What exactly is the problem in the HSE?

v638sg7k1a92bx · 13-01-2014 01:38PM #1

I've posted this here as opposed to AH or politics to avoid the thread descending into nonsense and also because it would be interesting to hear the opinions of people who work or are closer to the what goes on in the HSE and our hospitals.

From my own personal experience over the past week, a family member who has dementia was admitted to A&E in Tallaght and spend a day and a half on a trolley before being admitted to a ward even though we have private medical insurance. Even after getting onto the ward, it was extremely difficult to get to speak to a doctor. As it transpired, there was only two doctors working that night and one was in A&E! Is it not just a case of simply hiring more staff if they are needed? just for arguments sake we overstate and the salary and say every doctor who work in a hospital earns €200,000. If we hired and extra 100 doctors that's €20m which is a drop in the ocean for the overall HSE budget and would make a huge impact in front line services. Am I missing something or is there another reason why only two doctors would be working that evening?

Is my example over simplified or are is there something else I'm missing? What do other posters think?

sweetie · 13-01-2014 01:39PM

management.

Spook_ie · 13-01-2014 02:58PM

Tickers - we too have private health insurance, however, when it comes to A&E everyone is treated the same. The real benefit of private insurance is when treatment/surgery is elective. Our daughter visited a public A&E last year and was put into plaster, but after this was taken off it was determined that she still had a problem with a ligament and needed an MRI & surgery, the Consultant told us to get the MRI done privately (2 days later) and we were rung to say she needed surgery and this was done a week later.

munchkin_utd · 13-01-2014 03:22PM

I'll illustrate it by saying how it is done abroad, and then Ireland, and you can figure the difference

Abroad in say Germany you pay medical insurance (for me and the wife something like 15,000euro a year) and THEY pay the bills. The hospitals dont get a government subsidy for operations or running costs. It'd be similar in America where hospitals are never government ran so rely solely on income from insurance to cover their costs.
Every treatment the hospital provides is paid for by insurance. If they do extra operations they get more money. If they do more tests, they get more money. If they have such a demand for operations that they need to build a new operating theatre, then the extra staff and extra running costs are covered by extra income got by doing extra operations.
And if they have a low number of operations/ treatments or are otherwise not paying their way, they will go bust and close.

so basically, the services automatically tailor themselves in scale to the demand.

In Ireland, each hospital is given a bucket of money by the HSE each year to live off.
I like to think of it as sending a heap of cash in the back door of the hospital from the government whereas in Germany/ USA you come in the front door as a patient with a heap of funds virtually attached to you (via your medical insurance).
A german/ US paitent is an asset whereas in Ireland a paitent is an extra cost to somehow be treated from the resources that are already paid for.
They have a go to see how many operations and tests they can do and how many beds, doctors, nurses they can employ from the bucket of cash they were given but theres little room for expansion when needed.
If more people come to a hospital for disgnosis/ treatment then theres no extra cash (aside from the likes of VHI paitents) to cover the extra demand because of budgets being fixed by the HSE at the beginning of the year - so you get waiting lists.

Theres plenty of waste in medical systems abroad, and possibly more than in Ireland.
Still, to have a system that can have you go in with a pain in your hip and have scans and the hip replaced within 10 days (which happened a work colleagues mother recently), I'd live with a little wastage and the extra cost of what it is abroad!

Mucco · 15-01-2014 04:21PM

munchkin_utd wrote: »

in Germany/ USA you come in the front door as a patient with a heap of funds virtually attached to you (via your medical insurance).

Be careful what you wish for. The 'fee for service' model often leads to excessive care. More tests = more profit for the hospital. The patient often thinks that more tests = better care, so they are happier. However, whether the tests are needed or not is far from clear. What is clear is that the US spends >18% of GDP on healthcare compared to about 12% in western Europe. The health outcomes in the US are no better than Europe (often worse).
See this article by Atul Gawande:
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

We can spend 20% of our income on healthcare if we want, but what are you willing to sacrifice in order to do so?

Agnieszka_88 · 18-01-2014 12:51AM

munchkin_utd wrote: »

Abroad in say Germany you pay medical insurance (for me and the wife something like 15,000euro a year) and THEY pay the bills. The hospitals dont get a government subsidy for operations or running costs. It'd be similar in America where hospitals are never government ran so rely solely on income from insurance to cover their costs.

There are reasons for why the German health care system is so successful.
1: it's compulsory, everybody must be insured, no exceptions.
2: the high number of available Krankenkassen ("sickness funds") - to stay on the market, they need to compete with each other, so some of them offer lots of different benefits: treatment options, second opinions, max. double rooms in a hospital, preventive programmes, immunisations etc, for which the hospitals/doctors then of course get paid more.
3: really high premiums, especially for high-earning singles without kids ("social solidarity" they call it)- I pay almost as much as you do for yourself & your wife.
4: the German government doesn't provide health care or finance it directly, it only regulates insurance companies - and I think we will all agree that where there is politics, there is mismanagement and waste, no matter in which country. in here, the hospitals are businesses that have to earn their keep, free market principles apply, so if you won't try to employ good doctors/nurses and manage your hospital efficiently, you will go bust. It's kind of worth noticing that the people who run hospitals over here are usually very sharp, very experienced and expensive managers and no one complains about it as long as they manage to keep up the situation where the hospital can afford them.

SpaceTime · 18-01-2014 12:55AM

The biggest problem that I've found with the HSE's services is all about management and administration as well as just how the system is structured.

There are endless legacy services that are offered through all sorts of unaccountable 'trust' type organisations that seem to be in receipt of nearly 100% state funding.

The whole thing's long over due being taken apart and rebuilt from scratch. Too many festering legacy issues.
Changing the funding model will not change the duplication, triplication and separation of services in cities and sloppy administration and management.

An elderly relative of mine was undergoing cancer treatment in a major Dublin hospital and she was called in on several occasions for absolutely no reason. When she'd turn up they'd either lost the file or just kept her sitting in a waiting room for 4 hours (when she was having serious serious issues with walking, sitting, using toilets etc). Then when she'd get to meet the doctor, the consultation would turnout to be completely pointless.

They were also bringing her in to take blood samples and keeping her for hours and other really basic things that shouldn't have been done in a hospital setting at all or could even have been done by a district nurse.

We also found that there was basically zero communication between departments and when she'd arrive they'd have no idea why she was there or what the background to her case was.
It was even worse when she was transferred around the city to other units.

Basically, she had to start keeping copies of letters and build up her own file which she kept with her.
There didn't seem to be any kind of single liaison or point of contact or anything really. It was just like she was thrown into this big messy system and had to fend for herself.

I just always get the impression the Irish Health "System" is full of well meaning individuals all running around in chaos like headless chickens.

dissed doc · 18-01-2014 06:16PM

Jordyn Faint Pecan wrote: »

.....Even after getting onto the ward, it was extremely difficult to get to speak to a doctor. As it transpired, there was only two doctors working that night and one was in A&E! Is it not just a case of simply hiring more staff if they are needed?

That boat has long sailed. There is a worldwide shortage of doctors and government policy for the last decade has been to create many incentives for those doctors to leave the country.

You can't hire what is not available.

just for arguments sake we overstate and the salary and say every doctor who work in a hospital earns €200,000. If we hired and extra 100 doctors that's €20m which is a drop in the ocean for the overall HSE budget and would make a huge impact in front line services. Am I missing something or is there another reason why only two doctors would be working that evening?

(you are overstating drastically!!!) but even at that, doctors account in total of around 5% of the HSE's total budget (all consultants, all NCHD doctors). Needless to say, trying to reduce that 5% to 4.5% while ignoring the other 95% of costs won't make any difference. In a sense you are correct, despite the media-political industry attempting to focus the public on doctors' salaries.

The end driver of the healthcare delivery is the doctor who makes the yes/no clinical decisions. Endless money will not solve a problem which is now that no doctors both Irish or foreign want to stay working in Ireland is significant numbers to provide a reasonable health service.

This is why if even every doctor was forced to work for free, the cost overrun would not disappear, because the problem is the doctors.

Xeyn · 20-01-2014 02:36AM

The HSE's policies seem to be reactively driven rather than proactive. Anyone in the system could have foreseen the countless problems that are facing us today years ago.
As dissed doc states, the frontline staff have had enough. Doctors have left in droves and continue to do so.
Nurses are being treated quote badly as well and it remains to be seen what happens there. The HSE management failed to realise what a mobile workforce they employ. Doctors and nurses can find work in almost any country in the world should their mind be bent towards it.
The recent strike by the NCHDs sought to reduce potential harm to patients by cutting back dangerous work practices - in humane & illegal hours which consequently would actually reduce the pay of those on strike (less overtime) yet the spin doctors still tried to make it out as if it was in part a money issue.
They are making concerted efforts to try an rectify the situation now but it's too little too late for a lot of the staff.
I just completed yet another 36 hour shift in a major Dublin hospital.

If you look back at data over decades you can see a consistent trend with regards to A&E attendances and admissions to hospital as they increase year by year. Did the HSE make plans for this? Only once the situation came to a head (trolleys, deaths etc). Reactive.

The hospital management system in Ireland needs an overhaul.

treecreeper · 23-06-2014 11:29PM

we do have a problem, anyone ever get two letters on the same day telling you you had an appointment, duplicated? also sometimes, one letter for an appointment and another cancelling it, and another giving you another date? what about giving you an OT forty miles from where you live, can you imagine if that OT stayed in her own area how many clients she would be able to attend to when she has to drive eighty miles there and back to see one, take a paid for lunch and get back to office at closing time, the list is endless, management is in utter chaos. we have no health care in ireland, the wealthy may, the poor do not ever for a long time now.

SpaceTime · 23-06-2014 11:35PM

SpaceTime wrote: »

The biggest problem that I've found with the HSE's services is all about management and administration as well as just how the system is structured.

There are endless legacy services that are offered through all sorts of unaccountable 'trust' type organisations that seem to be in receipt of nearly 100% state funding.

The whole thing's long over due being taken apart and rebuilt from scratch. Too many festering legacy issues.
Changing the funding model will not change the duplication, triplication and separation of services in cities and sloppy administration and management.

An elderly relative of mine was undergoing cancer treatment in a major Dublin hospital and she was called in on several occasions for absolutely no reason. When she'd turn up they'd either lost the file or just kept her sitting in a waiting room for 4 hours (when she was having serious serious issues with walking, sitting, using toilets etc). Then when she'd get to meet the doctor, the consultation would turnout to be completely pointless.

They were also bringing her in to take blood samples and keeping her for hours and other really basic things that shouldn't have been done in a hospital setting at all or could even have been done by a district nurse.

We also found that there was basically zero communication between departments and when she'd arrive they'd have no idea why she was there or what the background to her case was.
It was even worse when she was transferred around the city to other units.

Basically, she had to start keeping copies of letters and build up her own file which she kept with her.
There didn't seem to be any kind of single liaison or point of contact or anything really. It was just like she was thrown into this big messy system and had to fend for herself.

I just always get the impression the Irish Health "System" is full of well meaning individuals all running around in chaos like headless chickens.

Elderly relative of mine had the exact same experience. Endless appointments for literally no purpose. It's like bureaucracy gone mad but also total lack of accountability, lack of auditing or analysis of why they do things or the outcomes of their administrative processes.
The entire system is totally incompetent!

It's like nobody ever tests how this works from a patient perspective and patients are seen as some kind of annoying thing to be ordered around and talked down to.

You also get the sense in some hospitals and services that you're being given something out of charity even though it's 100% state funded.

Xeyn · 23-06-2014 11:41PM

SpaceTime wrote: »

Elderly relative of mine had the exact same experience. Endless appointments for literally no purpose. It's like bureaucracy gone mad but also total lack of accountability, lack of auditing or analysis of why they do things or the outcomes of their administrative processes.
The entire system is totally incompetent!

It's like nobody ever tests how this works from a patient perspective and patients are seen as some kind of annoying thing to be ordered around and talked down to.

You also get the sense in some hospitals and services that you're being given something out of charity even though it's 100% state funded.

Actually patient audits are performed by doctors all the time. I did one myself. Unfortunately we as doctors, rarely get listened to by the administrative processes of the HSE. With the number of unnecessary admin staff in the health services you would think they would be the one to audit patient satisfaction etc

I don't quite get your last statement though about charity and state funding?

SpaceTime · 23-06-2014 11:46PM

I mean when you go to certain 100% state funded services you get the same 'vibe' as you world expect if you were asking for charity from a 'free' hospital. It varies from place to place, but some of the organisations my gran had to deal with had a very bad attitude.

In the French system that's definitely not the sense you get

Phill Ewinn · 23-06-2014 11:48PM

Xeyn wrote: »

Actually patient audits are performed by doctors all the time. I did one myself. Unfortunately we as doctors, rarely get liistened to by the administrative processes of the HSE. With the number of unnecessary admin staff in the health services you would think they would be the one to audit patient satisfaction etc

I don't quite get your last statement though about charity and state funding?

Can I ask why it is that doctors and nurses and their unions and associations don't push or lobby for changes to the administrative process??

Everyone understands the inefficiency of the administrative processes.

SpaceTime · 23-06-2014 11:54PM

They brought my gran in 6 times and lost her file. She'd a collapsed hip and a missing femour and terminal cancer.

She was also highly susceptible to infection.

Yet over and over they called her in for the most pointless reasons and made her wait in public waiting rooms with serious infection risks

She'd also go from dept to dept and for some reason they'd have no information when she arrived!

The staff seem to have trained under Computa Says No woman from Little Britain.

My impression was that they simply do not care about patients. The medical staff are run off their feet and generally fine. The admin system (if you can call it that) is just ridiculous though.

Xeyn · 24-06-2014 12:05AM

Phill Ewinn wrote: »

Can I ask why it is that doctors and nurses and their unions and associations don't push or lobby for changes to the administrative process??

Everyone understands the inefficiency of the administrative processes.

How exactly do you want them to go about that especially if they simply won't listen? It's 'them that make the rules' and believe me, many of my bosses have tried and they all say essentially the same thing- it's like banging your head against the wall.
But doctors are voting now. With their feet. (Admittedly for a variety of reasons though)

Xeyn · 24-06-2014 12:09AM

SpaceTime wrote: »

They brought my gran in 6 times and lost her file. She'd a collapsed hip and a missing femour and terminal cancer.

She was also highly susceptible to infection.

Yet over and over they called her in for the most pointless reasons and made her wait in public waiting rooms with serious infection risks

She'd also go from dept to dept and for some reason they'd have no information when she arrived!

The staff seem to have trained under Computa Says No woman from Little Britain.

My impression was that they simply do not care about patients. The medical staff are run off their feet and generally fine. The admin system (if you can call it that) is just ridiculous though.

I hope complaints were made. Bad PR is the only fire that warms their behinds apparently.

Phill Ewinn · 24-06-2014 12:10AM

Xeyn wrote: »

But doctors are voting now. With their feet.

Thats solving nothing.

Xeyn wrote: »

How exactly do you want them to go about that especially if they simply won't listen?

I don't know.

Xeyn · 24-06-2014 12:14AM

Phill Ewinn wrote: »

Thats solving nothing.

As stated the health service has always been reactive instead of proactive. This is a consequence not an intentional move- however it will force their hand.
I've been told by my last two consultant bosses that I would be a fool to stick it out here.
There are many politically motivated doctors who I have faith in will change things for the better once a platform is created for them. Unfortunately that platform is looking increasingly like it's taking the form of the rubble that will be left from our health system.

treecreeper · 24-06-2014 12:21AM

i am told there are thousands of complaints against the hse but the hse dont care nor listen.
the doctors say too that they are not listened to by the hse.
everyone says the hse is chaotic and appointments going nowhere.
doctors leaving due to chaos.
isnt it time to disband for good the hse as its the CHAOS, it seems nothing else.
what about a system where by get out by force eg legal actions, court cases, complaints to europe, human rights, amnesty and trade unions, ah forget the last they seemingly have bought in to an agreement not to enter into complaints of any kind within the health care system. we need to take a few test cases of incompentency and also danger to life.

SpaceTime · 24-06-2014 12:28AM

It's not a 'system' either. It's largely a state funded bunch of 'voluntary' organisations.

I'm not surprised that there's no accountability and chaos. That's how the 'system' is built!

It's more like something that just happened rather than a system that was planned

treecreeper · 24-06-2014 12:41AM

doctors, nurses, ot's, physios, psychologists etc are not part of any voluntary organisation, they are medics working in OUR health service, which isnt voluntary, its a paid job by the Department of health who give the HSE full rein to reign and do the job of running health in ireland, so who is the HSE 's boss?
the Department of Health who can if they want, pull the plug at anytime, when it comes to managers of the health care system.
if the department of health sacked the who shebang of managers then maybe we could start building again.
they know the hse is not fit for purpose but what do they do, go and give the next experiement and organisors of that experiement men who ran the hse to run the new experiment, thats what i call a department of health incompency which again means we need ride of reilly, pitty i cannot rid the typos as easily.

treecreeper · 21-08-2014 10:55AM

you wont find the department of health admitting they have anything to do with the HSE, both mary harney and this lot have actually told me that they have nothing to do with health, thats the job of the hse, seriously that was said to me.

treecreeper · 20-12-2014 01:42PM

we have a very complex health system, the private care and insurance shore up the public health system.
the system now is so chaotic many refuse to work in the overloaded chaos of all departments and the doctors feel its almost beyond repair due to taking so much out of the budget it is unworkable.
they have just enlisted ten more managers at the top level.
we have too many managers, too many foot soldiers and what happens then no one knows what they are doing.
files are all paper files so there is more trouble in the filing system, stuff gets lost and there is no cross communication.
communication is about the worst.
i am seriously ill and to me i have few services at all.
you try to get physio for neurodegeneration and there is none, been to a few departments and all are empty where they should be full of people needing controlled exercise regimes and deep massage. it doesnt happen anymore.
OT's have restrictive budgets and slam a patient to bits when they require such items as powered wheelchairs.
even some OT's refuse to take part payment for such an item claiming such things as 'who will own it then?\ they have an inability to sort that type of problem swiftly, this case of the powered wheelchair has gone to the legal advisers!
but the patient has been told they will not engage in a public/private funding for such a powered wheelchair, they have already spent three and a half years trying to figure all this out.
its chaos, thats the only word.
the patient is left depressed, unserved, disgruntled and blamed.
a new group has been formed on Facebook called 'Victims of the HSE unite' its there to see if the victims can unite and do something as a group.
many living with serious illness, disease and disability in the community cannot be monitered as in an institution setting which is beginning to happen thank god, but those in a house in the middle of community get neglected and so this is the group that is targeted for victims of the hSE unite.
if you feel harmed, abused or hurt by the HSe do call into that public facebook page.
all abuse, harm will be reported as obligatory to the guards.
but its a solidarity group in the making.
policy of what to do is in its infancy but that will be worked out with the group etc.
but at the onset confidentiality will be uppermost in this group and abuse will be reported to the authorities if it is named.

SpaceTime · 20-12-2014 02:34PM

The problem is that it's basically run for a load of in-fighting vested interests all wanting to build throw own power structure.

There's no point in blaming the current or recent Ministers for Health. They need to be given full public support to reform the system. Any attempts at serious reform are met with extreme resistance and even political behaviour by those with an interest in preserving the various status quos.

Honestly, I'm not sure how you'd fix it.

Harney, as much as I didn't really agree with her policies, tried to set up the HSE to rebuild from scratch only to discover that the old system wouldn't go away no matter what she did. So, she ended up in her attempts to 'tame the beast' creating two beasts that were even less tameable.

Michael Martin skirted the issue entirely and rolled out the smoking ban and left largely unscathed.

The fact that the HSE survived, almost totally unreformed, through the Trokia's period in power here shows just how serious an issue we have.

Nobody seems to have the political firepower to reform it and there are huge areas of the system that refuse to see the big picture, refuse to see it from an end user's perspective and do not really seem to want to change anything ever.

There's an argument that perhaps we should just abolish everything and start from scratch, but then everyone would probably sue everyone else for 1000 years costing the state trillions.

So, I don't know how you can fix it really.

I've no doubts that the HSE and Dept of Health will destroy Leo Varadkar too. He seems well intentioned, as does Kathleen Lynch, yet look what they're left dealing with... Hidden scandals like the care home thing etc etc etc.

Annabella1 · 22-12-2014 04:04PM

Every secretary /administrator is permanent and untouchable.
They get promoted based on years worked and pay increases continue thanks to increment structure.
There is no incentive to be any good

virtual_kick in the face · 22-12-2014 11:50PM

^^^

Step 1: Fire all the needless office/Admin people.

j.mcdrmd · 24-12-2014 03:04AM

Pretence.

The HSE pretend to deliver health care.

They don't.

drzhivago · 25-12-2014 02:30AM

treecreeper wrote: »

doctors, nurses, ot's, physios, psychologists etc are not part of any voluntary organisation,

Slightly off point here but there are all of the above working volunatrily (i.e. free) for some of the charitable organisations which provide much needed services

On top of that there are others employed who work for Voluntary Hospitals( tricky concept- these are not state or HSE owned facilities though in many cases they now receive bulk of funding from HSE, initially these were for example charitable institutions set up by nuns/religious orders who had "visiting" consultant staff who treated poor for free and had admission rights for their private patients- bulk of budget in those days came from the orders or the private patients while the reverse is the case now But these places remain independent or as the title given to them as a group "voluntary hospitals" so the phrase above could apply to either grouping of medics

treecreeper wrote: »

they are medics working in OUR health service, which isnt voluntary, its a paid job by the Department of health who give the HSE full rein to reign and do the job of running health in ireland,

again not entirely true 25% of hospital based healthcare is provided by Independent or Private hospitals as they are generally known and these have no input or funding from DOH or HSE

In General practice/Primary care where 90% of total health contacts take place the Doh/HSe only part fund provision of medical care for 40% of the population i.e. medical card system so again not run either by DoH or HSE

treecreeper wrote: »

so who is the HSE 's boss?
the Department of Health who can if they want, pull the plug at anytime, when it comes to managers of the health care system.

Ah sorry to be a pedant again but we had 11 health boards pre single HSE-- there were a lot of promotions in the run up to closure of health boards and no one laid off - Take for example a finance manager - Old system 11 finance managers (and the rest) - new system 1 HSE finance manager + 11 others (and deputies and assistants) who really did not have a job but could not be laid off without significant cash outlays

treecreeper wrote: »

if the department of health sacked the who shebang of managers then maybe we could start building again.
they know the hse is not fit for purpose but what do they do, go and give the next experiement and organisors of that experiement men who ran the hse to run the new experiment, thats what i call a department of health incompency which again means we need ride of reilly, pitty i cannot rid the typos as easily.

his_dudeness · 27-12-2014 10:03PM

In defence to the HSE, and it pains me to defend it, not all of its problems are of its own doing.

The Irish people, while wanting a better health service, also want this better health service to be at every street corner in ever county providing every service possible. How many protests have there been around the closure or downgrading of departments despite medical and financial arguments to support them? And how many times have parish pump politics taking hold and prevented them, thus perpetuating a lesser quality service.

As an example, HiQA recently published a report that maternity services in Portlaoise should be closed and patients moved to another "bigger" centre. This is the same department that has been in the news on three different occasions in the last year with scandals. And yet, minister Varadkar has said it won't close. Needless to say, the people of Laois don't want it to close. This is part of the HSE problem, not being allowed make the necessary big decisions.

Oddly, I think the downgrading of Roscommon and reconfiguration Of Ennis and Nenagh, and in particular the perseverance of same in the face of public opposition, albeit driven mostly by a costing argument, is some of the bravest decisions the HSE has taken.

echo beach · 28-12-2014 03:38PM

his_dudeness wrote: »

As an example, HiQA recently published a report that maternity services in Portlaoise should be closed and patients moved to another "bigger" centre. This is the same department that has been in the news on three different occasions in the last year with scandals. And yet, minister Varadkar has said it won't close. Needless to say, the people of Laois don't want it to close. This is part of the HSE problem, not being allowed make the necessary big decisions.

It isn't a 'big' decision to close a unit that has problems and move those patients to a 'bigger' centre that isn't given any extra resources to deal with them. All that does is move the problem from one place to another. HIQA has also been damning of A+E in Tallaght hospital, despite its size.
A 'big' decision would involve 'solving' the problem, either in the location that has the problem or elsewhere, and the HSE does not have either the resources or the management ability to do that. Political interference is part of the problem but if the HSE did its job properly politicians and public would trust it to make the correct decisions. At the moment we can't trust it.

What exactly is the problem in the HSE?

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