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Focus - Going Dutch

Is adapting the Dutch healthcare system to Ireland the answer to our problems, ask four doctor of nursing students from UCC

A variety of recent reports and strategy documents have highlighted the intimidating range of challenges facing Ireland’s health system as it seeks to improve its performance.1 Unprecedented cuts, a growing HSE deficit, inequitable access to care, long delays in emergency departments and on waiting lists, and a deterioration in the quality of care have left the healthcare system unable to meet the health needs of the population.2

Decades of underfunding prior to the boom years post 2000, resulted in a shortage of hospital beds, poor staffing levels in primary care and mental health services, and inadequate infrastructure for hospitals and primary care centres.2 Despite a dramatic increase in health spending from 2000 to 2009 (8.4% per annum), the Irish government still failed to implement structural key healthcare strategies and reforms, and to create a universal and high-quality public healthcare system (the public health service grew four-fold from E4 billion in 1997 to €16 billion in 2008).

The systemic failure of the Irish healthcare system is attributed to a lack of transparency and arbitrary decision making by successive political leaders,2 inadequate governance and financial systems, capability and management deficits and very significant increases in expectations and demand.3 This criticism is supported by Crown,4 who argues that “Ireland does not have the worst quality of healthcare in the developed world; rather the worst managed healthcare system in the developed world, run by technically deficient, medically illiterate bureaucrats”.

Notwithstanding such criticism, the Euro Health Consumer Index warns that Ireland, Spain and Greece, seem to have an ongoing problem with public perception of healthcare services being more negative than reality would warrant.5

Significant challenges ahead
The challenges facing the healthcare system come in what is, economically and financially, the most challenging period in the State’s history6 with unparalleled cuts in public spending prompted by the economic situation and the receipt of financial assistance from the EU and International Monetary Fund (IMF).

Total current expenditure for the public health service is being reduced by approximately €1 billion in nominal terms over the period 2011-2014 under the National Recovery Plan.6 However, in order to meet unavoidable pressure and government commitments, in excess of €2 billion will have to be taken out of the health budget in the same period.6

While Ireland’s situation is critical, it is not unique as healthcare systems internationally all face similar challenges with ageing populations, the parallel rise in chronic disease and the rising cost base of medical technologies.6,7 Not only are the methods for raising funds to cover the costs of healthcare inadequate, but, of even greater concern, the costs themselves are set to soar.8

According to World Bank figures, public expenditure on healthcare in the EU could jump from 8% of GDP in 2000 to 14% in 2030 and continue to grow beyond that date. The task is great as European governments try to find ways to balance budgets and restrain spending while providing a high quality health service to its population.8,9

Irish solution
In order to improve the healthcare system, Ireland must change from the traditional approach to healthcare, which was incremental, dictated by resources and system focused, to one which is comprehensive, led by innovation and patient focused.3 The Programme for Government promises the most fundamental reform of the health service in the history of the State. ‘Future Health – A Strategic Framework for Reform of the Health Service 2012-2015’ details the actions that will deliver on this promise.6

The core of the government’s health reform programme, which is designed around the Dutch model of healthcare and is in accordance with the principles of social solidarity, is a single-tier health service, supported by Universal Health Insurance (UHI), which provides equal access based on need, not ability to pay, and delivers the best health outcomes for Irish citizens.6

Dutch healthcare system
Understanding the Dutch model of healthcare may give more insight into Ireland’s chosen trajectory. The Netherlands has long been acknowledged as having one of the best healthcare systems in Europe and is the only country that has consistently been among the top three in the total ranking of any European index published by the Health Consumer Powerhouse since 2005.5

Since 2006, the Dutch state has stepped back from running the health system and healthcare is now financed through a ‘multipayer’ model of compulsory private health insurance from numerous insurance companies with no distinction between ‘public’ and ‘private’ patients.9

These insurance companies purchase care on behalf of their customers from hospitals and care providers and operate under what is known as ‘ managed competition’, which is defined as a system in which consumers can freely choose among health insurers and health packages. 10 The insurance companies are prohibited by law to refuse applications on the basis of a person’s age or health history.

A state regulator audits each company’s enrolment plans and activities annually and a central fund pays subsidies to insurance companies who end up insuring higher risk groups through a system known as ‘risk equalisation’.11 Competition is regulated centrally by government to ensure universal access to good quality and affordable healthcare.12 This ensures that neither insurers nor providers operating within the UHI system are allowed to sell faster access to services covered by the UHI standard package of care.

Is the Dutch system suitable for Ireland?
From a social and economic perspective, the Netherlands (pre-2006 reform) and Ireland have much in common, in particular the expectation that a mandatory single scheme can resolve the inequitable two-tier system and also increase solidarity in health insurance.12

Prior to 2006, the Netherlands had a dual structure of health insurance with 63% of the population covered by the statutory health insurance scheme and 37% covered by private health insurance. Also, a strong foundation of the Dutch healthcare system is the gatekeeping role of GPs to prevent unnecessary use of more expensive secondary care, and promote consistency and co-ordination of individual care.12 Other similarities include the ratio of nurses and doctors to population, and the rate of cardiovascular-related mortality.13

The Irish government has already implemented a number of strategies in an attempt to come into line with the Dutch model, particularly in relation to improving access to primary and community healthcare and the establishment of hospital groups and the implementation of the Framework for Smaller Hospitals.2,14

A significant s tep has been the introduction of the permanent Risk Equalisation Scheme in the Irish private health insurance market in January 2013 and the amalgamation of many healthcare services. However, despite the temptation to herald the Dutch model of healthcare as the panacea to Ireland’s problems, the Dutch reforms are still described as a work in progress despite two decades of preparation prior to its implementation. The full implications of this are still a matter of debate among politicians and among healthcare economists.8, 11 Indeed, some propose that the Dutch system may not reduce costs and suggest a lack of evidence that it improves quality of care.7

It has been noted that the introduction of a fully private health insurance in the Netherlands was accompanied by high expectations of market mechanisms to lower costs while securing quality.15 However, there are still no indications that the system contains healthcare costs. Rather, the Netherlands has risen in healthcare spend to actually having the highest per capita spend in Europe.5 The integration of public health and primary care is proving problematic and slow to develop.16

An analysis of the health insurance reform in the Netherlands,12 identified a number of issues in the implementation of the new scheme which included: the unanticipated amount of administrative problems for health providers and insurance companies alike; the emerging trend for insurance companies to consolidate in order to survive and build up bargaining power in negotiations with providers; and unfair distributive effects for some groups of people such as the unemployed and socially disadvantaged.

The latter point in particular, may be an issue of concern for the Irish government as the challenges of promoting equity in the system are likely to remain critical to public confidence in the performance of the health service.

Given the continuing commitment of successive Irish governments to support a ‘mixed’ healthcare system whereby the same personnel may deliver public and private services within the same facilities, a clarification of the ‘boundaries’ of each sector must be addressed if the rights and entitlements of the socially disadvantaged in particular are to be protected.16

A further significant issue of concern is Ireland’s track record in implementing planned change particularly in relation to one of the key areas of reform, namely primary care. A primary care strategy set out in 2001 aimed to integrate more fully primary, secondary and continuing care.17 The report identified a number of challenges including a poorly developed infrastructure. Central to reform was the development over a 10-year period of 400-600 multidisciplinary primary care teams across the country, each serving a population of between 3000 and 7000 people, depending on whether the team is located in an urban or rural area.

While work to implement the strategy is on-going, the primary care strategy had envisaged that 50-60 multidisciplinary primary care teams would be in place by the end of 2005, but at that point only 10 pilot projects were up and running.17 By February 2010 just 40% of the total number of primary care teams were operating in some fashion, meaning that most of the country is still without primary care teams.17

While the Dutch model of healthcare offers, in theory, a viable solution to Ireland’s healthcare crisis, its affordability and sustainability in light of our current financial circumstances must be questioned. Indeed, the Irish population might be forgiven for their general lack of confidence in its government’s plans to improve healthcare given previous failures to implement reorganisation and follow-through on the commitments in successive health strategies.

Pillinger2 argues that the creation of a modern, equitable and universal healthcare system needs careful planning and wide public consultation in order to engender public trust and confidence. But, there has been limited consultation with local communities, service users, patient organisations, professional associations and healthcare unions which only serves to undermine the government’s commitment to openness, transparency and consultation.2

Sean Kelleher is a nurse lecturer at the School of Nursing and Midwifery, UCC, Doman Alomari is a staff nurse at St Vincent’s Private Hospital, Dublin, Saed Azizea is a senior nurse at the Secure Psychiatric Acute Admission Unit in the Dublin North West Mental Health Services, Sinead O’Sullivan is nurse manager at the Milford Care Centre, Limerick

References available on request from nursing@medmedia.ie (Quote Kelleher S et al. WIN 2014; 22(3): 28-29)

Focus - Going Dutch
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