We have made remarkable progress in health as a global society, more than doubling life expectancy in just over two centuries. Public health and clinical innovations have been major contributors to this improvement. But across the Western world healthcare systems are facing a major crisis caused by a perfect storm of factors – rapidly rising healthcare costs, clinician burnout and attrition, and demographics going in the wrong direction. Since 2018 there are more people over 65 than under five in the world.
Time magazine recently wrote about the coming collapse of the US healthcare system, and the New York Times published an opinion piece about how that doctors are not burnt out from overwork but demoralised by a broken healthcare system.
But of all the global healthcare systems Ireland’s health system is perhaps the canary in the coal mine. Despite the recognition that we have excellent and committed clinicians and that, once you get into the system, care is good, we have a major problem. By a broad spectrum of measures Ireland’s health system is one of the lowest performing in the northern hemisphere.
The influential and credible CEO World rankings of health systems had Ireland ranked as number 80 in the world in 2021. This ranking, which considers factors such as government readiness, professionals, infrastructure, cost and medicine availability ranks the health systems of countries such as Iran, Albania, Algeria and Kenya above Ireland. Ireland is far richer and is one of the highest spenders per capita on health in the world.
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Dr Charles Larkin of Bath University has identified that Irish health spending overruns are masked by consistently higher than expected corporate tax returns. Ireland spends roughly the same amount as Denmark and Austria on healthcare per capita but they are ranked number three and four in the world.
Ireland has the highest acute hospital bed occupancy in Europe, and while we have a relatively low rate of acute beds per capita, both Denmark and Austria have similar ratios and yet seem to manage much better. Another ranking of health systems by Numbeo has Ireland ranked at number 84 globally.
There are many other indicators which indicate we have a major problem in health in Ireland. It remains the only western European country without universal coverage for primary care. Ireland’s health system ranked 22nd out of 35 countries in the broader European region in the European Health consumer index in 2018, but on the issue of accessibility Ireland ranked last.
Ireland has the highest rate of respiratory admissions in Europe – despite having the youngest population and relatively clean air. The mortality rate from respiratory disease in Ireland is 25 per cent higher than countries such as Belgium, Denmark and the Netherlands. Ireland is third last in electronic health maturity in the OECD countries despite the fact that almost all our GP practices have been digitalised for more than a decade.
Then there is obesity. Ireland has a high life expectancy compared to the European average, but recently ex-US surgeon general Jerome Adams highlighted at a seminar held at the Royal Irish Academy that Ireland has the second highest obesity rate in Europe – which is a top factor in future chronic disease manifestation. Considering unmanaged and undetected chronic disease results in over 70 per cent of all deaths and in the US drives about 90 per cent of all healthcare costs, this statistic is very worrying for an already stretched system.
Everyone is aware of the worsening A&E waiting list problem.
Then there is the fact that Ireland graduates the highest number of doctors per capita in Europe but has the highest rate of doctors from other countries. A Dublin hospital CEO recently said there are no longer any indigenous Irish nurses working in their hospital and that all their nurses were from abroad. Having foreign-trained clinical workers is not a bad thing, but there should be a balance.
Since the introduction of Slaintecare, Ireland’s wait-lists have almost doubled despite record and increasing spending. A highly touted €350 million waiting-list reduction plan last year resulted in a paltry one per cent reduction. There has been a catastrophic failure in strategy.
Do these problems translate into people and patient impact?
Likely so. In newly-released figures Eurostat ranks Ireland currently as the fourth worst in Europe for excess mortality at 12.2 per cent, compared to a European average of 2.7 per cent. Excess mortality is a count of all deaths from all causes relative to what would normally be expected, and there have been many thousands of deaths above what normally would be expected. In one six-week period alone there were 3,000 extra deaths.
But despite all of this there is hope. Digital is a massive democratising force which can deliver much better health equity and reverse the trends in our ailing health system. With much evidence in a network of living labs across Ireland of the potential of digital to transform our healthcare system – examples include a reduction in heart failure admissions by a factor of 10, costs of managing a patient in a virtual respiratory ward 10 times lower than a hospital stay – the solution is hiding in plain sight. However, the well-publicised blockage of Ireland’s digital health progress by senior health managers has stalled progress.
Slaintecare is a good policy, albeit missing a stronger digital component. A cross-party grouping led by TDs such as Róisín Shortall and Dr Michael Harty showed vision and leadership to create this strategy.
By any objective measure there has been a catastrophic failure in implementing it. However, there are positive signs that things are changing under Prof Breda Smyth, Ireland’s new CMO, and new HSE CEO Bernard Gloster.
Empowered, motivated and educated clinical leaders are a prerequisite to driving a digital transformation of our health service, and three years ago we created a unique masters in digital health transformation, with all Irish research universities to train a cohort of digital leaders. But according to the OECD the number one prerequisite is the political will and prioritisation of such a decision.
At Maynooth University we are adopting a collaborative approach to help drive a cohesive and co-ordinated attempt to get Ireland’s healthcare system to evolve into a leading system using digital solutions. Often major transitions need a burning platform. The Irish health system, despite excellent and committed clinicians, is blazing like an uncontrolled forest fire. We can’t wait to act.
Prof Martin Curley MRIA is professor of innovation and director of the digital health ecosystem at Maynooth University. He was the former HSE digital transformation director