Adapting International Best Practice
to Transform Irish Health Care
Ed Walsh
NAGP AGM
Dublin
23 November 2013
Barringtons Limerick
Consultants
Barringtons Hospital
80
70
60
50
40
30
20
10
0
1992
1999
2001
2004
2006
2008
2010
2012
Procedures
Barringtons
Health
Expenditure
Irish Health Expenditure HSE
m
Private
Public Expenditure as % GDP
OECD 2012
Public Expenditure as % GDP
Age adjusted
Source: Paul Redmon, Public Policy.ie based on OECD health data 2012. GNP used for Ireland
Private Health Expenditure as %GDP
Age Adjusted
Total Health Expenditure as % GDP
Age Adjusted
Paul Redmond, Expenditure and outputs in the Irish health system: a cross country comparison. Public Policy.ie c 2013
Age demographic adjustments are author’s own calculations. The denominator for Ireland is GNP.
Hospital Price Levels
OECD 2009
OECD 2009
Potential Savings % GDP
2009
from greater efficiencies in Public Healthcare Spending
Potential Savings % GDP
2009
from greater efficiencies in Public Healthcare Spending
Potential Savings % GDP
2009
from greater efficiencies in Public Healthcare Spending
Potential Savings % GDP
2009
from greater efficiencies in Public Healthcare Spending
€9.7b
(2003)
Keys to Sorting Irish Healtcare
•Not more Funding
but
•Smarter Spending
HSE Staff 2013
Practising Doctors per 1 000 Population
Per7 1 000 population
2011
2000
6.1
6
5.0
5
4.8
4.1
4.0
4
3.9
3.8
3.8
3.8
3.7
3.6
3.5
3.5
3.3
3
3.3
3.3
3.3
3.3
3.3
3.2
3.0
3.0
2.9
2.8
2.8
2.7
2.6
2.5
2.5
2.4
2.2
2.2
2.2
2.0
2
1.8
1.7
1.6
1
1.5
0.8
0.7
0.2
0
Hospital Beds per 1 000 population,
Per 1 000 population
2000
15
12
9
6
3
0
2011
56.1
45.9
9.5
11.7
12.3
13.5
13.8
23.2
62.3
77.1
65.0
62.0
15.8
56.9
61.4
50.2
40.3
15.9
16.7
18.0
19.6
19.7
20.1
62.1
85.4
76.9
71.1
75.7
Specialists (1)
20.3
20.7
22.7
24.9
61.4
25.1
68.4
29.3
57.7
66.1
29.8
25.9
63.7
53.2
32.0
32.0
33.1
46.3
63.4
36.7
33.2
59.7
55.7
38.9
41.9
46.5
51.2
47.4
38.4
40
46.9
47.9
GPs
4.5
0
46.0
20
48.8
60
49.0
49.8
GPs, Specialists and other Doctors 2009
%
Other physicians (2)
100
80
Specialists 40%
56.1
45.9
9.5
11.7
12.3
13.5
13.8
23.2
62.3
77.1
65.0
62.0
15.8
56.9
61.4
50.2
40.3
62.1
15.9
16.7
18.0
19.6
19.7
20.1
20.3
20.7
22.7
24.9
75.7
85.4
76.9
71.1
61.4
25.1
68.4
29.3
Specialists (1)
4.5
0
57.7
66.1
29.8
GPs
25.9
63.7
53.2
32.0
32.0
33.1
46.3
63.4
36.7
33.2
59.7
55.7
38.9
41.9
46.5
51.2
47.9
47.4
38.4
40
46.9
46.0
20
48.8
60
49.0
49.8
GPs, Specialists and other Doctors 2009
%
Other physicians (2)
100
80
GPs 50% of norm
Doctors Consultations per Capita
2009
Japan
Korea
Slovak Republic
Hungary
Czech Republic
Germany
Belgium
Spain
Turkey
Italy
Austria
France
Poland
Iceland
Slovenia
Australia
OECD
Estonia
Luxembourg
Israel
Netherlands
Canada
United Kingdom
Denmark
New Zealand
Finland
Portugal
Greece
Switzerland
United States
Ireland
Mexico
Sweden
Chile
6.5
3.3
14
12
10
8
6
4
2
0
Gynaecologists and Obstetricians
per 100 000 Females
2009
Czech Republic
Greece
Italy
Slovak Republic
Israel
Germany
Austria
Estonia
Switzerland
Mexico
Slovenia
Poland
Luxembourg
Sweden
Portugal
OECD
United States
Belgium
Hungary
France
Iceland
Norway
United Kingdom
Finland
Korea
Denmark
Turkey
Australia
Netherlands
Chile
Japan
Canada
New Zealand
Ireland
50
40
30
20
10
0
Key Issue
• Misallocation of Resources
–Too few medics at the front line
–Too many others in offices
• Failure
–to rationalise HSE when created
–Integrated computer system
Medics Key Action
• Increase number of GPs by factor of 2
• Increase number of Consultants by factor
of 2.5
• Redeploy resources
Redeployment of Resources
Where the savings?
Introduce
State of the Art
InformationTechnology
&
reduce size of
Administration
HSE Staff 2013
Management Administration &
Support Staff
• If numbers reduced by 25%
• Potential savings ≥ €500 m
*Number November 2012, NSP 3013
Drugs
Treasure Island
• Pharma sector dub Ireland: ‘Treasure Island’
• Atorvastastin
– UK
€2
– Ireland (new reference price) €9.14
Pharmaceutical expenditure growth
Annual per capita 2000-09
Greece
Ireland
Korea
Estonia
Slovak Republic
Mexico
Canada
Hungary
United States
OECD
Czech Republic
Poland
Netherlands
Finland
Japan
Germany
Australia
Spain
Iceland
Belgium
Austria
United Kingdom
Israel
Portugal
Slovenia
France
Switzerland
Sweden
Denmark
Italy
Norway
Luxembourg
-2
0
2
4
6
8
10
1
Expenditure on pharmaceuticals per capita
% GDP, 2009
677
662
572
518
493
Irish expenditure 36% above
OECD average
487
391
381
Prescribed medicines
Over-the-counter medicines
1000
USD PPP
249
500
United States
Canada
Greece ¹
Ireland ¹
Belgium 2
Germany
France
Italy ¹
Japan
Slovak Republic ²
Spain
Switzerland
Austria
Portugal ¹
Australia
Hungary
OECD
Netherlands
Iceland
Finland
Slovenia
Sweden
Korea
Norway ¹
Czech Republic
United Kingdom ¹
Luxembourg ²
Estonia
0
Israel ³
Poland
Denmark
New Zealand
Mexico ¹
0
Cost of Month’s Supply
2012
Donegal Derry
Aspirin
Clopidogrel
Simvastatin
Bisoproiol
Ramipril
Glceryl Trinitrate
TOTAL
Source; Sligo Today 10 Aug 2012
€96
€22
Savings: Drugs
• Current expenditure €1.9 b
• Cut expenditure by 36% to OECD
average
–Savings €690 m
• Or cut by 73% to UK level (based on
Donegal/Derry report)
–Saving €1,380 m
Absenteeism
Absenteeism Rates 2012
• Varies between 2.9% and 7.06%
• Mean value ~ 5%
• Private sector norm ~ 2.5%
Absenteeism
• Medical/Dental
1.2%
• Nursing
5.3%
Savings: cut absenteeism
• HSE pay bill 2013:
– €7,147 million/y
• cut in absenteeism from 5% to 2.5%
–saving €180 million/y
Nursing
Practising Nurses per 1 000 population
2011
16.6
Switzerland
Denmark
Belgium²
Iceland¹
Norway
Ireland¹
Netherlands¹
Germany
Luxembourg
United States¹
Sweden
Finland
Australia
Japan
New Zealand
Canada
OECD34
France¹
United Kingdom
Slovenia
Czech Republic
Russian Fed.
(2006)
Austria³
Italy¹
Hungary
Estonia
Portugal¹
Slovak Republic¹
Spain
Poland
Israel
Korea
Chile²
Greece¹
Mexico
Turkey¹
China
Brazil
South Africa
India
Indonesia
15.4
15.4
14.8
12.9
12.2
11.8
11.4
11.3
11.1
11.1
10.3
10.1
10.0
10.0
9.3
8.8
8.7
8.6
8.3
8.0
8.0
7.8
6.3
6.2
6.2
6.1
5.9
5.5
5.2
4.8
4.7
4.2
3.3
2.7
Note: Data includes all nurses in healthcare , including
those who work as managers, researchers, etc
20
15
Per 1 000 population
http://dx.doi.org/10.1787/888932524279
10
5
1.7
1.7
1.5
1.1
1.0
0.9
0
Hospital Nurses' Remuneration
2011
Luxembourg
United States ¹
Ireland
Australia ¹
Denmark
Norway
Canada ¹
Belgium
New Zealand
Germany
Chile
Netherlands
Spain
Israel
United Kingdom
Japan
Iceland
Finland
Italy
France
Greece
Slovenia
Mexico
Turkey
Poland
Czech Republic
Estonia
Slovak Republic
Hungary
82
70
64
56
54
52
51
50
49
47
47
46
46
45
44
42
40
39
37
36
36
34
28
24
23
23
20
18
17
0
10
20
30
40
50
USD PPP, thousands
60
70
80
9
Nursing
• HSE had 37,540 nurses in 2009
• Number reduced by c. 4,000
• OECD numbers list all practicing
nurses including those in
management, education, etc.
Primary Care
Irish Healtcare Staffing
HSE NSP 2013
million
Public Health Expenditure 2013
HSE spend on General Practice
million
Number Medical or GP Visit Cards
million
Payments per GMS patient
GMS income before variable and fixed costs of each practice
€400
€350
€300
€250
€200
€150
€100
€50
Source: HSE, PCRS
€0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
www.oliveroconnor.co
51
Headline News
HSE Payment to Doctors 2011
Headline News
€
26 Doctors receive
more than €500,000
One receives €729,485!
HSE Payment to Doctors 2011
Not made clear payments is
Gross to large practice
Average
HSE Pay Cuts %
2010 cuts
HSE Salary Scale Cuts
& GMS/patient Cuts %
Primary Care Key Actions
• Transfer €800m/y of c. €2b/y savings
to Primary Care
–Increase spend on GPs by €400 m/y
–Increase spend on practice support by
€400m/ y
• Primary care is more cost-effective
than hospital care
EDUCATION
&
RECRUITMENT
Medical graduates
per 1000 physicians
2011
Mexico
Ireland
Netherlands
Denmark
Austria
United Kingdom
Turkey
Slovenia
Poland
Chile
Korea
Iceland
Hungary
Czech Republic
Finland
Belgium
Australia
OECD33
Norway
Germany
Portugal
New Zealand
Canada
Estonia
Italy
Japan
United States
Slovak Republic
Greece
Switzerland
Sweden
Spain
France
Israel
0
10
20
30
40
50
60
Medical graduates
per 100 000 population, 2011
Austria
Denmark
Ireland
Netherlands
Greece
Czech Republic
Iceland
Portugal
Mexico
Australia
Germany
United Kingdom
Finland
Hungary
Norway
Italy
OECD33
Belgium
Slovenia
Switzerland
Estonia
Spain
Poland
Sweden
Slovak Republic
Korea
New Zealand
Canada
Turkey
United States
Chile
France
Japan
Israel
19.9
16.8
16.1
14.5
14.3
13.9
13.8
12.2
12.1
12.1
11.8
11.7
11.5
11.5
11.5
11.0
10.6
10.2
10.0
9.4
9.3
9.0
8.7
8.6
8.5
8.0
8.0
7.4
6.9
6.6
6.2
6.0
6.0
4.9
0
5
10
15
20
56.1
45.9
9.5
11.7
12.3
13.5
13.8
23.2
62.3
77.1
65.0
62.0
15.8
56.9
61.4
50.2
40.3
15.9
16.7
18.0
19.6
19.7
20.1
62.1
85.4
76.9
71.1
75.7
Specialists (1)
20.3
20.7
22.7
24.9
61.4
25.1
68.4
29.3
57.7
66.1
29.8
25.9
63.7
53.2
32.0
32.0
33.1
46.3
63.4
36.7
33.2
59.7
55.7
38.9
41.9
46.5
51.2
47.4
38.4
40
46.9
47.9
GPs
4.5
0
46.0
20
48.8
60
49.0
49.8
GPs, Specialists and other Doctors 2009
%
Other physicians (2)
100
80
Recruitment & Education Key Actions
•
•
•
•
Double numbers of GPs
More than double numbers of Consultants
Reduce numbers of ‘other’ medics accordingly
Develop Irish training/education system for
new doctors....to reduce % that go abroad
• Phase out traditional educational system in
favour of ‘Graduate Entry’
MONEY
FOLLOWS THE
PATIENT
Money-follows-Patient Governance
Competition
• Bidding for Patients (& funding)
– Hospitals that meet contracts can bid for patients
and funding on other hospital waiting lists
• Basis forPayment
– Initially on ‘Average Costs’
– Subsequently on ‘Best Practice Costs’
Sweden
‘Stockholm Revolution’
• Since 1994 private encouraged to compete
with public
• Strict quality regulation
• 200 new private health facilities opened
• 25% Primary Care Clinics run by private firms
• 450 state pharmacies sold to private firms
• All public hospitals in Stockholm now under
private management
St Gorgan’s
• Stockholm’s main acute hospital
• ‘One of the glories of the Swedish welfare
system’*
• Private management under contract since 1994
• Remains under public ownership as a public
hospital
• Capio uses Toyota’s ‘lean’ management model
• Waiting lists down, patient satisfaction up
*Woodldridge, Adrian, Economist.
Key Actions
to Transform
Irish Health System
1. Introduce state of the art Information Technology
2. Fewer in offices more on the ‘front line’
– Primary Care
– Hospital Front Line
3. Create competition to drive reform
– ‘Money-follows-the-patient’
4. Stockholm Model
– Private/Public Hospital competition
– Level playing pitch/ strong regulation
– Management of public hospitals out to tender
GPs the Key to it All
• GPs run cost-effective small businesses
• 22 million patient visits per year
• Support and motivation of Ireland’s 2,728 GPs
fundamental
• General Practice part of healthcare that works
• Transferring resources to Primary Care the key
to reform of the whole system