What is wrong with the health service, HSE

Not a particularly surprising story, the decline of our critical sectors continues

touts wrote: »

No doubt they will have to hire a few hundred more accountants to run the project to reduce services.

I think it was Stephen Kinsella who did a study a couple of years ago that found 42% of staff in HSE are admin staff. In NHS that is 20%. In private healthcare it is 10%.

The health service is run by administrators and accountants as a cash cow for administrators and accountants. They keep the system as bloated and inefficient as possible so that it takes an army of administrators just to keep it from toppling over.

i think joe stiglitz has argued in the past, the more privatized a health care system becomes, the more bloated it becomes with admin and accountants, so whos right?

Eric Cartman wrote: »

The problem is that you had the 4 regional health boards, The HSE was formed and because of unions instead of sacking 2 or 3 of the 4 people doing the same job, they all stayed, so you just had all the same people from the same boards under one roof , As time has gone on , backed up by unions , even as staff have retired these positions have been retained, and worse still, computerising and automating of services has led to more staff being needed because some older staff just refuse to upskill, so you need younger staff to be the link between them and a computer. Then theres the procurement infighting where buying expensive equipment for one hospital causes a budget issue and a political fight because a hospital in another region wants the same machine at the same time. Then we decided to give Really good specialised doctors the ability to write themselves a blank cheque as a consultant , then we allow political peer pressure to chose putting hospitals on land thats slow to access because of traffic and really expensive to buy just so they can score points with locals.

Then we hand out medical cards to too many people who kick up but because of an inadequate out of hours / close GP service, some people are determined to bring themselves and their kids to A&E for a cough, Then because we have a massively overpriced nursing home strategy and an ineffective strategy to tackle drug abuse , we have junkies and the elderly bed blocking to spend as much time in hospital as they can to offset the cost of the accomodation they do need. Couple that with a mantra of working frontline staff to the bone and never coming in underbudget on anything and you have a timebomb waiting to happen where the standard of public care gets further and further away from private care standards , eventually creating a complete two tier medical system where you can either afford it or may aswell not have gone to hospital at all.

For the most part I agree but disagree with a couple points.

1) Consultants haven't really been given a blank cheque. In fact consultants since 2012 are on 30% less pay than their pre-2012 counterparts which has led to us haemorrhaging consultants. As someone who works in the health service I cannot stress how absolutely dire the situation is with consultant recruitment and retention. For example, the Mater lost 3 orthopaedic surgeons to private practice all at once at the beginning of last year. That is literally thousands of OPD patients who had their appointments and surgeries postponed indefinitely as the remaining consultants had closed their lists due to being overcapacity. To my knowledge the mater has been able to recruit only a single consultant to replace them. The general public cannot appreciate how dire a situation it is that we are near bottom of almost every OECD league table for no. of specialists per capita, and we still have had 500 consultant vacancies (the most there has ever been in the health service) for the past 1.5y. We literally can't even recruit to maintain our bottom-of-the-table position.

2) The location of the children's hospital was probably the one non-parochial, evidence-based decision that was made in this health service. Would encourage you to read the report outlining the justification for the hospital and why the locations were chosen. Was devised by experts from UK/Aus etc. Ease of access was considered and given some weighting, but quality of care and range of services available with co-location superseded it which was only right.

3) In general from my experience in a busy paediatric ED, the majority of presentations were justifiable. Very few cases of coughs or simple stuff presenting to ED, especially since under-6s GP care came in. For the most part the patient isn't to blame for the state of our ED waiting times, it's bed capacity

FreudianSlippers wrote: »

Scrap the HSE, sack all the employees, bust the unions and then start all over.

could this lead to ultimate collapse of our health service?

to add another stephen kinsella piece of research, productivity has increased dramatically across most sectors over the last couple of decades, but wage inflation has remained relatively low, him believing the deunionisation of our economies being the main contributor.

Berserker wrote: »

They are. My post is a start and the unions and structure of the service are a big part of the problem.

i will agree that unions can and do have a negative effect in running elements of our economies, but i also do think economists such as kinsella also have a point about productivity and unions.

mariaalice wrote: »

I would do the exact opposite give everybody free at point of use accesses to an enhanced GP services all allied medical services and diagnostic services should be from a GP type services with the exception of something like a pet scan. procedure only hospitals with no A and E department. Enhanced step down facilities.

It's probably not realistic to have a complete set of diagnostic services in the community. You could have basic radiology like X-Rays and that would take a great deal of strain off the health service I imagine, but you couldn't have CTs/MRIs which are extremely expensive to buy + run and need a department behind them as well as follow-on care.

I think some of the rhetoric from politicians has sold primary care as the cure for all. It will certainly help and more routine procedures will be done in the community, but in general people who attend hospital need to be there. Our problem is bed capacity. We in general have suitably sized EDs and modern facilities but there is nowhere for patients to go if they need admitted.

mariaalice wrote: »

https://www.affidea.ie/prices/ how do they do it, the one in Dundrum is in an office building near a shopping center no huge infrastructure backing them up.

Certainly you could be right- I don't fully know the ins and outs of running the health service. However I don't think a small private operation is comparable to running a national health service.

- They outsource their radiology reporting so there's no on-site radiology staff, just radiographers. In fact (and I could be wrong), I think they outsource some of it abroad like the online GP services. That's not a direction I'd like to see our service moving in as I think it would compromise patient health and safety.

- Private businesses like Affidea can pick and choose where they locate. There's 10 MRI locations on their site which leaves a large proportion of the population out of their catchment, but the HSE can't pick and choose. They'd have to ensure coverage is at least as good as it is now offered by hospitals. But we can't take the MRI & CT scanners out of the hospitals, so we'd have to buy multiple more scanners than we currently have to ensure coverage in the community. The HSE doesn't have the money for this. Wexford is raising money from the community to try and get one. We'd be spending millions for no real clinical benefit.

- Because it's a small private operation they only do elective scans and there's some scans they won't do. For example my own aunt has a chronic medical condition they would not scan and advised her to attend one of the Dublin hospitals. This sort of relates to the above point, because hospitals allow for centralisation of care which then further allows for sub-specialisation. We have fantastic radiologists in our hospitals with a high degree of specialisation, but if you split them up into the community then all you will get is generalists rather than specialists.

- There's no clinical or cost benefit of moving these scans into the community. The justification for moving X-rays into the community is because they are simple to perform, very little can go wrong with them, it's usually a simple complaint which can be managed in the community (like a simple fracture) and it constitutes a large volume of the radiology workload in hospitals. CTs & MRIs however are usually for people who are much more sick or the complaint is much more severe and need to be managed in a hospital by specialised staff. These patients are managed by a team, and best practice is that the team meets regularly to coordinate their care. The radiologist is a key part of that team and it would be detrimental to their care if that radiologist was taken out of the hospital and moved into the community.

If you want to abolish waiting lists, then a cheaper and more clinically effective solution is to increase investment in the current hospital radiology departments- increase the no. of radiologists per capita and specialist radiographers we have, and invest in more MRI machines so we can operate a 24h service as opposed to the normal 9-5 we have now.

Can I add a light hearted take on how the purpose of a Health Service can be interpreted by different players within it.

The irrefutably exceptional Yes Minister.

One thing that I am always intrigued by when discussing circumstances in Ireland is the the number of people who work within a particular area as a portion of the population.

In terms of healthcare professionals. The HSE has approximately 102,000 people working for it either directly or indirectly. That is about 1 in 23 of all workers in the country.
This means that the "HSE" which we all refer to is made up by friends, partners, family members of a large portion of the country. And yet, everyone knows it doesn't work, but nobody every can identify how their area is overstaffed or they themselves are under utilised. I can understand this to some degree, why would they, turkeys voting for Christmas kind of thing.

But it must be an incredibly difficult challenge for any Minster of Health given the behemoth that it is.

Ireland median age

Wanderer78 wrote: »

Can anyone point to data to support these claims?

Ireland has the lowest median age in the EU at just over 35.


Healthcare expenditure as a proportion of total government spending is the highest in the EU (20% VS 15%) and is the 2nd highest in the OECD as a % of GNI (12.4% VS OECD average of 9%)

If anybody wishes to delve deeper, here is an analysis of the price level in Irish hosps.

Comparing Hospitals and Health Prices and Volumes
Across Countries: A New Approach
Francette Koechlin, Paul Konijn, Luca Lorenzoni, Paul Schreyer

https://link.springer.com/article/10.1007%2Fs11205-015-1196-y

This article is probably behind a paywall.

It finds that Irish hosp price level is 81% higher than the EU28 average.

Matt Barrett wrote: »

My point is maybe it's not down to an easy fix some are aware of but unwilling to address as you were suggesting.

I'm not suggesting an easy fix. In fact, I'm suggesting that given the intricacies of there being so many people and so many structured influences, it is nearly impossible for a Minister for Health to effect change.

Matt Barrett wrote: »

Your Turkeys voting for Christmas suggested that people who might see fixes, won't put them forward. While nobody would do themselves out of a job I think it's widely regarded that the system isn't working. Letting people go won't solve that.
Only a Minister/Government can. I can see it being so complex it might take some study, but how long? We've had the same issues for decades and now we have a Taoiseach who was formally a health minister. If not now when do we start? If they don't know at this stage maybe it's time they hired professionals or people with an interest in health to look into not lads on their career path having to pay dues by serving as Health Minister for a stint.

Leo Varadkar isn't the first Taoiseach who had also served as Minister for Health in recent times. Brian Cowan also held both roles.

In fact, with the exception of Mary Coughlan who only held the office for a short period, we have had Ministers for Health who have either proven to be quite competent in the political space (Mary Harney, Micheal Martin, Leo, Brian Cowan, Harris) or medical professionals themselves (James Reilly, Leo).

I'm not arguing the overall qualities of these individuals but none of them could be described as being completely unaware of the challenge associated with the Health service or have been expected to be completely incapable of improving it.

So, why are we where we are? There's been enough studies done.

Matt Barrett wrote: »

Well going by the above the question seems to be why are they pretending they don't know what to do and why aren't they doing it?
In the case of Harney there were questions over her husbands connections to private health and we had Reilly and his allocation of Clinics. Maybe it's a case of either not wanting to get too deeply involved or only using it for their own advances?

Politicians have no incentive to fix the health service. The fixes that would have the biggest impact and need to happen are too politically unpalatable:

1) Cut administrative staff and reinvest that money in frontline staff

2) Close rural hospitals and centralise care in larger urban hospitals

3) Increase bed capacity, requiring substantial investment.

The health service just isn't an issue for the general public, as evidence by the fact that both Fine Gael & Fianna Fail along with their health ministers continue to enjoy popular support. Why would either risk their chance of re-election when the general public would rather moan than do anything about the health service?

From my experience in the HSE, I don't think there's actually that much easy fat to be trimmed within the hospitals themselves.

I know there's the popular perception out there that you can go into a Hospital and it'll staffed almost entirely by managers and administrative staff but it's not quite true. One hospital I worked in had about 300 beds and 800 staff, and there were maybe only about 15 in roles people would see as useless (even if they're not) e.g. medical records, quality assurance, statistics etc. Most departments have no full time clerical support and might have a secretary for 2 days a week. There was a 7 person senior management team, and maybe another 3-4 more directors of nursing/bed managers etc.

If I were to guess, a lot of salaries are spent on the "business" side of the HSE, called HBS or Health Business Services. People who never see a hospital but work in large office buildings (presumably rented at generous expense by the HSE).

My job involved dealing a lot with HBS procurement, and you'd regularly have to email 5 different people to move one step you could have done yourself in one phone call to a supplier/contractor/service provider. There's project managers, procurement specialists, tender supervisors, procurement officers etc. You've to run every action up and down the chain of supervisors and officers and get a response from each of them, who'll often just pass it to their secretary and cc you in the email.

I'd love to skip the bullsh*t but of course the system is designed so that they control the money so if you don't jump through their hoops you get nothing. I'm told that 10+ years ago when money was flying around, procurement were only involved in large events e.g. new hospitals being kitted out, large expansions, property deals etc. but then the crash happened and they found themselves with nothing to do, so to justify their existence they began asserting that they were in charge of all aspects of buying everything in the HSE.

All of this is supposedly in the name of efficiency and fairness for staff and suppliers etc. but I'd say they've spent €100 and wasted hundreds of man hours for every €1 they've saved. Now I know the HSE can't function without a business,accounting, administrative side, but there's no way in hell that that's the way to go about it. That's just one aspect of the HSE I've found to be a bloated mess, I'm sure there's other parallel bodies soaking up money.