New health policies and strategies needed

Policies, programmes and strategies needed to tackle the increasing demands on the Irish health services posed by the enormous increase in the number of our older people and those with chronic disease have been spelled out by Mr. Jim Breslin, Secretary General of the Department of Health. Maureen Browne reports.

Jim Breslin
Jim Breslin

He was speaking on “The Policy Context For Health & Social Care Improvement” at a packed HMI West Forum in Ballyshannon, Health Campus Co. Donegal.

Mr. Breslin opened the forum by saying he was a great believer in the HMI. “I think we undersell the management part of the health services. We have to show confidence in our profession and the HMI is an important part of this, so I always prioritise HMI invitations.”

He said the number of older people and those with chronic disease in Ireland had increased dramatically because of increasing life expectancy due to new and improved treatments and the population bulge resulting from a significant reduction in the number of young people who emigrated in the 1950s and ‘60s. The current demographics and the burden of chronic illness, expected to grow by 20% by 2020, required a major shift in our model of health and social care.

Since 1990 life expectancy in Ireland had increased by 6.3 years and was now 79 years for men (one year above the EU average and 83 years for women (at the EU average)

Between 2005 and 2014, mortality rates here had been reduced by 31.5% for circulatory system diseases, by 7.9% for cancers, by 20% for respiratory system diseases and by 20.7% from external causes, while infant mortality had fallen by 4.2%.

Between 1998-2003 and 2008-2013, the five years relative survival rates for breast cancer increased from 75.8% to 81.5% and from colorectal cancer from 51% to 60.3%. The cases of Meningitis C decreased from 130 cases in 1999 to six in 2014.

However, we still had a long way to go. Only 32% of the Irish population was sufficiently active, 60% were overweight or obese, 19% smoked on a daily basis and 41% of Irish adults drank alcohol at least once a week…

On the plus side, Ireland was now ranked second in Europe for its tobacco control measures. Between 2006 and 2014, the number of day case procedures had increased by 54% from 558,813 to 860,763, in patient procedures at approximately 600,000 per annum had remained constant and between 2008 and 2014 the cost per weighted unit of care fell by 19% for inpatients and 18.7% for day cases, while day of surgery admission rates increased by 9%.   Nineteen older psychiatric hospitals had either been completely closed or had closed to new admissions.

GP care without fees was provided to approximately 800,000 in the over-70s and under-6 age cohorts and 63,000 patients were registered by the GMS Diabetes Cycle of Care by the end of 2015.

The Secretary General said waiting lists, budgets and trolley waits were among the main challenges now facing us. It was not acceptable to have people waiting on trolleys for 24 hours and we had to come up with a shift in the way we delivered services so that this did not happen.

Mr. Breslin said additional funding for the health service had been provided this year, which HSE Director General, Mr. Tony O’Brien said had in effect stabilised the finances for 2016 and allowed a realistic target to be achieved by year end. breaking the historical annual cycle of large health service deficits and supplementary estimated.

“I think we undersell the management part of the health services. We have to show confidence in our profession and the HMI is an important part of this.

“It is absolutely imperative that we come in on budget this year.   The half a billion euro was provided on the understanding that there would not be a supplementary at the end of the year. If we can come in on budget, then we can state a case in October for further investment next year. If we do not, the Minister will have a weakened position to argue for increased funding for next year. I do not want any manager in the health service to be on the wrong side of the line at the end of the year. We have to get the budget right in the short term and in the medium term we have to focus on the challenges of demographics and chronic illness.”

He said the number of people aged over 65 had increased by 20% between 1950 and 2015 and was projected to increase by over 24% between 2013 and 2021, compared to an EU average increase of 15%. An increasing number of older people required emergency admissions – over 30,000 people aged 85 and over required emergency admission in 2014.

In 2010, over three quarters of deaths in Ireland were due to three major conditions – cardiovascular disease (34%) cancer (30% and respiratory disease (12%). Approximately 38% of Irish people aged 50 and over had a chronic disease and 11% had more than one. As the number of older people increased, the HSE estimated this burden of chronic disease would grow by 20% by 2020. Estimates projected a 70% increase in cancer cases in females and an 83% increase in males between 2015 and 2040.

In 2011, 40% of all hospitalisations in patients aged 35 and over related to four chronic diseases – cardiovascular disease, cancer, respiratory disease and diabetes (either as a direct reason for hospitalisation in the case of 19% or a contributory factor in the case of 22%). Seventy six per cent of all bed days used (either directly, 46% or as a contributory factor, 30%) were used by patients with these four conditions.

A total of €1.68bn of the country’s acute hospital budget (55%) was attributable to the care of patients with these conditions, either directly or indirectly and chronic disease accounted for 80% of all GP visits. How we managed the four chronic illnesses had a direct bearing on all hospitalizations, as they accounted for 76% of all bed days.

If we can come in on budget, then we can state a case in October for further investment next year.

Mr. Breslin said that those with low risk disease, about 80%, could be managed by health education and health promotion, 15%, the moderate risk patients with a single chronic illness or risk factor, could be managed by health coaching and lifestyle management and just 5%, those with high risk or with multiple chronic illnesses, required intensive case and disease management.

He said the HSE Integrated Care Programme for Older People had all the principles for the management of chronic illness and provided a response to long term complex care,   It was community delivered but integrated across all agencies and services. It covered population stratification of risk, anticipatory care planning and care coordination by a case manager

Good quality primary care could help prevent the need for hospital admission, well established treatment guidelines were established for chronic conditions. This would never eliminate the need for hospital treatment, but there was potential to significantly improve hospitalisation rates and the standard of care for this condition.

Looking at the burden on chronic diseases, Mr. Breslin said there were 381 hospitalisations per 100,000 population for COPD in 2014, the equivalent of 300 acute beds and there had been a slight increase in age standardised hospitalisation for COPD between 2005 and 2014.

Asthma accounted for 41 hospitalisations per 100,000 population in 2014. Although there had been a 25% reduction between 2005 and 2014 it still accounted for 1,433 hospital stays consuming 6,953 bed-days.

There were 129 hospitalisations per 100,000 population for diabetes in 2014, again a 25% reduction compared to 2005,   However it accounted for 4,406 hospital stays, consuming 42,200 bed days.

He said the HSE Integrated Care Programme for Prevention & Management of Chronic Disease provided for a GP enrolled population, risk stratification, shared care pathways and protocols, care planning and care delivery and co-ordinations.

Quicker and more decisive evolution was required from episodic reactive response to supporting population health models of care which provided greater integration, continuing and coordination of care.