Zoonotic diseases are a major global challenge. David Lynch examines how the progress of Covid-19 has led to renewed calls for a ‘One Health’ approach to the pandemic According to the World Health Organisation (WHO), all available evidence on Covid-19 suggests that SARS-CoV-2 has a zoonotic source. One of the most common hypotheses is that…Read More
Covid-19 is accelerating changes to the delivery of continuing medical education, which is the focus of a broader review at the Medical Council. Catherine Reilly reports on what it could mean for registered doctors Continuing medical education has undergone seismic change due to Covid-19 and physical distancing guidelines. In large numbers, doctors have dialled in…Read More
Dr Rob Hendry, Medical Director at the Medical Protection Society, advises on some medico-legal dilemmas faced by healthcare professionals managing Covid-19 in Ireland. Q. I am having to do increasingly more remote consultations – is there any advice and how does this affect my indemnity? We understand that in the current situation doctors may have…Read More
We chart 12 months in healthcare in a year dominated by the CervicalCheck controversyRead More
Calls for greater investment and concerns over the recruitment and retention of consultants are sure to figure at the 2016 IHCA Annual Conference, writes David LynchRead More
Our acute hospital and mental health services have suffered from decades of chronic under-investment. The health service has a much lower number of inpatient beds per capita in comparison to the average of the OECD countries.
There are growing demographic pressures. In the last decade the population served by the hospital system has increased by 12 per cent and is expected to increase by a further 4 per cent by 2021. The portion of the population over 65 is expected to grow more rapidly.
The challenges facing the healthcare system have a clear and growing impact on the care of patients. There is an increased number of patients being treated after hospital admission on trolleys this summer and this can be expected to become even more common in the winter months. The numbers on waiting lists for essential care are growing. This month 514,000 people are on waiting lists for consultant outpatient appointments and over 74,000 patients are awaiting surgical appointments.
The Sláintecare Implementation Strategy, published in August, fails to provide real solutions for these capacity deficits in our acute hospital and mental health services. The Strategy’s proposal to introduce 2,600 new beds over the next 15 years fails to address the very urgent needs of patients who, in this year, need access to care in our acute hospitals. We need a clear year-by-year strategy for the delivery of increased capacity starting this year.
Dr Donal O’Hanlon
Currently, the health service is unable to attract sufficient suitably qualified candidates for consultant posts. In contrast to the situation in the past, there are much fewer candidates interested in vacant posts in recent years. During the three years 2015 to 2017, over one-third of the posts advertised received between zero or one application and over half received between zero to two applications. Fewer candidates are presenting for interview for posts and from 2015 to 2017 the health service has failed to fill up to one-third of the consultant posts advertised by the Public Appointments Service.
Over 500 consultant posts are not filled on a permanent basis throughout the country’s acute hospital and mental health services. This represents a serious crisis with nearly 20 per cent of consultant posts that cannot be filled on a permanent basis.
The IHCA survey of over 300 recently-appointed consultant members carried out in July confirmed that our acute hospital and mental health services face an escalating and unprecedented consultant recruitment and retention crisis. This is due to ongoing discrimination by the State and health service employers against new-entrant hospital consultants. Respondents to the survey confirmed that the lower salary terms are having an adverse impact on the delivery of patient care due to the large number of consultant posts that are unfilled or filled on a temporary basis. Of equal concern, over 70 per cent of the new-entrant consultants have confirmed that they will seriously consider resigning from their public hospital posts unless the discriminatory salary terms imposed on them by the State are corrected. The survey has provided categorical evidence that our highly trained specialist consultants will not continue to work in our health services if the persistent discrimination against them continues. This is not surprising as there is currently up to a 57 per cent salary differential between newly-appointed consultants and their colleagues appointed prior to October 2012.
On a population basis, Ireland has one of the lowest number of hospital consultants in the OECD, at approximately half the OECD average. Our health services are uncompetitive in attracting and retaining consultants given the high levels of international demand for specialists and considering the terms and working conditions on offer in other countries. The Government must, without further delay, address the capacity issues that make posts unattractive and end the discrimination against new consultants. The failure to fill a third of the advertised consultant posts is having an adverse impact on practically all medical and surgical specialties and most hospitals throughout the country. The country has already lost a large percentage of the highly-trained specialists who qualified in the past decade. If the Government does not end the discrimination, in another decade we will have lost most of a generation of the specialists that we need. We have taken the exceptional action of outlining the stark realities in letters to the Taoiseach, Ministers for Health, Finance, Public Expenditure and Reform and the main political party leaders and spokespersons on health, finance and expenditure.Read More
The failure to invest in essential acute hospital services and the blatant breach of the 2008 Consultants Contract combined with the persistent discrimination against new-entrant consultants have seriously undermined the capacity of our acute hospital services.
They represent serious mistakes by the State, which will adversely impact on services for decades to come unless rectified.
Overwhelming capacity deficits
The Association has repeatedly highlighted the extreme capacity deficits in our acute hospital services. The Capacity Review and the National Development Plan (NDP), published earlier this year, acknowledged the deficits, but there is a lack of urgency in addressing them.
The NDP provides €10.9 billion in funding for capacity expansion between 2018 and 2027, including an additional 2,600 acute hospital beds and 4,500 long-stay beds. The replacement of equipment and the extension of facilities have also been funded in the Plan.
Mr Martin Varley
The more recently published Sláintecare Implementation Strategy is less specific and over a longer time period. Neither document contains the required commitments on when the much-needed beds will be provided. This is a major concern as the unacceptable number of patients being treated on trolleys and the growing waiting lists confirm that the additional beds are absolutely required without delay. Similar problems exist concerning ICU beds. The HSE Prospectus Report in 2009 recommended a 45 per cent increase by 2010 and doubling by 2020. Today we have fewer ICU beds than in 2009.
Ireland’s acute hospital capacity is significantly below the EU average, therefore if the State fails to increase the capacity urgently, it will be condemning the population to ever-deteriorating acute hospital services. This, after decades of insufficient capital funding, would be irresponsible in the extreme.
Recruitment and retention crisis
The State has driven and continues to drive highly trained specialists abroad to work in health services where they are valued, where they are not discriminated against, and where they are provided with facilities to treat patients. The result is a prolonged and deepening consultant recruitment and retention crisis.
The fact that about 700 IHCA members had to take High Court proceedings to vindicate their contractual rights highlights the State’s disregard for them. The High Court settlement in June is an important and essential development, but it does not represent the full solution.
Our hospitals are increasingly uncompetitive in recruiting and retaining the number of consultants required. They are in a serious crisis with nearly 20 per cent of the permanent consultant posts vacant or filled on a temporary basis through agencies and otherwise. The State’s discrimination against new consultants is preventing the filling of over 500 permanent consultant posts. On a population basis, Ireland has one of the lowest numbers of hospital consultants in the OECD, at approximately half the OECD average. It is clear that the Irish population and patients can ill afford to have nearly 20 per cent of the approved permanent consultant posts unfilled. This represents a false economy from both financial and patient care perspectives, with steeply increasing waiting lists due to a shortage of consultants and growing medical agency costs which exceed €100 million per annum.
Over the past three years the health service has failed to fill up to one-third of the consultant posts advertised by the Public Appointments Service. During those three years, 39 advertised hospital consultant posts received no applicants and a further 153 received only between one and two applicants. This is having a severe impact on practically all medical and surgical specialties and hospitals throughout the country. Unfilled posts in 2017 include the following: Medicine (9), psychiatry (9), obstetrics /gynaecology (4), geriatrics (3), emergency medicine (3), pathology (4), radiology (3), paediatrics (2), and gastroenterology (2).
These developments contrast sharply with the situation that pertained prior to 2008. Any employer knows that you will no longer be an employer of choice if you breach contract terms and discriminate against new appointees. It is unacceptable that the State, of all employers, has persisted with such behaviour.
It is illogical that the State continues to perpetuate extreme levels of discrimination against new-entrant consultants given the growing number of vacant consultant posts and increasing patient demand for care. There is up to a 57 per cent salary differential between newly-appointed consultants and their colleagues appointed prior to October 2012. This discrimination must be ended without delay if our health service is to attract back highly trained specialists who have gone abroad. This is especially relevant as hospitals are paying agency doctors up to three times the salary they are paying new-entrant consultants.
Furthermore, it is of even greater concern that approximately 80 such doctors who have been appointed since March 2008 to temporary consultant posts are not on the Medical Council specialist register and, therefore, are not in a position to practise as specialists. This is a basic requirement to be appointed to a consultant post.
Given the improving economic situation, there is an opportunity and a pressing need for the State to end the discrimination against new-entrant consultants and fill the vacant posts. This makes sense on every level.Read More
I am once again very happy to contribute to the Medical Independent’s IHCA Annual Conference Preview.
I was delighted to be in a position to submit the Sláintecare Implementation Strategy to Government in July and to have received significant support from my colleagues. The Government is committed to achieving the transformation set out in the Strategy and it will require investment, strengthened governance and accountability and a coherent programme of reform.
The Implementation Strategy, which I published on 8 August, is a further step in the detailed implementation process and sets out four over-arching goals and 10 high-level strategic actions, which will be the key focus for the first three years of the reform programme. The Strategy focuses on establishing the building blocks for a significant shift in the way in which health services are delivered in Ireland. A Sláintecare Programme Office in my Department, led by an experienced Executive Director, is currently preparing a detailed action plan, which will be published before the end of the year.
Mr Simon Harris
I have always been clear that we must match reform with investment, and with an increase in capacity. The Health Service Capacity Review (2018) recommended an increase of 2,600 acute hospital beds and 4,500 additional long- and short-term community beds. The Government’s National Development Plan 2018–2027 commits that €10.9 billion will be invested in health infrastructure and reform. This will support the Sláintecare reform programme; increased capacity, including the provision of three elective-only hospitals in Dublin, Galway and Cork; and additional facilities will also be provided for primary care, mental health services and disability services.
I have also obtained Government approval for the establishment of an independent Board for the HSE. The General Scheme of a Bill has been published and I hope that legislation will be enacted this year. I have already announced that Mr Ciarán Devane is my designated Chairperson for the new Board. Early tasks for the new Chair will be to participate in the selection of the CEO of the HSE, the process for which is underway and to participate in the process for identifying other Board members. This is another important step in the implementation of a key Sláintecare recommendation.
I believe it is unfair that private patients can access treatment more quickly than public patients. I understand, however, that removing private practice from public hospitals is a complex process and the consequences of doing so must be analysed and carefully considered. I expect to receive the report of the group established to examine the impact later this year.
The Public Service Pay Commission in its report, published last month, covering medical staffing, highlighted the recruitment and retention of highly-skilled, well-trained and appropriately qualified healthcare professionals in the public health service as a dominant imperative. In order to deliver high-quality care across the health services, the Government and I recognise that the recruitment and retention of highly-trained and skilled medical staff is essential.
I see the settlement agreement reached in June as an important step towards ensuring that we retain our established consultant cohort and I am pleased that most consultants have responded positively to the Agreement. New-entrant consultants are encompassed by the process announced for new entrants across the public service under Section 4 of the Public Service Stability Agreement. However, the Commission had noted the degree of pay differential that is likely to apply following the settlement agreement notwithstanding this process and proposed that the parties to the Public Service Stability Agreement jointly consider what further measures could be taken, over time, to address this difficulty. The challenge will be doing so in a manner that respects pay policy and our budgetary constraints.
The Commission also highlighted the need to ensure that the overall employment, professional development package, working conditions and culture available in Ireland be sufficient to attract the right people when and where they are needed. I recognise this as an equally significant challenge and one that must be met. The Medical Council has reported on the need to facilitate the training of not just junior hospital doctors, but also consultant trainers. It is evident that the current difficulties in ensuring protected time for junior doctors and consultants is indicative of the current level of demand for services and related work pressures. I believe that the Government’s commitment to increasing capacity across our health services and the full implementation of Sláintecare can have a significant positive impact on improving the working conditions of all of our medical staff.Read More
Every September, World Alzheimer Month raises awareness and challenges the stigma that surrounds dementia. Internationally, two out of every three people (67 per cent) believe there is little or no understanding of dementia in their countries. The ‘Dementia: Understand Together’ campaign, led by the HSE in partnership with The Alzheimer Society of Ireland and Genio, has been working to increase awareness and understanding of dementia in Ireland since 2016, and recently released the results of a nationwide dementia survey conducted earlier this year.
The survey of more than 1,000 adults offers a number of insights into changes in dementia awareness, understanding and attitudes among the population at large in Ireland since a similar survey was undertaken in 2016. The results highlight the success of the campaign and identify areas where additional work is needed. They also offer an insight into the impact and direction of the broader implementation of the National Dementia Strategy, published in 2014.
Early diagnosis of dementia is crucial so that people can access the appropriate services and supports and can help with making decisions about care and support for the future. More than three-quarters of respondents (78 per cent) understood the importance of being diagnosed early. However, a quarter (24 per cent) of respondents to the survey said that they would delay seeking help if they had concerns, highlighting that stigma and fear still exist as barriers to early diagnosis.
A visit to the GP is usually the first step for people who have concerns about their memory or cognition, with patients usually referred to a general outpatient clinic or a specialist memory clinic for further investigation.
A number of education programmes and resources have been developed to support GPs and members of the primary care team in this role and a dedicated primary care website — www.dementiapathways.ie — provides education, resources and signposting for clinicians. The National Dementia Office is also leading on a project which aims to develop a national diagnostic framework to ensure everyone has equitable and timely access to diagnostic services.
Receiving a diagnosis is only the first step for a person living with dementia and it is essential that there are post-diagnostic supports available immediately after diagnosis and throughout the course of the condition. While there are still gaps in the availability of post-diagnostic services nationally, a number of new initiatives are addressing this.
‘Memory technology resource rooms’ are being established around the country to provide information and advice on the assistive technologies that are available to support people living with dementia to continue to live as independently as possible. The project aims to establish one memory technology resource room in every county, and 23 rooms will be open by the end of the year.
A number of grants were recently awarded to facilitate the provision of cognitive rehabilitation, cognitive stimulation and psycho-educational programmes around the country as part of a post-diagnostic support project being led by the National Dementia Office. The project is working towards the development of a national post-diagnostic support framework, which will provide guidance on the pathway of care after a diagnosis. In addition, The Alzheimer Society of Ireland provides a highly responsive and individualised information and signposting service through a network of dementia advisors who cover 11 counties nationally.
Over half of respondents (52 per cent) in the survey were aware that there are things they can do to potentially reduce their dementia risk — up from 46 per cent previously. Healthcare providers play an important role in highlighting the importance and benefits of staying physically, mentally and socially active, not only for general health, but as strategies for reducing the risk of developing dementia.
While health and social care services play an integral role in supporting a person with dementia and their families, a ‘whole-society’ approach is needed to ensure the person can live as well as possible, for as long as possible. Increasing understanding and reducing stigma is needed for this, and the results of the survey show progress, in that one-in-three (33 per cent) respondents described themselves as knowing a lot about the disease — up from 24 per cent in January 2016. Over half of respondents (52 per cent) recognised that people with dementia participate in a wide variety of activities and interests, and three-in-five people (59 per cent) who saw the ‘Dementia: Understand Together’ TV campaign said that they were impacted in some way as a result of the personal stories featured.
The next phase of the ‘Dementia: Understand Together’ campaign is building on this increased understanding, creating inclusive communities, empowering individuals, businesses and service providers to raise awareness and take action to support people living with dementia and their families. The campaign is calling on people to become ‘Community Activation Champions’ and information, resources and supports are available at www.understandtogether.ie.Read More
When patients and healthcare professionals are talking about a medical issue — big or small — both want to know that they have been fully understood. This is not always easy but improved health literacy, for both patients and healthcare professionals, can help.
For people working in the healthcare sector, health literacy is about communicating clearly and taking account of a person’s possible health literacy and numeracy needs. For patients, health literacy is the ability to understand and act on health information. It is also about empowering patients to ask questions, exploring their options and making informed decisions about their health.
Worryingly, a recent EU Health Literacy Survey showed that four-in-10 Irish adults had limited health literacy. This means that when dealing with health services, many adults find it challenging to fully understand health information and their health condition and treatment. They might also have difficulties working out and following instructions on medicine labels.
This is part of a wider literacy problem, as an OECD research study showed that one-in-six Irish adults find reading and understanding everyday texts difficult. For example, this could include bus timetables or restaurant menus. One-in-four Irish adults struggle with everyday maths, such as basic addition and subtraction.
However, even many patients who deal effectively with other aspects of their lives can find health information difficult to obtain, understand, or use. In fact, research shows that one-in-five Irish people are not fully confident that they understand the information they receive from their healthcare professional. In a survey conducted in 2015, 17 per cent of respondents said they had taken the wrong amount of medication on at least one occasion.
New research by the Healthy and Positive Ageing Initiative (HaPAI) also shows that a better understanding of health literacy by nurses and doctors could improve the health and wellbeing of people aged over 50. The findings show that:
24 per cent of older people said that their doctor or nurse rarely or never explains the results of medical exams.
26 per cent said that their doctor or nurse rarely or never explains different treatment options.
29 per cent felt discouraged to talk about emotional, nervous or psychiatric problems, such as stress, sadness or anxiety.
42 per cent felt discouraged from talking about sensitive problems, such as their sex life or incontinence.
The HaPAI outlines several steps that healthcare professionals can take to ensure older people feel more comfortable. These include explaining results and listening to opinions, and also supporting patients with cognitive issues and little or no education.
So, the benefits of improving health literacy for all concerned are clear. Patients who are better informed about their health have:
More effective consultations with their healthcare provider.
Are better informed about the medicines they are prescribed.
Are more likely to comply with their medication and as a result, have improved health outcomes.
People with improved health literacy skills are also more likely to make use of health screening programmes, tend to present at much earlier stages of disease and are less likely to be hospitalised.
Research has shown that health literacy interventions can significantly impact healthcare costs, outcomes and health disparities. Healthcare professionals have a real responsibility to engage in health literacy. However, they must be equipped with the awareness and tools to improve patient understanding. In practical terms, we need to undertake awareness-raising and training activities with healthcare workers at all levels, beginning in their undergraduate courses.
Health literacy also needs to be integrated into all national health campaigns and screening projects. Thankfully, many health services, including general practices, pharmacies and hospitals, are now looking at how they engage with their patients, particularly those with limited health literacy. By being aware and making it easier for all patients to use their services, they are becoming health literacy-friendly and delivering a better service.
A GP that is health literacy-friendly will look out for signs that a patient may not understand the instructions they just gave them. They might then use a ‘teach-back’ approach, where they ask the patient to repeat in their own words what they understand they have to do now. If the patient hasn’t fully understood the instructions, then this approach enables the GP to repeat them, perhaps using different terms and examples to explain what they mean.
Pharmacies also play a critical role in helping people understand their health issues and the steps they can take to improve their health. To help them achieve this, pharmacies can take part, along with general practices, in the Crystal Clear Programme. This national programme offers pharmacies and general practices the opportunity to gain a unique health literacy quality mark. It has been developed by the Irish Pharmacy Union (IPU), Merck Sharp & Dohme (MSD) and NALA. This Crystal Clear Mark recognises pharmacies and general practices that deliver a health literacy-friendly service to their customers. This means the service takes account of and supports the literacy and numeracy needs of its customers and regularly evaluates and improves its health literacy practices.Read More