a genuine medical problem underlying their presentation and they would not be admitted unless there was a good reason? Sure, there are massive delays in transfers of care out the back door after the acute issue has been sorted, and waiting times for nursing home transfer are ridiculous, but the problem does not lie at the A+E. Most older people want to go home and not to a "well-run" nursing home (which the HSE has had multiple failings on over recent years) and we need to be able to look at what our citizens' needs are before deciding to place vulnerable people where they dont want to be, when good social care arrangements could prevent this.

We need a serious look at how we are planning to look after older people in the coming years, and the answer isn't always nursing homes. If we had a properly integrated health and social care system (happening in NHS Scotland and other parts of the UK) we would be trying to keep people at home and healthy for as long as possible, before resorting to nursing home care (which the state is already struggling to afford)

BrianBoru00

Unz88 wrote: »

Erm, so putting all the older patients into a nursing home is the answer?
Do you realise that when older people attend A+E there is usually a genuine medical problem underlying their presentation and they would not be admitted unless there was a good reason? Sure, there are massive delays in transfers of care out the back door after the acute issue has been sorted, and waiting times for nursing home transfer are ridiculous, but the problem does not lie at the A+E. Most older people want to go home and not to a "well-run" nursing home (which the HSE has had multiple failings on over recent years) and we need to be able to look at what our citizens' needs are before deciding to place vulnerable people where they dont want to be, when good social care arrangements could prevent this.

We need a serious look at how we are planning to look after older people in the coming years, and the answer isn't always nursing homes. If we had a properly integrated health and social care system (happening in NHS Scotland and other parts of the UK) we would be trying to keep people at home and healthy for as long as possible, before resorting to nursing home care (which the state is already struggling to afford)

Erm, no. There is no single answer.
The multiple failings is why the HSE is broken. The title of this thread is "How to fix the health service in 10 years".

Do you realise that when older people attend A+E there is usually a genuine medical problem underlying their presentation and they would not be admitted unless there was a good reason?

which in a well run nursing home /day facility could be treated there and then without needing to visit A&E.

The "good reason" doesn't escape that fact.

Unz88

Nursing homes have GPs that attend for home visits. In working hours, it is usually a GP that makes a decision to send an older person into hospital from a nursing home, because they deem that the person is not well enough to remain in the nursing home for medical treatment. Out of hours GP services to nursing homes are lacking and this needs to be addressed.

I'm not sure what kind of set up you are envisaging for sick people in this well run nursing home. If someone is medically unwell then keeping them in a nursing home for treatment and denying them acute hospital management is unjust. If somebody is unwell enough to need intravenous antibiotics for example, then they should be looked after in an acute inpatient environment and discharged back to the nursing home when they are well enough.

Yes admission avoidance needs to be a key priority for nursing homes - that requires an increase in the number of GPs (ideally dedicated GPs looking after a group of nursing homes), it needs community geriatricians (which we don't yet have), we need more palliative services, we need to have a cultural and societal change around discussions regarding end of life and advance care planning (and ensure HIQA don't penalise nursing homes for having increased mortality rates for decisions to keep people in a nursing home to die).

Kurtosis

Speedwell wrote: »

As an IT database and CRM professional, I have often wondered if my fellow IT professionals would be interested in donating a few hours of their time to a great general data conversion and end-user training project to get the Irish health system on its technical feet.

There's actually been a lot of movement on this in the last couple of years with the setting up of eHealth Ireland (www.ehealthireland.ie). It's headed up by the CIO of the HSE who seems to have real vision. In terms of progress, eReferrals have been rolled out, the wheels are in motion to introduce individual health identifiers and three "Lighthouse Projects" are underway as proofs of concept for the delivery of an electronic health record...exciting times!

locum-motion

One of the elements of eHealth, when it happens, will probably be to make it legal to have ePrescriptions.

Currently, only a piece of paper signed in ink by a registered prescriber is a legal prescription. E-mails, scans, photos and (crucially) faxes ARE NOT legal prescriptions. If a fax were a legal prescription, there would be no way of knoowing that the fax hadn't been sent to ten different pharmacies, and therefore no way to know that the patient wasn't merrily obtaining ten times their prescribed dose of Mother's Little Helpers! (These methods do provide evidence that a prescription exists, but are not prescriptions themselves. If the prescriber requests it, they can form the basis of an emergency supply, and the prescriber must supply the original prescription within three days. However, that's getting off topic)

An ePrescription is a secure method of transmitting the prescribers intentions to the pharmacy. There are a couple of different models that can be employed; Pull & Push.

In both models, the prescriber uploads the ePrescription to some sort of HSE-run secure central database.

In the Push model, the prescriber (in theory anyway) asks the patient which pharmacy they'd like to use, and the ePrescrition is 'pushed' to that pharmacy only.

In the Pull model, the patient turns up in the pharmacy they want to use, and the pharmacist 'pulls' the prescription down from the database.

One of the key concepts of the profession of pharmacy is the independence of the pharmacist from the prescriber. One of the reasons that two separate professions exist is that the person choosing the treatment should not have a financial interest in supplying that treatment.

Another key concept is that it is always, and always should be, the patient's choice which pharmacy they use.

Both of these concepts are at serious risk of being compromised by a Push model.

It is imperative, when eHealth becomes a reality, that the ePrescription element of it is a "Pull" model.

Speedwell

locum-motion wrote: »

...In the Push model, the prescriber (in theory anyway) asks the patient which pharmacy they'd like to use, and the ePrescrition is 'pushed' to that pharmacy only. In the Pull model, the patient turns up in the pharmacy they want to use, and the pharmacist 'pulls' the prescription down from the database.

One of the key concepts of the profession of pharmacy is the independence of the pharmacist from the prescriber. One of the reasons that two separate professions exist is that the person choosing the treatment should not have a financial interest in supplying that treatment. Another key concept is that it is always, and always should be, the patient's choice which pharmacy they use. Both of these concepts are at serious risk of being compromised by a Push model.

It is imperative, when eHealth becomes a reality, that the ePrescription element of it is a "Pull" model.

From a data security standpoint, I think you argue well for the "Pull" model. I have personal experience with the "Push" model in the US system, as it happens.

I was a clinic patient. I had a primary doctor, but could be seen by any practitioner in the large, comprehensive, and multi-campus practice that missed being a hospital pretty much only because it did not have round-the-clock hours or inpatients. Every practitioner in the clinic had access to a central system with my records in it, and could see my entire medical history, tests and results, treatments, and medications. I mention this because I think it's likely that a high-tech system like this might be necessary to properly implement either the push or pull model. (I have no reason to believe, incidentally, that the practice shared any of my records with anyone but my insurance company, and that only to the extent allowed by law. I wasn't on Obamacare, so there was no central anything to which the clinic would have reported.)

Anyway, the doctor would ask me which local pharmacy I preferred to patronise, and I would almost always choose a reliable and inexpensive one in a nearby supermarket. I could choose others, but I had a good relationship with that particular pharmacist, and if I had gone to another independent pharmacy, my records would not have been consolidated. (Yes, sometimes people were able to get more than one prescription; I had accidentally done so myself when a new doctor called in a prescription for something of which I still had the bulk of a three-month order left.) By the time I got to the place to pick up the prescription, it would have already been called in by the doctor's assistant and placed in the queue to be filled, or even filled already depending on how busy they were.

I never had any significant issues with the system. From the pharmacy side, I don't know what precautions were taken to ensure the caller was really qualified to call in a prescription; perhaps they did it by e-mail, but I know that it was sometimes just a phone call. Occasionally I would request a different medication because the prescribed medication would make me too drowsy or my insurance wouldn't cover the requested formulation, and I know the pharmacist would just phone up the clinic and speak to the doctor's assistant.

Hope that helps. I like the idea of a central database that every doctor and pharmacist could access. Privacy rights are, I think, trumped in this case by the potential avoidance of medication errors and injuries (a pharmacist has in more than one case said, "Are you still taking X? You shouldn't also take that and this new medication Y", for example).

palmcut

There is another major problem that needs to be sorted before eprescribing in Ireland comes into vogue.
This is the area of correcting errors on prescriptions. Currently the average Irish pharmacy corrects at least 6 prescription errors every day.
The proposal is that these scripts will go through the HSE on their journey from GP to pharmacy.
Corrections would have to be done immediately by the GP or else the pharmacy would have to be allowed to make corrections electronically.
At present there are frequently extra items on scripts, wrong strengths prescribed, omissions from scripts, wrong directions, no directions and very rarely is an MDA script presented correctly.

Alun

When I lived in the Netherlands, my prescriptions were being transmitted electronically to the local pharmacy and that was 20 years ago, along with full electronic records, the lot. It came as a shock when I moved here and everything was still being scribbled illegibly on cards.