The health minister’s in-tray

June Shannon analyses the state of healthcare in Ireland and the issues facing the incoming Minister for Health.

In the run up to the recent general election you would be forgiven for thinking that the health service consisted solely of the acute sector and that all activity was restricted to Emergency Departments (EDs). Trolley numbers dominated the headlines and candidates spoke of little else.

It is inexcusable that anyone, let alone the frail elderly, is left to wait for acute care on a trolley for any longer than is absolutely necessary.

According to figures from the Irish Nurses and Midwives Organisation (INMO) on 1 March 2016 there were 544 patients waiting on trolleys in hospitals across the state. This was the second highest figure recorded so far this year. While the incoming Minister for Health whoever he or she may be, will be under pressure to deal with the perennial problem of overcrowded EDs, there is so much more in our health service that also requires immediate attention. These include primary care and mental health to name just a few.

Primary care

Primary care or to be more specific general practice has, to date, been one of the few areas of the health service that works and works well. However the sector has come under increased pressure in recent years due to income cuts to GPs under Financial Emergency Measures in the Public Interest legislation; which has resulted in a reduction of approximately 40 per cent in investment in the specialty since 2008, and the introduction of free GP care to those under-six and over-70s.

General Practice in Ireland is facing a manpower crisis as, much like their hospital colleagues, young GPs are opting to work abroad rather than practise in Ireland and a significant section of the current cohort of GPs is rapidly reaching retirement age.

A survey of GPs released late last year by the Irish College of General Practitioners (ICGP) reflected this crisis. The survey revealed that 55 per cent or more than half of GPs who tried to recruit a sessional doctor or assistant in the past year were unable to do so. It further revealed that only 44 per cent of GPs who tried to recruit a locum in the past year were able to do so on more than half of the occasions that they tried.

Rural GPs were less successful in terms of recruiting assistants or locum cover, the survey found, demonstrating the particularly unique crisis facing rural general practice in Ireland.

According to the ICGP survey the majority of GPs thought that free GP care to under-sixes and over-70s would impact on waiting times in general practice.

Perhaps more telling of the state of general practice in Ireland was the fact that 47 per cent of GPs described their morale as poor or very poor and 77 per cent, reported that their morale had worsened over the past five years. Almost three quarters or 74 per cent rated their current stress levels as high or very high. These figures indicate that our GPs are at high risk of professional burn out.

Up to 95 per cent of patients are managed in general practice and in excess of 20 million GPs visits occur in Ireland every year. Irish GPs are highly trained and can provide a range of services including chronic care management that can prevent patients from having to access costly hospital care. However, they are currently working under a GMS contract that dates back to the 1970s, which in no way reflects a modern primary care service or indeed the service they are expected to provide. Contract negotiations for a new GMS contract are currently underway and these must be a priority for the new Minister for health as should the provision of additional resources such as access to diagnostics and increased funding for general practice.

Mental health

One in four of us will suffer from a mental health condition at some stage in our lives and according to the World Health Organisation depression alone accounts for 4.3 per cent of the global burden of disease. It is among the largest single causes of disability worldwide, particularly for women.

Ireland’s mental health sector has undergone enormous change in the past decade since the publication in 2006 of ‘A Vision for Change,’ Ireland’s national mental health policy. Since its publication, the provision of mental health care has been slowly moving from what was once largely institutional based care to a situation where today it is largely provided in the community. However, despite some advances, particularly in the adult mental health sector, ten years on the implementation of A Vision for Change remains slow and uneven.

This is evident among vulnerable groups whose mental health is most at risk. These include the homeless, people with an intellectual disability, the elderly and those with a severe mental illness and substance abuse difficulties.

The lack of progress in the development of mental health services for these populations was highlighted in a report on the implementation of ‘A Vision for Change’, carried out by Mental Health Reform (MHR).

In its report, ‘A Vision for Change Nine Years On’, a coalition analysis of progress, (published in June last year) MHR described the implementation of the national mental health policy as “incomplete and uneven”, despite pockets of innovation. One area in which it was clear that implementation had been almost non-existent was in the provision of mental health services to specialist or high-risk groups.

According to the MHR report “People with intellectual disability, co-occurring substance misuse difficulties, or who are deaf or homeless all have higher risk of developing mental health difficulties than the general population, yet they are least well served by existing mental health services. With just 4 per cent of the staffing required for adult mental health and intellectual disability teams, no increased beds for eating disorders, just 13.84 posts in homeless teams, and no development of a specialist team for people with co-occurring substance abuse and mental health difficulties, it is clear that these high-risk groups have not received the priority they should have in the implementation of ‘A Vision for Change’.”

Ireland’s mental health budget is currently just 6.4 per cent of the total health budget compared to the UK where it is 12 per cent and Canada and New Zealand where it stands at 11 per cent.

While the provision of €35 million of additional investment in mental health announced in the HSE Service Plan for 2016 was most welcome, the new Minister for Health must ensure that these funds are invested in the provision of care for those who are most at risk.