An "Irish NHS" - what needs to change?

astrofool

I'm a firm believer that there should be a nominal payment for everything, even €2 for a "free" GP visit would handle 90% of the missed or unnecessary visits. Everything truly free is abused and people take more than they need. If they had put the water charges at some very low level it may have worked, instead Hogan flew all sorts of kites and had lots of different allowances that no one believed or trusted the system.

Economics101

A point which has been missed in the discussion so far is that the NHS costs less per head than the HSE, especially when the NHS covers over 95% of the UK population whereas over 40% of Ireland's population subscribe to private health insurance. I don't have the exact numbers to hand but overall Ireland spends a higher amount per head on total healthcare than does the UK.

The scandalous bit is that all that money seems to get such poor results (especially in terms of delayed treatment). TO make matters worse Ireland has a significantly lower % of its population aged over 65 than does the UK. And generally the oldies cost an awful lot more on average.

Mad_maxx

a willingness to put parochialism to one side , opposing the closure of hospitals in towns like roscommon etc , that needs to stop but due to our electoral system , its meat and drink to the likes of the healy raes

we need to get behind the " centres of excellence " strategy

Geuze

dulpit wrote: »

But none of this explains (apart from the free gp) what is different between the NHS and the HSE? What do you get with the NHS that the HSE doesn't give us?

Four fees in Irish healthcare:

(1) GP fee
(2) Pharma up to monthly DPS limit of 124?
(3) A&E fee = 100
(4) overnight fee in hosp = 80pn


NHS waiting time = max 18 weeks in England, from GP referral / 2 weeks for suspected cancer
[note that it seems this 18wk target isn't been met]


HSE waiting time = up to 15 / 18 months

https://www.irishtimes.com/news/health/leo-varadkar-targets-15-month-waiting-limit-for-treatment-1.2076970

Geuze

Economics101 wrote: »

A point which has been missed in the discussion so far is that the NHS costs less per head than the HSE, especially when the NHS covers over 95% of the UK population whereas over 40% of Ireland's population subscribe to private health insurance. I don't have the exact numbers to hand but overall Ireland spends a higher amount per head on total healthcare than does the UK.

The scandalous bit is that all that money seems to get such poor results (especially in terms of delayed treatment). TO make matters worse Ireland has a significantly lower % of its population aged over 65 than does the UK. And generally the oldies cost an awful lot more on average.

Yes, we over-spend on healthcare, relative to the age profile of our population.

dulpit

Geuze wrote: »

Four fees in Irish healthcare:

(1) GP fee
(2) Pharma up to monthly DPS limit of 124?
(3) A&E fee = 100
(4) overnight fee in hosp = 80pn


NHS waiting time = max 18 weeks in England, from GP referral / 2 weeks for suspected cancer
[note that it seems this 18wk target isn't been met]


HSE waiting time = up to 15 / 18 months

https://www.irishtimes.com/news/health/leo-varadkar-targets-15-month-waiting-limit-for-treatment-1.2076970

So if we ignore how well (or not) the HSE is performing, the key difference of the service between HSE and NHS is that we currently pay for GPs, A&E, stays in hospitals, pharmacy, things like that.

But the actual offering of the 2 services is essentially (or theoretically, at least) the same?

dulpit

Oh actually, is private health insurance a think in the UK?

Geuze

dulpit wrote: »

Oh actually, is private health insurance a think in the UK?

Yes, e.g. BUPA.

I think about 10% of the pop buy it.

Geuze

dulpit wrote: »

So if we ignore how well (or not) the HSE is performing, the key difference of the service between HSE and NHS is that we currently pay for GPs, A&E, stays in hospitals, pharmacy, things like that.

But the actual offering of the 2 services is essentially (or theoretically, at least) the same?

Another big difference is consultant contracts.

Most of ours have contracts that allow them to do private practice.

Pandiculation

Given the shape of Irish healthcare, with lots of different providers and a significant private insurance setup, I think a continental model would make more sense in many ways.

If we went for something like a version of the French, German or Dutch systems it would give you universal healthcare with an element of a social market economy in the system for providers.

The NHS is a pretty old monolith that originated at a time when healthcare was very simple, and relatively cheap to provide and was built almost from scratch in the aftermath of a war and out of a system that was pretty old school.

I think were 70+ years late to create an NHS, but we could easily transform into a model like one of the better implementations on the continent.

There are multiple ways of doing a public health system and it doesn’t have to be the NHS, which to be quite honest has many of the issues of the HSE.

I think part of the problem the HSE has is it never made its mind up on what model It is using. It has aspects that have evolved more like the NHS and other aspects that look more like the continental systems and a layer of top up private insurance and far too much out of pocket payment.

We aren’t getting value for money nor are we getting adequate universality, yet we are paying a pretty serious amount of money into it.

There needs to be some very serious analysis of why the costs are so high.

I think an element of it could be that we are competing with some very over paid health systems for key staff. If you look at the US system, the costs are almost at an unsustainable level. It’s a balance that’s more towards private insurance but the costs per capita have grown almost exponentially since the 1990s to the point that they’re paying way more than the most expensive EU public systems, yet getting worse results.

I always get the sense here that we are both influenced by it and also we have people expecting those levels of payments, or they disappear across the Atlantic or to Australia.

The NHS has similar issues with medical staff moving abroad. The Irish system probably even more so due to issues with extremely over loaded working conditions in a lot of areas and poor career paths.

I don’t think we’re getting to the bottom of why our costs are so high though.

quokula

Geuze wrote: »

Four fees in Irish healthcare:

(1) GP fee
(2) Pharma up to monthly DPS limit of 124?
(3) A&E fee = 100
(4) overnight fee in hosp = 80pn


NHS waiting time = max 18 weeks in England, from GP referral / 2 weeks for suspected cancer
[note that it seems this 18wk target isn't been met]


HSE waiting time = up to 15 / 18 months

https://www.irishtimes.com/news/health/leo-varadkar-targets-15-month-waiting-limit-for-treatment-1.2076970

That NHS target isn't even close to being met. I lived in the UK for ten years and I can say that my wait times varied from 6 - 18 months, never once was it less than 18 weeks. Also, you can forget about seeing a GP in under 2 weeks. It got consistently worse from year to year too as the Tories dismantled the system.

My experience with the HSE since moving home is that it's far easier to see a GP (though having to pay, obviously), and the wait time to see a consultant has been about similar. I noticed a marked difference in quality of care though - on the NHS their main priority was always to get you out the door as quickly as possible and onto the next patient, in the HSE they're actually trying to help, to the extent that I've seen much more progress in treating a chronic condition I'd been suffering in two years here than in ten years in the UK.

This is anecdotal of course and will vary by consultant but it is a pattern I saw consistently across multiple NHS trusts. I think it's a natural result of a system where they are measured according to the speed they get through their waiting list, with actual outcomes seemingly being far less important. If you have a life threatening condition it's different, but if you have a chronic condition that impacts your quality of life, the NHS just doesn't really care.

Something else I will add is that my partner is a health care professional and worked for the NHS, but earns a lot more for the same job in Ireland. Some will say that's a reason why the HSE is more inefficient and say the unions have too much power, but I personally prefer to live in a country where nurses don't routinely have to use food banks to survive, even if that does mean we get less bang for buck on healthcare expenditure.

Pandiculation

The NHS was probably at its peak decades ago. The issue is a mixture of the Tories dismantling things and more expectations of high tech and expensive treatments in a budget that isn’t keeping up.

I find one issue in the U.K. is that the NHS tends to be seen as a national treasure, and often discussed as if there’s no public health systems anywhere else except in the U.K. The reality is it’s a mid-performer in the European public health league tables and has growing issues in some areas.

We need a far more universal system, but I’m not sure the NHS is the model to follow. It’s aims about universality are, but I think there are probably better ways of achieving that that turning the HSE into a giant, vertically integrated, monolithic organisation.

To me that would seem to be a recipe for an even more inflexible and admin heavy setup.

The continental models can achieve mixes of public and private ownership and very high levels of universality.

Kermit.de.frog

Pandiculation wrote: »

I find one issue in the U.K. is that the NHS tends to be seen as a national treasure, and often discussed as if there’s no public health systems anywhere else except in the U.K.

It's the UK. Always been like that. It's the same uninformed misguided sense of exceptionalism as they use with their migrants whom they refer to as "ex-pats", for example.

Wanderer78

dulpit wrote:

I get that the HSE management is a bit all over the place, but apart from that, what sorts of services would an "Irish NHS" offer that the HSE doesn't?

A functioning health care system

Economics101

Economics101 wrote: »

The UK NHS has a lot in common with the Irish GMS as operated by the HSE. Biggest differences are coverage for GP services, Drugs costs, and dental treatment.

What is not realised is how much else the HSE and the NHS have in common: they are both basically free or heavily subsidised at the point of usage and are both almost entirely financed directly through taxation. They both seem to have a propensity to generate long delays and queues for treatment. Sometimes the HSE is worse (for hospital treatment and consultant services) and sometime the NHS is worse (apparently to get a GP appointment).

The big contrast is with many systems in continental Europe, which tend to be more insurance-based. This does not necessarily mean a State insurance scheme, but it does mean a very high degree of regulation. Often there are relatively modest co-payments to deter frivolous usage. The main result is that providers have an incentive to get people treated so they can get paid. Also the providers are not necessarily State-owned. As long as they meet all the regulatory requirements that's what matters.

People in the UK tend to think they have the world's best health service. They don't. For some reason (mainly Irish Times journalism, in my opinion) many Irish people also suffer from NHS delusion.

I would disagree having worked in both the HSE and the NHS.
The NHS is far ahead in it's IT infrastructure, MDT involvement and it's public health screening.

As an example, in the NHS, I could pull up anybody's medications prescribed by their GP and also every electronic note that their GP has written on them since they introduced it 3-4 years ago (The access to this information literally is a live saver in acute med/ED.

Transfer of care between primary and secondary care is absolutely horrendous. Nobody second checks a patient's discharge in the HSE (you would be quite lucky to get one from my experience, sometimes it's just a prescription you receive.

The HSE is improving slowly but the NHS does provide a better service and better value for money (although I acknowledge it's easier to provide better value for money due to size of population.

Economics101

The Dazzler: you say you disagree with my post, but in fact you didn't really disagree!. You mainly raised a new point, and a very valid one: the continuing train wreck which is the HSE's lack of a proper IT system. This will become more apparent when it comes to the ongoing tracking and management of covid vaccinations

tommybrees

Eric Cartman wrote: »

anything that could realistically fix the HSE would cause strikes or riots, pissing off the unemployed or the heavily unioned public service is not something any career politician would even consider.

Agree 100%
It's a big mess that will probably never be fixed

Geuze

Pandiculation wrote: »

Given the shape of Irish healthcare, with lots of different providers and a significant private insurance setup, I think a continental model would make more sense in many ways.

You may recall in 2011 (?), the FG/Lab Govt planned to introduce UHI.

UHI = universal health insurance

Plans were developed, but eventually abandoned.

I think it could be a good idea.

I am not confident about Slaintecare.

Geuze

Deleted User wrote: »

I would disagree having worked in both the HSE and the NHS.
The NHS is far ahead in it's IT infrastructure, MDT involvement and it's public health screening.

.

+100%.

We are a centre for ICT, we have dozens of MNC here, and yet our own healthcare ICT is poor.

If I collapse 200km from home, I want the ambulance staff and local medical staff to be able to access my health history.

dulpit

I think a lot of people are now comparing how the HSE operates versus the NHS - but my query was more to do with the idealised offerings of the 2. So if the NHS was operating perfectly and the HSE was operating perfectly, the key differences so far are:

1. You don't pay anything for NHS services essentially
2. You pay for GP, medicines, A&E, hospital stays with HSE

Are there any other key differences?

Duckworth_Luas

Duckworth_Luas wrote: »

Nothing is free

In the context of what we are discussing it’s free. I’m aware that tax payers pay for it.

dulpit

dulpit wrote: »

I think a lot of people are now comparing how the HSE operates versus the NHS - but my query was more to do with the idealised offerings of the 2. So if the NHS was operating perfectly and the HSE was operating perfectly, the key differences so far are:

1. You don't pay anything for NHS services essentially
2. You pay for GP, medicines, A&E, hospital stays with HSE

Are there any other key differences?

I don’t know what you are exactly looking for. There may well be, and are if I’m remember correctly, management differences. Lots of hospitals over there are trusts.

Let me put it this way, private health insurance is very uncommon over there. Most companies don’t offer it. No need.

ancapailldorcha

Wanderer78 wrote: »

A functioning health care system

Structures like the NHS don't just appear from nowhere. The 1946 NHS Act just established a network between existing structures which were already present in Britain.

Any issues plaguing NI's NHS and/or the HSE aren't going to be fixed by an all-Ireland NHS.

Pandiculation

Geuze wrote: »

You may recall in 2011 (?), the FG/Lab Govt planned to introduce UHI.

UHI = universal health insurance

Plans were developed, but eventually abandoned.

I think it could be a good idea.

I am not confident about Slaintecare.

I think it needs more reform than just UHI as you could get into rapidly escalating costs if it’s poorly designed or if there’s an incentive to over treat and hike prices, as is the case in the USA.

However, I think we have an issue where the Irish system is trying to be all models at the same time.

In public health, most European countries run on a version of “the Bismarck model” which has evolved from usually credit Union style local, regional or work based insurance funds into a very highly regulated, universal insurance model. They’ll typically have some small degree of out of pocket payment, but far less than here and mostly recouped.

Or there’s the Beveridge model which is the U.K. NHS approach.

What worries me if the Irish system is a mix of both of those and has a completely private layer that’s semi integrated into it.

A big part of the problem seems to be that we’ve never really decided what the system is here and how it works. It’s just loads of ad hoc messes bolted together.

The objective needs to be universality and minimisation of point of use fees. The grand philosophies of what type of model is used aren’t all that relevant to the end user but they’re very important if we are trying to design a system that works.

It can’t really continue as an unfair two tier model where you’ve huge public funding, yet relatively low cost private insurance gets you priority access. I think that’s where we’re are seeing most of the distortions but it’s also why we’re not solving them as we aren’t confident that the public system is able to deliver, so large numbers of us (and many of whom aren’t exactly the wealthy) hold onto private insurance as a precaution.

That to me is why we’re stuck.

If you moved to a continental style model, you could integrate the two, providing decent coverage for the whole population.

BrianD3

My fear is that the time for our NHS moment was years ago but at that time we were too poor. Healthcare has obviously become far more complex now than it was in 1948. How are we going to dismantle and rebuild a system that has been in reactive if not firefighting mode for so long.

Like buying an old house in a cramped and unsuitable location and continually extending it as you have more children and ending up with a monstrosity. The best solution is to demolish it and start again but then you have no house. As time goes on, it gets more and more difficult to bite the bullet.

Unions are a factor but it is too simplistic to continually point at them. With such fundamental and long standing problems, it may be the case that some of the unions are keeping the system from collapsing entirely by forcing some structure to the mess. Without unions would we see situations along the lines of nurses being dragged away from their jobs to do the work of porters because "the porter is sick and we've got nobody to cover for him", in effect bailing out management.

magicbastarder

i think a lot of the issues are down, in large part, to what i've seen in both public and private sector - inefficiencies 'bake in' more than efficiencies do as organisations (especially large ones) mature.
i think it might have been in 'the wire' where i heard the line 'the system evolves to protect itself'; as in, the system itself becomes more important than what the system is supposed to deliver.

i've heard quite a few stories over the years about how large organisations (and i'm including multinational corporations in that) become incredibly slow and inefficient.

Pandiculation

Well, we were poor but the Catholic Church and a vast array of vested interests ensured our NHS moment never happened back at the launch of the Mother & Child Scheme in 1950.

I think the VHI could have formed the basis of a continental style system though. It just needed to be turned into a state owned, universal insurance fund. You’d have had to basically add a layer of PRSI like universal contributions to a health fund.

We still could create that model though. I think we’re getting a bit over fixated on recreating the NHS, even though it’s not necessarily possible in the system we have evolved.

What we have looks a lot more like say, France but we’re not there with universality of coverage and have bits of an NHS like approach and bits of private voluntary insurance.

You’re not realistically going to turn a system like it’s into a monolithic NHS. Most of that was built in an era when healthcare was evolving from a very basic level and also in the aftermath of WWII when there was huge economic upheaval and an ability to rebuild from scratch.

You’d also risk reinforcement of the HSE and Dept of Health bureaucracies, neither of which seem to be showing much ability to be efficient or flexible.

trixi001

dulpit wrote: »

I think a lot of people are now comparing how the HSE operates versus the NHS - but my query was more to do with the idealised offerings of the 2. So if the NHS was operating perfectly and the HSE was operating perfectly, the key differences so far are:

1. You don't pay anything for NHS services essentially
2. You pay for GP, medicines, A&E, hospital stays with HSE

Are there any other key differences?

Paying for services is the major difference - but like said the IT system means all parts of the HSC (which is the NHS plus social care in the North) can access the records of patients

The free at the point of use especially for GP's is an important feature though - how many people put off visiting a doctor in the South as they have to pay and give things a few weeks see if they resolve on their own - this has an impact on health care

The free at the point of use means issues are caught sooner and the focus is on early detection

Geuze

Is it helpful to separate financing from provision of healthcare?

While I think everybody should have access to h/c, and the State should regulate that, I don't think the State should provide all h/c.

Pandiculation

I had the discussion about the centralised health data system, which was being much lauded in Denmark during the vaccine rollout, and I found a lot of people wouldn’t be all that comfortable with such a system, despite its usefulness.

If you could imagine all your health data, possibly including very personal details about physical health, mental health and potentially social worker type information all being held in a state database, probably linked to your PPSN.

Personally, I wouldn’t be at all comfortably with that.

I could see a role for limited, efficient data interchange for things like records flying back and forth between a consultant and your GP, medical imaging etc but a big huge treasure trove of information on single database is always a data breach or misuse waiting to happen be it through malicious use or function creep.

I prefer data to be shared only when needed and to be largely within the control of the person to whom it relates.