Healthcare Forum Removing Private Activity from Public Hospitals & its Impact on the Healthcare System Society of Actuaries - Mr Martin Varley ...
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Healthcare Forum Removing Private Activity from Public Hospitals & its Impact on the Healthcare System Society of Actuaries Mr Martin Varley 3rd December 20191 Secretary General
History of Health Reform • Track record: unimplemented reports and strategies • Fitzgerald (1960s), Hanly (2003), VFC Mental Health (2006) • Health Boards, HSE, Integrated Areas, Hospital Groups, CHOs, UHI • Removal/Reinstatement of HSE Board • Regional Integrated Care Organisations (RICOs): Health Boards revisited • Rationalisation, colocation, reconfiguration, integration … • Strategy, Planning, Management churn • Indicator of dysfunctionality 2
2017 Sláintecare Recommendations Sláintecare Year 10 Costs (%) 1% Acute Hospital Expansion 4% 10% Primary Care Expansion 27% Social Care Expansion 15% Reduce/remove charges 17% 26% Expand Health & Wellbeing Mental Health Programmes Dentistry Expansion • First decade cost: €20bn plus €3bn transitional • Second decade cost: €28bn + inflation 3
Sláintecare Qualifications & Unintended Consequences “The Committee acknowledges that removing private care from public hospitals will be complex. It therefore proposes an independent impact analysis of the separation of private practice from the public system with a view to identifying any adverse and unintended consequences that may arise for the public system in the separation. Given the acknowledged need to increase capacity in the public system, it is important that any change should not have an adverse impact on the recruitment and retention of consultants and other health professionals in public hospitals.” 4
Sláintecare & Capacity Expansion?? • Expand Hospital Activity???? o Replace private insurance income year 2 – 10: Year 10 cost €649m o Increase consultant numbers by 593 (+20%): Year 10 costs €119m 5
Other Capacity Expansion Needs Bed Capacity Deficits o 2,600 additional public hospital beds (€2.6Bn) o 4,500 Community beds (€4Bn) ICU Capacity Equipment & Facilities o Need 330 more ICU o Replace obsolete beds (€412m) o Expand facilities as inadequate o €3.64bn to replace equipment (2017-2021) 6
2019-2021 Capital Plan • HSE to provide 480 new hospital beds between 2019-2021 • This is 100 less beds over each of 3 years 7
de Buitléir Recommendations • Legislation so public hospitals exclusively public patients from conclusion of 10 year Sláintecare implementation period • New Consultant appointments Sláintecare Consultant Contracts – public only • Restore pay parity to pre-2012 levels for all Consultants • Offered “contract change payment” • All existing contracts 39 hrs • Declining Salaries A → B → B* → C ?? 8
Outpatient Waiting List (March 2013-Oct 2019) Capacity Deficits 600,000 567,211 (Oct- 550,000 19) 500,000 450,000 400,000 375,440 384,632 350,000 300,000 300,752 Jul-13 Jul-14 Jul-15 Jul-16 Jul-17 Jul-18 Jul-19 May-13 Nov-13 May-14 Nov-14 May-15 Nov-15 May-16 Nov-16 May-17 Nov-17 May-18 Nov-18 May-19 Mar-13 Sep-13 Jan-14 Mar-14 Sep-14 Jan-15 Mar-15 Sep-15 Jan-16 Mar-16 Sep-16 Jan-17 Mar-17 Sep-17 Jan-18 Mar-18 Sep-18 Jan-19 Mar-19 Sep-19 Total Outpatients Linear (Total Outpatients) Source: NTPF (2013 - 2019) • 567,200 in October • ↑ 51,059 (9.9%) in 2019 • ↑ 189,709 (50%) in 5 years • 500 Permanent hospital Consultant posts can’t be filled 10
Consultant Vacancies and the Recruitment and Retention Crisis Specialist medical practitioners per 1,000 population in EU in 2018 (or nearest year) • 42% Ireland France 1.44 fewer Denmark Belgium 1.76 medical Finland Poland specialists Netherlands Norway 1.97 than EU Luxembourg UK 2.09 average Sweden Slovenia EU Average 2.47 Latvia Portugal 2.49 • Over 500 Spain Switzerland posts Hungary Estonia 2.62 vacant or Austria Czechia 2.75 filled on a Italy Germany 3.1 3.25 temporary Lithhuania Greece 3.51 4.95 basis 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Source: Eurostat 11
Specialist medical practitioners in Ireland per 100,000 population as a percentage of the EU average (2016 or nearest year) % of EU Average 100 • 1/to 1/2 in 4 90 80 82 82 many 70 66 specialties 61 58 60 55 53 52 51 48 46 50 40 37 32 32 30 • UCC at 30 25 20 23 Connolly 10 Hospital only 0 open for 1/3 of planned hours Source: Eurostat 12
Increased Acute Hospital Capacity Requirements Public Hospital Inpatient and Day Case Beds, and Population Growth 2008 to 2019 Total Inpatient and Day Case beds Total Population 2008-2019 (April) 2008-2019 YTD 13,584 4921.5 4,857.00 13,231 4,792.50 13,141 13,096 4,739.60 4,687.80 12,847 12,835 12,732 4,645.40 12,630 4,614.70 4,593.70 4,574.90 12,48612,499 4,554.80 12,38612,432 4,533.40 4,485.10 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 YTD 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Source: Department of Health Open Beds Report Sept 2019; Health in Ireland: Key Trends 2017, DOH; CSO • Population ↑ 9.7% • 22% ↑ (273,433) in inpatient and day cases performed • Bed capacity ↓ 2.6% • 12.3% increased deficit 13
Total Inpatient and Day Case Waiting List (March 2013-Oct 2019) 90,000 86,111 85,000 80,000 75,000 68,086 67,511 (Oct- 70,000 19) 65,000 60,000 55,000 50,000 47,413 45,000 44,870 40,000 Jul-13 Jul-14 Jul-15 Jul-16 Jul-17 Jul-18 Jul-19 May-13 Nov-13 May-14 Nov-14 May-15 Nov-15 May-16 Nov-16 May-17 Nov-17 May-18 Nov-18 May-19 Mar-13 Sep-13 Jan-14 Mar-14 Sep-14 Jan-15 Mar-15 Sep-15 Jan-16 Mar-16 Sep-16 Jan-17 Mar-17 Sep-17 Jan-18 Mar-18 Sep-18 Jan-19 Mar-19 Sep-19 Total Inpatients/day cases Linear (Total Inpatients/day cases) Source: NTPF (2013 - 2019) • ↑ 24,089 (55%) in 7 years 14
Hospital beds per 1,000 of population in EU, 2018 (or nearest year) Sweden 2.04 UK 2.11 Denmark 2.44 Spain 2.43 Italy Ireland 2.62 2.77 Our hospital Finland Netherlands 2.8 2.92 bed capacity: France 3.09 Portugal Latvia 3.25 3.3 • 31% below Cyprus Estonia 3.43 3.45 EU average Greece 3.6 Luxembourg EU28 3.7 4.02 • Regular bed Czech Republic 4.11 shortages Slovenia 4.2 • Rationing Hungary 4.27 Malta 4.69 Poland 4.85 Slovak Republic 4.91 care Belgium 4.98 Austria Lithuania 5.45 5.47 • Delays Croatia 5.49 Germany 6.02 Romania 6.84 Bulgaria 7.27 0 1 2 3 4 5 6 7 8 Source: OECD.Stat; Eurostat 16
Consultant Vacancies and the Recruitment and Retention Crisis • Over 500 Vacancies + 108 non-specialists in Consultant posts since 2008 • “Jeopardising patient safety” – Justice Peter Kelly • Medical agency spend 2012-2018 ↑€57m p.a. • Agency Consultant costs up to three times New Entrant Permanent Consultant Cost • New Entrant salary is up to 51% below colleagues • Failed to fill 38% of posts advertised 2015-2017 • Not competitive – salaries in Australia, Canada and US up to 48% above non-new entrant salary • Annual Medical Indemnity costs quadrupled between 2013-2018. Increase of €184 million 19
Number of patients treated on trolleys annually (2008 – 2018) 108,227 98,981 100,000 92,998 93,621 86,481 80,000 75,859 77,091 Number of Patients 66,308 67,863 63,713 59,435 60,000 40,000 20,000 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Source: INMO Trolley Ward/Watch • 108,000 admitted patients treated on trolleys in 2018 • Nearly double ‘national emergency’ level of a decade earlier 21
Trolley Analysis January/July 2008-January/July 2019 Source: INMO Trolley Ward/Watch • Year round problem • July 2019 (9,439) a record for the month – ↑ 33% on July ’18 • August 2019 (9,562) highest ever for the month – ↑ 10% Aug ’18 • September 2019 (10,641) – worst Sept on record – ↑ 36% Sept ’18 • Oct 2019 (11,452) – worst Oct and 2nd worst month ever – ↑ 26% Oct ’18 22
Delays in Accessing Treatment resulting in missed Cancer KPI targets • Symptomatic Breast Disease Clinics 44% < target • Rapid Access Clinics for Prostate Cancer patients 21% < target Source Health Service Performance Profile January to March 2019 23
Media Coverage
de Buitléir Report Terms of Reference “The Review Group will examine and enquire into the effects of the removal of private activity from public hospitals and will specifically examine potential benefits and potential adverse consequences, including any unintended consequences that may arise, in the removal. In particular the group will examine and consider… • possible impacts, both direct and indirect, immediate and over time, of removing private practice from public hospitals, including but not limited to impacts on: access; hospital activity (including specialist services); funding; recruitment and retention of personnel; and any legal or legislative issues that might arise.” 25
Sláintecare and the de Buitléir Report • €20bn to implement Sláintecare in first decade (€28bn thereafter) • Confirms need for more Consultants and beds • Removing private care from public hospitals to cost €6.5bn over 10 years (€8bn thereafter) • In reality loss in private health insurance income will not be replaced • Exacerbate Consultant recruitment and retention crisis & hospital capacity deficits • Ideology v Pragmatism 26
Real World Challenges on Hospital Frontline • Hospitals crumbling after a decade of cuts (€1.88bn health capital cuts 2009-2019) • Health capital budget in 2019 €667m, including €325m for acute hospitals • Delays in bed capacity ↑ by 2,600 beds before 2027 • Delays in community beds ↑ by 4,500 beds by 2027 • Rationing of care, growing waiting lists, and trolley crisis • Nearly 50% population with PHI: Capacity & Delays 27
Real World Challenges on Hospital Frontline • Need separate additional funding for National Children’s Hospital (€2Bn vs €0.63Bn estimate) • National Children’s Hospital Cost Overrun: o €100m in 2019 (€25m from HSE) o €107m in 2020 o €120m in 2021 o €150m in 2022 • Ongoing problem • Cost of Relocation of 3 Dublin Maternity Hospitals 28
Real Strategic & Hospital Needs o Fill all approved Consultant posts on a permanent basis o ↑ Frontline capacity to treat people awaiting outpatient appointments, and inpatient and day case elective procedures o ↑ Public acute hospital bed capacity o ↑ Funding to address capacity deficits o Meet KPI targets for cancer care, surgical procedures and key aspects of patient care 29
Solutions to Frontline Problems • Resolve public hospital access crisis • Insufficient public hospital capacity o Record waiting lists o Record numbers on trolleys • All patients in public hospitals are public hospital patients who need care without current delays 30
Sláintecare & de Buitléir Reports • Unintended consequences • Loss of €6.5Bn PHI per decade • Won’t be replaced • Substantial other investment and operating costs • Already lagging behind NDP 2,600 hospital bed timetable • Counter productive – Prolonging Access Crisis 31
Sláintecare & de Buitléir Reports • 2.22m (45%) PHI members • 50:50 reliance Public & Private Hospital care • Increased by 64,000 (3%) since May 2017 • Little or no capacity freed up in Public Hospitals • Market segmentation • 10% PHI members with Public Hospital cover only 32
Removal PHI Income • Capacity expansion delayed • Unprecedented Consultant Recruitment & Retention Crisis o Type A tried 2008 & 2011 and failed o Current Pay Inequality: 500+ vacancies o Increased exodus & greater recruitment problems o Deterioration in public hospital care 33
Conclusions • A strategy or plan which is based on ideology over pragmatism and focuses on the symptoms rather than the root cause problems is damaging and deflects from addressing the real problems. • Capacity deficits need to be addressed. • Let’s focus on fixing the real problems. 34
Thank You Support the IHCA campaign at: 35
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