IRISH MEDICAL ORGANISATION PRE-BUDGET SUBMISSION 2006 Published – 27 October, 2005 Irish Medical Organisation Irish Medical Organisation, IMO House, 10 Fitzwilliam Place, Dublin 2, Ireland Tel: + 353 676 7273 Fax: + 353 1 661 2758 www.imo.ie IMO – 2 Introduction The Irish Medical Organisation’s (IMO) mission statement clearly states that it is committed to a caring, efficient and effective health service. In this pre-Budget submission, we have identified a number of proposals which, if implemented, will facilitate the Government in its task of improving the overall quality and efficiency of the health service and improve health outcomes for the people of Ireland. Within the context of our proposals, there are key principles to funding which must apply: o ring-fenced funding and multi-annual budgets for health services o an integrated capital and current expenditure structure o the adoption of the OECD System of Health Accounts (SHA) published annually Summary of IMO Recommendations Care of the Elderly o that the deficit in hospital beds for the elderly – acute, rehabilitative and long term care beds –be immediately addressed o an accelerated building programme of public nursing home beds o an immediate increase in the Nursing Home Subvention o an increase in home-based, multi-disciplinary care packages for the elderly o the provision of adequate resources for old age psychiatry services Acute Bed Capacity o an increase to 15,000 in the numbers of Public Acute Hospital Beds o that private facilities not be given undue favour with tax breaks – with funding diverted to the public hospital system Accident & Emergency o implementation of the recommendations of the Report of the Committee on Accident and Emergency Services and Acute Medical Units to accelerate the expansion of appropriately staffed consultant physician led AMUs and additional A&E consultants o reduction in demand through the implementation of the Primary Care Strategy o employ liaison staff in A&E facilities to address alcohol related cases Preventative Health and Alcohol that the Department of Health and Children o leads a change in health service planning and delivery which places due emphasis on creating environments which support healthy food choices, regular physical activity and emphasises the dangers of tobacco and alcohol consumption o collects and evaluates data for the full life of the patient including epidemiological studies, blood testing, the consumption of contraceptives and regular obesity checks o offers, through the appropriate agencies, high quality continuing education and training programmes for health professionals, teachers and others in the sensitive management of obesity, alcohol and smoking related health problems o Cigarettes are price sensitive. The IMO recommends a €2 increase on a packet of 20 cigarettes. This will lead to a decrease overall in tobacco consumption, improve cardiovascular health and lessen the development of tobacco related cancers o the implementation, adequately funded, of a comprehensive preventative health policy on alcohol which includes a series of specific measures to address alcohol abuse IMO – 3 Care of the Elderly The IMO recommends o that the deficit in hospital beds for the elderly – acute, rehabilitative and long term care beds – be immediately addressed o an accelerated building programme of public nursing home beds o an immediate increase in the Nursing Home Subvention o an increase in home-based, multi-disciplinary care packages the elderly o the provision of adequate resources for old age psychiatry services Deficit in Hospital Bed Provision The A&E crisis, which as been highlighted by the IMO and other health professionals, has its roots in the drastic cuts in bed capacity made in the acute hospital sector in the 1980s. As the second table below shows the provision of beds for care of the elderly has declined dramatically in the years from 1968 to 2001. It is widely acknowledged that the failure to provide appropriate hospital care for the elderly is a significant cause of the A&E crisis. Table 1 below indicates the level of bed usage divided by age groups compared to the proportion of the relevant age group to the general population. Table 1.1 Level of Bed Usage Age 0-14 15-44 45-64 65+ % of Inpatient 16 39 18 27 bed days % of general 22 11 population Source: Acute Hospital Capacity – A National Review Table 2. Provision of Public Beds for Care of the Elderly Category Care of the Aged Report 2001 (1968) County Homes / Geriatric 8,057 Beds 8671 Beds Units District Hospitals 960 Beds 0 Beds Psychiatric Units (>65 years) 4,577 Beds 1,3962 Total Public beds for the 13,594 Beds 10,067 Beds Elderly Irish Population (> 65 years) 3 323,007 432,001 Public Beds for the Elderly 42 Beds per 1,000 23 Beds per 1,000 per 1,000 population > 65 years. Source: Dr. Christine O’Malley, Consultant Geriatric Physician 1 Acute Hospital Capacity – A National Review, DOHC, Dublin 2002, Figure 4.7, p.46 2 5th Psychiatric Census 3 1996 Census and 2002 Census respectively. IMO – 4 Public Nursing Home Beds The Health Service has neglected to match public nursing home care beds with the growth of the population in our large cities. In the 1980s, the bed complement per 1,000 elderly people in Dublin was only half that available in the rest of the country. This trend has been aggravated with the urbanization of Irish society. Between 1961 and 1996 the population of the Greater Dublin Area increased from 719,000 to 1,056,700 (47%). This has compounded the situation. A significant number of beds have been taken out of the system while only a small number of community units have been built. The collision of urban growth, reduction in existing bed stock, and a failure to develop services at an appropriate rate has caused great distress and suffering to many elderly Irish people and their families in the Greater Dublin Area. Cork, Galway and other growing urban centres exhibit symptoms of the same problems. The failure to develop public nursing home services causes, to a significant extent, the current A&E crisis. The promise in 2002 (if realised) of a Public Private Initiative of 850 public nursing home beds in Dublin (450) and Cork (400) represents a beginning. To truly match need, policymakers must plan for a programme that recognises that up to half of all citizens may experience nursing home care during their lives, and that to plan for this in an organised way will yield great benefits. It will maximise general hospital use by freeing beds occupied by those awaiting long term care rather than increase the numbers of more expensive hospital beds. More importantly, it will begin to allow elderly people to enter nursing home care in a more organised and dignified manner than at present, without spending up to a year in a general hospital bed first. The presence of elderly people awaiting nursing home care in general hospital beds is a system failure. It is pejorative to use terms such as ‘bed-blockers’ for them. Not only have they not caused this situation, but they and their families have often made Herculean efforts to stay at home for many years. Private Nursing Homes Although private nursing homes can manage care for some elderly people, there is a clear need to provide a significant proportion of care in public nursing homes. Private nursing homes have no obligation to take all who present to them. Current subvention rates will not meet the cost of many nursing homes. Multi-Disciplinary Services – Home-based Care The IMO believes that elderly citizens value their independence and prefer to remain in their homes within the community. They have expressed repeatedly their desire to receive treatment in their homes and to live independently with the support of their families. 4 The increased provision of home-based multidisciplinary professional care, in collaboration with enhanced support from the voluntary services, will do much to make this a reality. In its position statement An Age Friendly Society, the National Council on Ageing and Older People highlighted the following: o In 2003 87% of people questioned preferred to remain in their homes with family members taking care of all needs and health services providing respite care o The study stated that the most frequently used Community Services were 4 NCOAP, An Age Friendly Society, (Dublin, 2002) IMO – 5 o Chiropody o Optical services o Dentistry o Public Health Nursing Those who need continuing therapy should receive domiciliary services including Physiotherapy, Occupational Therapy, Speech and Language therapy, and mental health. Services must be delivered in partnership with the elderly, their families and carers and a range of statutory and non-statutory voluntary and community groups. General Practitioners and Public Health Doctors have a key role in the planning of community services. A co-ordinated development of integrated Primary Care Services and Community Health and Rehabilitation Services will be cost effective and humane. It will deliver the appropriate services to the elderly citizen in the appropriate place, at the appropriate time. Psychiatry Services Existing services have significant resourcing deficits. Most services have populations in excess of the recommended norm of one consultant per 10,000 people over 65 and there are gaps in the provision of important members of the multidisciplinary teams. It is recommended that existing Old Age Psychiatry services must be consolidated with the provision of separate acute old age psychiatry units. These units should be staffed with psychiatric nurses and with an appropriate number of such staff. In addition, these beds should be on the same site as the General Adult Psychiatric unit. Each service should have access to long stay beds designated under the Mental Treatment Act. The number must be based on the norm of 3 beds per 1,000 of the population over the age of 65. IMO – 6 Acute Bed Capacity The IMO recommends o an increase to 15,000 in the numbers of Public Acute Hospital Beds o that private facilities not be given undue favour with tax breaks – with funding diverted to the public hospital system The Department of Health and Children published a report in 2002, in conjunction with the Department of Finance and in consultation with the Social Partners, on publicly funded acute hospitals in Ireland. The following conclusions were reached. Table 1.5 Year Beds % Change Inpatients ALOS Day Cases Outpatients 1980 17,665 100% 543,698 9.7 8,377 1,460,198 1986 16,878 95.54% 566,105 7.4 50,136 1,621,035 1990 13,753 77.85% 522,864 6.9 124,748 1,675,529 1995 11,953 67.66% 529,393 6.6 207,308 1,890,702 2000 11,832 66.97% 548,834 6.6 319,837 2,006,332 Taking 1980 as a baseline, a third (33.03%) of the acute bed capacity has been removed from the system while at the same time the health professionals have managed to increase efficiency and productivity. The Average Length of Stay has dropped from 9.7 to 6.6 days. The review indicates that the public hospital service is efficient and productive, contrary to popular opinion. There are however problems which centre on capacity. The review revealed the following additional facts about acute beds in Ireland; o The number of acute hospital beds in Ireland is among the lowest across both EU and OECD countries; in 2000, the number of beds per 1,000 population was 3.1, down from 5.1 in 1980 o Despite these reductions, the review reported that total hospital activity (excluding outpatients) increased by 57% since 1980, due largely to an increase in day activity o Currently, 71% of inpatients are admitted through A&E departments with the majority of admissions being older people with medical (as opposed to surgical) conditions o The data reveals that older people have a disproportionate need for hospital services; in 2000, this age group consumed 46% of acute hospital inpatient bed days. Demographic projections suggest that by the year 2026, the age cohort over 65 years of age will have doubled and will constitute 16.4% of the population. It will have major implications in planning for the provision of acute hospital services o Many hospitals have bed occupancy levels greater than an internationally recognised measure of full occupancy of 85% 5 Acute Hospital Capacity – A National Review, DOH, Dublin, 2002. Table 1.1 p.18. ALOS is Average Length of Stay. IMO – 7 Throughout the period 1980-2000, the number of in-patients remained around 500,000 annually despite falling bed numbers and the rising number of day cases. The acute hospital system requires the simultaneous introduction of a number of strategies with the potential to reduce need for additional beds in conjunction with an increase in acute bed capacity in order to enhance service provision in this sector. In 2000, it had almost 12,000 beds. The review produced a gross estimate for an additional 4,335 beds. In total, the system needs at a minimum, 15,000 beds. This estimate was derived as follows Table 2.6 Acute Hospital Bed Complement in 2000 11,832 Additional beds needed to reduce average bed occupancy in major hospitals 883 to international norms (85% occupancy) Additional beds required to facilitate treatment of waiting lists 492 Additional beds due to demographic changes 1,630 Additional beds due to increased demand for services 1,330 Additional inpatient beds required (Gross Estimate) 4,335 Potential bed capacity which could be utilised more efficiently -1,495 Additional bed capacity required (Nett Estimate) 2,840 It is estimated that up to 1,495 beds might be available within the system if the following strategies were followed: o Investment in measures to insure prompt discharge from acute hospitals o Efficient use of available capacity in some hospitals o Substitution of elective inpatient surgery with day surgery o Treatment of 33% of waiting list patients as day patients o Improved management of public and private beds for elective patients 6 Acute Hospital Bed Capacity – A National Review, DOH, Dublin, 2002, p.80 IMO – 8 Accident & Emergency The IMO recommends o implementation of the recommendations of the Report of the Committee on Accident and Emergency Services and Acute Medical Units to accelerate the expansion of appropriately staffed consultant physician led AMUs and additional A&E consultants o reduction in demand through the implementation of the Primary Care Strategy o employ liaison staff in A&E facilities to address alcohol related cases Ireland’s Accident and Emergency problems are not insoluble. There are viable solutions to the A&E crisis. Two recent reports - on Accident and Emergency Services (February, 2002) and Acute Medical Units (October, 2004) both published by Comhairle na nOspidéal – offer clear recommendations which, when implemented, will have a significantly beneficial effect and should prompt appropriate and efficient management of emergency hospital referrals; 79% of these referred patients have medically related problems, and many of them are in the older age group. The Department of Health and Children must seek to reduce demand on the A&E services through increased provision of services at primary care level and through a coherent Alcohol Policy. Primary Care, A New Direction, published by the Department of Health and Children, is designed to integrate the service delivered by the primary care sector fully with the secondary care system. €1.3 billion over ten years had been earmarked for the Primary Care Strategy. As of 15th June 2004 the Minister of Health and Children admitted on national radio that only €22million had been spent on the Primary Care Strategy. 7 The A&E Departments across the country experience a high volume of alcohol related cases. The IMO understands that the cost to the health system of Alcohol related illness is enormous. This subject is treated below in the section on Preventative Health. 7 RTÉ, Morning Ireland, 0700-0900hrs, 15/7/04, Minister Micheál Martin, T.D. in conversation with Mr. Cathal MacCoille. IMO – 9 Preventative Health and Alcohol The IMO recommends that the Department of Health and Children: o leads a change in health service planning and delivery which places due emphasis on creating environments which support healthy food choices, regular physical activity and emphasises the dangers of tobacco and alcohol consumption o collects and evaluates data for the full life of the patient including epidemiological studies, blood testing, the consumption of contraceptives and regular obesity checks o offers, through the appropriate agencies, high quality continuing education and training programmes for health professionals, teachers and others in the sensitive management of obesity, alcohol and smoking related health problems o put €2 increase on a packet of 20 cigarettes. This will lead to a decrease overall in tobacco consumption, improve cardiovascular health and lessen the development of tobacco related cancers o the implementation, adequately funded, of a comprehensive preventative health policy on alcohol which includes a series of specific measures to address alcohol abuse The European Union has begun a consultation process entitled Enabling Good Health For All – A Reflection Process for a New EU Health Strategy (July, 2004).8 This process focuses attention on: a. The costs of health care to the European Economy b. The effects of poor health on economic growth c. The necessity for healthcare policy to concentrate increasing efforts and resources on promoting good health rather than just fighting ill health HEALTHY PEOPLE ARE THE KEY TO GLOBAL ECONOMIC SUCCESS. European Commissioner David Byrne speaking, in July 2004, at the launch of a major consultation exercise on EU health policy emphasised the fact that in the future the health of Europeans will be a key factor in their economic success. He said: Modern economies are built on good health. Their competitiveness increasingly depends on enabling their citizens to lead healthier, more productive lives. Good health is a key driver of growth. There is evidence that a 10% rise in life expectancy can generate up to 0.35% in GDP increase. Put simply, health generates wealth. Each health euro better spent could make a net saving both for individual well-being and for EU competitiveness. This is why achieving good health must become an economic priority. 8 David Byrne, Enabling Good Health For All, (July, 2004) IMO – 10 Alcohol Policy Table 1. Health Costs of Alcohol Related Problems in 1999.9 Real Resource Costs € millions Health care costs 433 Alcohol presents one of the most acute problem to the Health Services which can be addressed by a comprehensive Preventive Health policy. The IMO advocates: o the banning of the advertising of alcohol products, in particular to young people and children o that the duty on alcohol should be reviewed and increased so that economic success does not facilitate the culture of binge drinking especially among the young o a ban on practices by publicans which encourage excessive drinking (e.g. happy hours; alcohol beverage promotion events) o a ban on the sponsorship of sporting events by alcohol suppliers o an increase in Garda resources to improve the enforcement of the law in relation to underage purchase of alcohol o a reduction of the legal blood alcohol limit from 80mg/100mg to 50mg/100mg 9 Source: Strategic Task force on Alcohol, DOH September, 2004.