A focus on A&E problems and surgery waiting lists obscures the significance of chronic illness and its impact on the health service, writes Orla Hardiman
Tánaiste Mary Harney's proposal to transfer patients with private health insurance from public hospitals to private facilities, thus increasing the bed capacity within the public sector, has generated considerable debate. Discussion of this proposal has centred on the possible financial implications for public hospitals. Unfortunately, less consideration has been given to the suitability of the private sector to cater for the types of patients who utilise public hospitals.
Up to 80 per cent of all admissions to public hospitals occur through A&E departments, and nearly half of the population has private medical insurance. In theory, a large proportion of patients who are admitted to public hospitals fall into the category of "private patients in public beds".
However, most patients require medical rather than surgical attention and most of these medical admissions arise from exacerbations of underlying chronic diseases. The most appropriate method of delivering healthcare to patients with chronic illness is a central theme in medical practice and yet the suitability of the private healthcare sector to provide these services has been largely overlooked in the current debate.
Most chronic conditions require frequent contact with specialist services for optimal management. For many diseases, such as diabetes, stroke and coronary artery disease, the most effective care is provided by a multidisciplinary team led by physicians and including a wide range of clinical professionals such as specialist nurses, physiotherapists, occupational therapists, speech and language therapists and social workers.
Liaison between hospital and community-based services is key to the success of these efforts to ensure a seamless transfer of care from the acute (hospital-based) to the chronic (community-based) phase of management. It is unclear how such services will be catered for in a private sector that is based on a "one patient, one doctor" model of healthcare provision.
Neurological disorders are a useful model to examine how we treat chronic illness in Ireland. At least 500,000 people suffer from a chronic neurological disorder. Stroke remains one of the leading causes of death and disability in Ireland and accounts for a high proportion of admissions through A&E. In a recent global survey, eight of the 10 leading disabling conditions were caused by disease of the brain, and neurological problems account for up to 30 per cent of all hospitalisations.
By necessity, Irish neurologists have embraced the model of multidisciplinary care. High quality multidisciplinary services have now being developed for patients with Parkinson's disease, dementia, multiple sclerosis, epilepsy, stroke, motor-neuron disease, neuromuscular diseases and migraine. Some of these services have been developed collaboratively with voluntary organisations.
The important contribution of nursing and non-physician members of multidisciplinary teams is frequently undervalued by those who generate health policy.
Measurement of outcome in our health service is biased in favour of "procedural medicine" and surgical care. There is little or no funding to conduct systematic audit of general medical services, let alone multidisciplinary care. Clinical professional staff, such as specialist nurses, physiotherapists, occupational therapists, speech and language therapists, are seen as a "cost" rather than as a means to improve overall clinical care and efficiency of healthcare provision.
The budgets for hospital-based care and community-based care are managed separately, making the development of liaison posts between hospital and community services very difficult. Funding of non-physician and liaison services enhances the utilisation of healthcare resources and significantly cuts costs in the long term.
There is an abundance of published evidence demonstrating multidisciplinary management works well. The delivery of care is more efficient, hospitalisations are reduced and clinical outcomes can be improved. This is true for conditions with potential for recovery, such are stroke rehabilitation, and for conditions that are chronic and progressive, such as multiple sclerosis and motor-neuron disease. In all cases, there is evidence to suggest that investment in multidisciplinary teams and liaison services between hospital and community both improves clinical care and would save money in the long term.
To date, the Department of Health has largely ignored developing and promoting services for people with chronic disease. There is a dearth of reliable information about chronic diseases in the Irish population, and this lack of recognition of the problem has translated into a deficiency of funding required to measure the problem. Instead, priority for investment in the health services is driven by areas of healthcare that are "measurable" and that can be presented to the public as evidence of success. The story of those with chronic illness goes untold.
There are currently no reliable ways of measuring the true burden of chronic disease within the Irish population. This is in part due to stringent data protection laws.
By extension, there is no way for those who generate and implement policy to determine the hardship that the absence of services engenders.
As to the relative benefits of transferring patients with private insurance to private hospitals, the problem is that multidisciplinary teams effectively do not exist in the private sector. This is because the "model" by which the private sector operates relates primarily to patients who require surgical care. The ideal patient does not have a chronic illness and does not require liaison services between hospital and community.
The National Treatment Purchase Fund was set up to reduce waiting lists for those who are waiting for long periods for surgery because public hospitals are overwhelmed by admissions from A&E. This initiative has been successful. However, this model cannot be extended to other categories of patients who require hospitalisation for a more integrated type of care unless private facilities recognise the value of multidisciplinary management and the importance of liaison with community services. What Should be Done?
Multidisciplinary teams that address the needs of people with chronic diseases must be urgently funded. These teams should provide a liaison service between hospital and community, and should include clinical nurse specialists who provide care to both inpatients and outpatients. We should ensure patients with chronic disease are not disenfranchised when encouraged to avail of private facilities.
Measurement of our healthcare is not just about hospital A&E, admissions and operations. The vast majority of people who utilise the public health service are managed as outpatients, and do not attend A&E. They have chronic problems that are not treatable by surgery. We must accurately gauge the needs of these patients and measure the effects of long-term, multidisciplinary intervention.
There is an urgent need to amend the data protection laws so that we can generate complete and reliable data regarding disease prevalence, which in turn can lead to appropriate planning of services.
The rigid division of budgets between hospital- and community-care services must change. The importance of liaison services and seamless transfer of care must be recognised and adequately funded.
Orla Hardiman is consultant neurologist and director of neurology at Beaumont hospital