It is a cliché in the airline industry that to make progress the focus must shift from flying aeroplanes to carrying passengers. In the same way to make real progress in the delivery of health services we need to stop focussing on running services and concentrate on caring for patients.
More than three quarters of spending on health services is for managing established, chronic health problems, but the system (as in many other countries) is organised mainly to handle one-off events. Many diseases that were previously killers are becoming chronic. The great majority of men with prostate cancer die of other causes, and many people live for long periods following heart attacks, stroke, cancer and HIV. As the population ages we are seeing more people living with a range of chronic diseases and the challenge is both to treat each one effectively and to get an appropriate balance between the competing needs of each disease. The Ruane report (DOHC 2010) recognised that the challenges of managing chronic disease requires a much more integrated system of care, and one where the incentives were better aligned to ensure people are treated in the right places by the right people. The recent reorganisation of the HSE has also recognised that it is unhelpful to manage the hospital and community health systems separately.
The current political debate has focused on the high level questions of funding mainly through taxation or universal health insurance. While this debate is important, no change in the way we raise money will work unless it is underpinned by a clear focus on what sort of service is needed, and what structures and incentives are most likely to achieve the desired access to services. The key challenges are better planning of care, finding better information to support service delivery, better ways of paying providers and developing facilities and skills that are more fit for purpose.
While people are different and have particular needs, much is predictable.
Protocols and treatment guidelines can ensure that interventions follow best practice and are linked together. A person who has heart surgery needs follow up care in hospital, but also can benefit from follow up services in specialised rehabilitation facilities and the community. A person with diabetes has ongoing needs for assessment, monitoring and review of treatment. The current work in the HSE to develop service guidelines is welcome, but is only a start. It remains difficult for most people to navigate the different (and often separate) providers of services, and what you get is often a matter of luck. Entitlements are often arbitrary – people with diabetes get their drugs (almost) free, but those with heart problems may not. Therapy services in hospitals may be free of charge but many people pay the full price in the community. This can mean both that people are treated in wrong (and expensive) settings and that in many cases people only get part of what is needed. Planning for long-term and ongoing needs is not easy, but a good start is to recognise that most patients have ongoing and continuing needs.
Paying care providers
Despite discussions over many years, there has been only limited change in the way hospitals and community services are paid. Annual budgets are only loosely tied to the types and quantity of services provided. Additional patients bring costs to the provider but no additional resource. Efficient hospitals that do more work can run into financial difficulties, and there are absurd practices of paying staff to do nothing while theatres are closed (saving only modest amounts). Designing better ways to pay service providers is complicated, but there is experience in many countries. In principle the money should follow the patient; in some cases this would be a fee for each intervention, but in others it may involve a flat fee for looking after a need for a period of time. The payment system should support the desired pattern of care. A major advantage of changing the way providers are paid is that real responsibility can be devolved to local management, who will be judged only for the quality, mix, volume and cost of what they deliver.
Improving care for patients is very dependent on better information. Paper records are hard to use, easy to lose and difficult to share. They do not lend themselves to use in management and audit. It is understandable that people are cautious given the experience of unsuccessful (often over ambitious) IT projects but experience shows that care can be safer, better and cheaper when supported by timely and accessible information.
Few general practices would go back to paper records, and where electronic records are used in hospitals they have helped to change the way care is delivered. Serious errors can be avoided; for example, a move to electronic prescribing could reduce risks of the wrong medicines or the wrong doses being given. Electronic data make it easier to plan the management of a range of diseases. Much more use could be made of existing health care information to improve planning and management. Other countries safeguard patient confidentiality while allowing administrative data on patients to be used for research and planning. For example work using Canadian data has allowed detailed understanding of the effects of ageing. This shows that ageing is not the major driver of higher costs, but does change the mix of services that are needed.
Building the infrastructure
While we agonise over where and what to build, we forget that buildings are cheap compared to what we do inside them. We often use unsuitable buildings which can lower quality and increase costs. Evidence shows that for most patients single rooms are cheaper than open wards, partly because patients recover quicker, use less drugs, suffer less infection and have fewer falls. The development of primary care has been hampered by the lack of suitable facilities. Most patients visiting hospitals are out- patients, but facilities for these services are often poor. Some out-patient clinics could be run in primary care centres, bringing services closer to where people live. Part of the problem is that capital funds are hard for hospitals to obtain, but once they get them they are treated as a free good. Much could be achieved with proper financial management of capital costs.
Recognising that most patients have chronic, ongoing needs changes the types of staff and skills that are needed. For example, a person with mental illness may have needs for supervision of medication, counselling and welfare rights support. Currently these skills are held by a range of people, but could easily be provided by one person. Evidence has shown the value of nurses in chronic disease management and there are potentially wider roles for pharmacists and health care assistants.. The move from consultant led to consultant provided hospital care changes the ways we should provide education and continuing professional development. GPs could play a greater role in managing chronic diseases, but that would have implications for training (and recently the numbers of GPs relative to the population have been falling). Workforce planning is never easy, but we need to be more serious in planning the workforce for merging roles.
There is a tendency to be pessimistic about reform of health services. Gains that have been made are not always recognised. Some issues will not go away, but it would be a help if at least we were clearer about what we want to achieve. Grand schemes have their place, but many problems need careful and painstaking work. Health systems are complex, and outcomes of reforms are often different from what was planned. Traditional ways of doing things are hard to change. To meet growing needs and to better meet the current needs there must be improvements in efficiency and quality of care. These require careful changes in the ways we plan, fund, organise and staff the services.