Welcome to a minority government (well Irish style)


Whether health is seen as a business or public service depends on your ideology... and while both can co-exist within one model - in Ireland we seem totally confused in terms of our ideological approach - left wing public health care with universal access together with right wing mechanisms that actively supports private health care and market mechanisms. Whether health care is seen by some as a business or a right depends on whether you see access to health services as a right - whether rights come with responsibilities and remember our legislation vis a vis the Health Acts does not even establish an unequivocal right of access. Taken further, Lisbon mark 2 vis a vis the Charter of fundamental rights has dumbed down the right of access to a high level of health protection. I disagree with the view that health care is not a business - and that's were Ireland has gone wrong in my view... we've pumped endless resources into a system that does not deliver value for money... and if value for money is to be achieved we need persons who are competent - those who understand business and health service management.... and most important fiscal management....
 
Caveat said:
Fair enough, not literally - but do you agree or not agree that it needs to be 'run like a business' in any sense of that phrase?
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Generally no. Businesses are run to make money. The public health service exists to provide health services to the public.

Of course, there is much room for improvement in the current health services, just as there is much room for improvement in many private sector businesses. I am extremely cynical about ´business acumen´being seen as a panacea solution for our health service. If you incentivise doctors financially to do more or quicker procedures, they will do more or quicker procedures, regardless of whether that is what the patients need. If private sector ´business acumen´is the solution, why didn´t any of those super-smart and highly-paid cream of business consulting world (IBM et al) get PPARS sorted, or at least call a halt? Because the ´business approach´ incentivised them to keep going.

If the ´business approach´was the solution, why would Obama have spent the last week on ´town hall´meetings right across the US talking about the problems in their healthcare system? The responses from some of the Republicans to discussions of UK-like NHS services reminds me of the responses of the bishops to Noel Browne´s ´mother and child´scheme.
 
I agree that healthcare is not a business and maybe the phrase “it should be run like a business” has a bit too much ideological baggage attached. What I do think is that the primary skill set required is management experience. The head of the HSE needs next to no clinical medical experience, they need management experience. It is, I think, in that context that people talk about the necessity for it to be run like a business.
It would be lovely if we had limitless resources to pump into health and all of our public services but we don’t so value for money has to be the overriding concern. This can only be achieved if the right structures are in place with the right measurement matrix that are relatively simple and clearly understood by all concerned. A relation of mine was made matron of a hospital in St. Louis Missouri in the 90’s. The first thing the owners of the hospital did when they promoted her was send her to the local university to do a masters in business administration. Her promotion was conditional on her getting the qualification.
If the right person for the job is somebody from the private sector then they should get it, the same is true if the right person is from the public sector. The main thing that should be looked for is a track record in restructuring a large organisation which delivers a complex and diverse service so that it improves output and quality while not increasing costs.
Then the restructuring plan is being thrashed out ideologies, be they left or right wing, should be left at the door and the best solution for the benefit of the service recipients should be the only topic for discussion.
 
Sir Gerry Robinson, the former chairman of Granada, Allied Domecq, and the Arts Council and management expert is re-known for conducting a six-month investigation into the problems in Rotherham General Hospital in the NHS. His originally set the task of reducing waiting lists at the hospital and using business models tackled and reformed it including the sectoral interests…. This is the sort of thinking that should be running our health services.


http://www.telegraph.co.uk/news/uknews/3346920/Sir-Gerry-Robinson-How-I-would-fix-the-NHS.html
 
I was at a talk he gave and this came up in the open questions segment at the end. He said the solution was simple; basic good management from the ground up with each hospital doing its own thing.
 
I was also at a lecture given by Prof. Brennan on her Report - brill lecture and she was so blunt about her findings and what she saw as the services inefficiencies...!
 
My concern would be is the "business expert" in a position to identify inefficiencies? Maybe administrative, and there are plenty of those, but operational? That's where the medical background is essential.

Focus on waiting times is a red herring. It looks good on paper, that's all, it's easy to make a nice graph out of and keeps politicians happy. But health care isn't like a business, you can't have a predictable input and output.

Like the discussion in the US, the whole focus is on costs of a health care system, not the benefits. The US model isn't that efficient. For starters, 16% of GDP is spent proping up the so-called "private industry". That's a lot. And that's run exactly like a business, if you have a pre-exisiting medical condition you wont get insurance. If you do get insurance it will cost you a heck of a lot. But of course you can get insurance with your job, except there's huge unemployment, so no insurance. Plus without the labour laws of Europe, an employer can just decide to remove health insurance to save money, as they are.

That's why the insurance industry is behind Obama's plan, it's losing clients.

Then there's the medicard in the states, because the rates for care are negotiated with the doctors at a lower rate, they bump up their private fees to cover this. So a rate of $200 on medicard is $1600 at private. Which bumps up premiums, makes insurance companies even twitchier about who to insure etc.

But it's not just the cost of care and treatment that is in the equation. People treated quicker and made better quicker has knock on consequences. Less social welfare, less disability, less sickness, less absenteeism, etc etc. The initial cost of the treatement to us as tax payers is paid back in them being healthier and fit for work (where there is work). The odds of returning to any form of work after 6 months sick are minute. However, rehabilitation can have many people back in a short period of time. Initial cost, huge savings.

But then its too easy to look at the more selfish option of its costing me x to treat scroungers and ill people who're too lazy to get a job and look after themselves.

Like education, health care is beyond the realms of business because they contribute and add more to society...and business.

And there's some evidence for that too. All the focus has been on job losses and not the jobs that are still here. We all know there are major costs to doing business here, and yet there are still multinational (and American) businesses based here and willing to stay here. Even though they could be penalised through taxes, even though they could do the same jobs elsewhere for much cheaper. Why? It's not just incentives.

Because, even though we believe the Leaving Cert has been dumbed down, we still have a largely educated population. That's good for business and Intellectual Property too. We also have a decent enough healthy population.

Of course there's room for improvement in both areas, but I'm slightly concerned with some of the posts all around this board that seem to want to throw the baby out with the bathwater in the name of change.
 
Latrade said:
My concern would be is the "business expert" in a position to identify inefficiencies? Maybe administrative, and there are plenty of those, but operational? That's where the medical background is essential.
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No, a medical background is not essential. A good manager appoints the right people to do the digging and propose solutions then he/she acts on those proposals informed by their advisors. Why do you think that the head of large medical device corporations are more likely to have a financial rather than engineering or science background (or if it's both the financial side is their main area of expertise for most of their career).
 
I agree that focus solely on waiting times is a red herring – however it is symptomatic of the wider problems in that exist in the sector. Analysis of waiting times can indicate general inefficiencies in the running of the sector. Cutbacks in the 1980’s together with successive years of underinvestment have created enormous inefficiencies in the sectors infrastructure. We have medical, surgical and emergency admissions in our acute services. While bed designations are half medical and surgical this is not reflective of actual clinical activity, which then leads to medical encroachment on surgical beds and cancellation of elective surgical procedures. We have bed designations that are 80% public and 20% private – but then as numerous studies have identified – we have private use of public designated beds which then leads to extended public waiting times. We have inappropriate admissions, seasonal bed-closures, lack of step down facilities and delayed discharges which all contribute to lost bed days. While the publication of waiting lists had its inbuilt faults in terms of general accuracy, since the inception of the National Treatment Purchase Fund accurate waiting lists are not even published. Yes, we have seen increases in day case procedures and the benefits of earlier treatment has knock on benefits you say of decreased levels of disability, less chronic illness, less demand on social welfare and social welfare and increased levels of economic activity. However, while our health services adopt a medical model to rehabilitation, serious shortcomings and a lack of joined up thinking exists between the DOHC, HSE, DSFA, FAS and various charities and representative patient interest groups into integrating effective vocational rehabilitation into our broader health and social services. It is not just an issue of focusing on the acute sector it is looking at the entire health services – primary care, step down facilities, minor injury units, rapid access units for specific illnesses etc. The US has its faults – it is not a system that I would subscribe to…. there are great inequalities be it through medicare system or insurance providers who cherry pick and refuse to cover certain chronic conditions. In the European context, Ireland is one of few countries that have a public private system of funding... these type of systems dont work.

Ireland in my opinions needs to go back to basics, establish what type of system it wants – public, private or both – how is that going to be funded – through taxpayer’s money or insurance – does it want a system based on equality or inequality – will access be determined on need rather than ability to pay – without sorting these basic values reforming and deciding what basic infrastructure you are going to provide to meet the health and social needs of our society wont work.
 

But my point was that a private enterprise and the health care system are not analogous. Just because it may work in a certain private sector, doesn't mean it will work in a health care setting.

In theory though you're right, the old myth of Napoleon picking the right generals (except they all seemed to have the Bonaparte surname). However, in practice it doesn't always work, engineering, production, operational expertise and advice is ignored and overruled based on financial myopia and too great a self belief in their own abilities. Fine in a setting where there is the opportunity to self-correct and all that is at stake is a few widgets or whatever, but not a risk worth running for a health care system (public or private).

But I'd also agree that someone from a pure medical background is possibly too close to the very operations they may have to make tough decisions on.

Personally, my model would be the medic at the top and the finance/business advisor just below them as Grand Vizier.
 
Latrade said:
But my point was that a private enterprise and the health care system are not analogous. Just because it may work in a certain private sector, doesn't mean it will work in a health care setting.
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I'm not saying that they are the same, I'm saying that good management skills are required for both.
 
Latrade said:
That's why the insurance industry is behind Obama's plan, it's losing clients.
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Didn't I hear Obama railing AGAINST the insurance industry and talking about how it has successfully lobbied to block progress on healthcare in the US for decades?
It's easy for Prof Brennan to have all the answers when she doesn't have any the responsibility. She hasn't exactly covered herself in glory in her own boardroom down the docks recently, having lost a CEO in unexplained circumstances (so much for openness and transparency). We've all seen the barstool experts who can fix everything from the credit crunch to the HSE.

Unfortunately, the reality is a bit more difficult. It is very difficult to run health service with unpredictable and unlimited demand, based on limited financial and human resources.
 

Interesting debate on this thread about best model, management and public V private - however, it seems to me that the core issue is being missed i.e. a complete lack of political will to effect any significant change in the health sector. This government is in thrall to vested interests, it has not, and will not make the courageous decisions required to restructure the health sector - or indeed any other state agency or body.
A hallmark of good management is a capacity to make and act on decisions - Fianna Fail are paralysed, there one-trick-pony philosophy is bankrupt i.e. buy, buy, buy ...... buy 'friends', buy corporate funding, buy support.....but never ever, ever, say no to those you have bought...who in effect have bought you.
All sectors of our economy need to change, radically and quickly - this is happening in most parts of the private sector. Meanwhile, the state sector remains largely speaking, untouched. The one-trick-pony crew have made one decision - that they will stay 'bought' - that they will sarcrafice the national interest to that of the 'party' and of the friends they have bought, and who have in turn bought them. The price tab for this corrupt and rotten strategy is being borne by the ever diminishing band of private sector, middle-income workers.
This strategy is doomed to failure, because obliterating the middle-income sector, will ultimately bring the whole rotten edifice crashing down. Unfortunately, the damage done to the economy and society by that point may well be irreparable. It will take a generation or more to put the economy back on an even keel.
So, forget about health sector reform.....or any reform.....anywhere.......anytime soon....
 
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