Alexandra Prosser
International Experience Reflection
3/31/2017
Objectives:
1) To determine the effect of the public/private healthcare system on the delivery of care.
2) To evaluate the advantages/disadvantages of the system.
3) To assess the Irish perception of their access to healthcare.
Historically, Ireland has relied upon a publicly funded healthcare system. Over the past twenty years, the system has evolved to adapt to growing needs of the population and is better characterized as mixed, with both publicly and privately insured individuals. In 2005, the government established the Health Service Executive (HSE), which is the country’s public health service.[1] According to the HSE, any individual who has resided in Ireland for one year is entitled to either full or limited public provision of healthcare. If approved for full status, which is determined by means, an individual receives a medical card that pays for all health services. Otherwise, individuals have limited coverage and can either pay out of pocket or get private insurance to cover additional costs. In 2014, 40% of Irish residents had medical cards, a proportion which has been rising due to recent economic strife in the country.[2]
Private insurance has been growing as well due to difficulties of supply meeting demand. According to Dr. Zara Fonseca-Kelly, a gynecology oncology fellow at Mater Misericordiae, private coverage and the idea of market competition in the healthcare field is novel for Ireland and just beginning to develop.[3] She shared that the public system has been under duress due to an increasing population, changing patient populations (getting older, multi-international), and budget cuts. From 2009 to 2013, the budget for HSE dropped 22% due to severe recession in the country.[4] Since then, the issue of “rationing of care” has become a prominent issue in Ireland. Dr. Fonseca-Kelly explains that the quality of care is the same whether you are seen in a public or private hospital. However, access is limited due to lack of resources, resulting in long waiting lists for patients.
There is also controversy surrounding the reimbursement of medications. The National Centre for Pharacoeconomics (NCPE) has the responsibility of assessing the cost-effectiveness of medications and determining their coverage.[5] For example, there was recent dispute over a decision to not cover a new cystic fibrosis drug.[6] The argument was that the drug did not provide enough quality of life to make it cost-effective. Citizens soon protested this decision and argued that the system for determining “quality of life” is antiquated and needs reform. Of course, defining quality of life is no easy task, making the allocation of limited resources all of the more difficult.
Individuals in the cystic fibrosis case did prevail in putting enough pressure on the Minister of Health to address the issue. Dr. Fonseca-Kelly explained that the ability for individuals to be heard on a national level is key to the public system working. She said, “When an individual in a small town has a complaint, it is usually reported by the local paper and then picked up by national media. It is easy to put your case forward and end up impacting national policy in Ireland.” It seems that the country’s small size and homogeneity play an important role in maintaining their public health system.
At the end of the first week of my rotation, a documentary aired that made a shocking revelation that half a million patients (out of only 4.6 million in the entire population) are on waiting lists, primarily for surgical procedures but also for clinic visits. While I had not come across issues with waiting lists at the National Maternity Hospital (I suppose laboring patients do get prioritized), I had heard from my friend rotating at the Mater that gynecology oncology surgeries were being canceled daily due to the lack of beds. She shared that the trainees often expressed their frustration regarding the lack of resources and the strain put on them to answer to their patients. In the documentary, “Living on the List”, several physicians shared similar frustrations.[7] A pediatric surgeon shared, “If I mark [the surgery] routine, that child will never be seen.”
In another scene, a young girl is shown with scoliosis who has been waiting for surgery for over a year. She initially had a curve of 20 degrees but it has since advanced to 80 degrees. She is now in severe pain daily and misses school regularly. Although her situation is not emergent (albeit becoming more so as her pain increases and lungs start to be compressed), she clearly has worsening quality of life affecting her day-to-day activities. Her story reflects the many stories shared in the documentary, of individuals awaiting spinal surgery, cataract removal, gynecological care, and even brain tumor resection. I do not think it is because these cases are not regarded as important. Rather, it is that public healthcare only has so many resources and has to make priorities in some way. Although the goal with universal care is that there is access for all, access is still limited and just controlled by someone new. As big changes come for our healthcare system back home, I can only hope that we will take these lessons, as well as those from other countries, into consideration.
During the second half of my rotation, I spent time at the public Mater hospital in the operating theater and clinic for gynecology oncology. I was part of a team made of a fellow, several “regs” (registrar being equivalent to our resident), rotating consultants, and a nurse. I learned during my time there that every public institution has extensive organization and support built in for patients. Our nurse attended rounds every morning, knew every patient and she participated in every clinic, providing support and resources for patients in need. I had wrongly assumed that public hospitals would have less supportive resources built in than the private institutions. However, I found out that it is more difficult to find private services such as counseling for new cancer patients. Apparently, there is no equivalent for our oncology nurse at the private Mater down the street. It seems that patients that need more complicated care are usually referred to public hospitals for that reason. While I would have thought that specialists at the top of their field would more likely be employed by private hospitals, I learned that they would work for both as to benefit from the built-in infrastructure and academic opportunities at the public hospitals while making extra profit with their private employment. I was surprised that there is such a symbiotic relationship between public and private providers. There always seems to be a push for one extreme or the other but perhaps there is an appropriate role for both in the ideal system.
MOST PROFOUND CLINICAL EXPERIENCE
During the last gynecology oncology clinic of my rotation, we had an admission come in with a new diagnosis of Stage IV ovarian cancer. When she arrived, along with her husband, I accompanied the fellow and the oncology nurse to attain a history. They had told me that she was just 34, but seeing her in person and conversing with her, the reality of how very young she was astounded me. She was a stay-at-home mom with two children under the age of six. She and her husband had moved from India to Dublin ten years ago and always planned to go back so that they could be close to their families once again. Instead, his father was making arrangements to come to Dublin to be of assistance and to provide support to them in their time of need.
After learning about their story, the fellow began to ask her about her diagnosis. She shared that a few months ago she noticed she was gaining weight and had leg swelling, but it was not until she had trouble breathing that she sought medical attention. Without knowing the details of her recent diagnosis and work-up, I knew that was an alarming sign. With the metastases, confirmed by imaging and evidenced by her symptoms, she would not be coming to our surgical service. She would be admitted to the medical oncology service and started on chemotherapy, per her wishes. The fellow appropriately tread the fine line of providing reasonable expectations moving forward without bombarding the couple with the overwhelming likelihood that she did not have much time. I had just interviewed the fellow a few days earlier and we had discussed why physicians choose this line of work. She said, “The good days are great but they are easy. The reason we do what we do is for the bad days. Because we want to be the ones who go on that journey with our patients, to help them through it, when we know they aren’t getting better.”
MOST PROFOUND CULTURAL EXPERIENCE
As part of my OB/GYN rotation, I spent a few evenings in the labor ward at the maternity hospital. Each shift, I was assigned to work with a midwife and to observe and assist with her assigned patient. At first, I was not sure what to expect. At home, both at University of Kansas hospital and in rural Kansas, physicians played a primary role in the care of all laboring patients. We would constantly check on all of the mothers and be present for every delivery, whether simple or complicated. In Dublin, the physician role is much less broad. The physician remains the overseer of the labor ward but is only directly addressed when problems arise. The uncomplicated cases are completely led and delivered by the midwife, who also carries out the responsibilities held by nurses at home.
From the start I also noticed that the environment of the labor ward was different. It was somehow more personalized and less regimented. There were protocols to be followed but the focus was always the patient and her comfort. I also felt more connected with the patient because it was the first time I had the opportunity to be present for the entirety of a patient’s labor and delivery. While some deliveries were quick and uncomplicated, I witnessed several that were difficult and stressful. I came to agonize with the parents over every cervical check and would cheer when the baby had made progress. I could see the appeal of the midwife role because you have the opportunity to participate in every aspect of the labor with the patient.
IMPACT
My biggest takeaway from my experience in Dublin was seeing a public/private healthcare system in action. I believe any physician should have a working knowledge of healthcare systems, especially in the United States where so many changes will likely take place in our lifetime and affect the way we can practice medicine. I think it is critical that we carefully evaluate the successes and failures of other systems around the world before implementing any overhaul that is based on politics alone. My rotation also reinforced that, regardless of the healthcare system and the resources that are at hand, the patient should always come first and that we should never take the responsibility of taking care of them lightly.
[1] "Ireland's Health Services." Ireland's Health Services - HSE.ie. Accessed March 23, 2017. http://www.hse.ie/eng/.
[2] Byers, V. (2017), “Health Care for All in Ireland? The Consequences of Politics for Health Policy”. World Medical & Health Policy, 9: 138–151.
[3] Fonseca-Kelly, Zara. International Elective Interview. Conducted February 22, 2017.
[4] Byers, “Health Care”.
[5] "National Centre for Pharmacoeconomics." National Centre for Pharmacoeconomics. Accessed March 23, 2017. http://www.ncpe.ie/.
[6] “’Not fit for purpose’: How an ‘arbitrary’ system decides what drugs get funded in Ireland,” The Journal. January 4th, 2017. Accessed March 23rd, 2017. http://www.thejournal.ie/drug-approval-ireland-3133822-Jan2017/.
[7] RTE Investigations Unit, “Living on the List”, RTE News. February 10, 2017. Accessed February 15, 2017. http://www.rte.ie/news/investigations-unit/2017/0203/849955-living-on-the-list/.