Emerald Isle
Although its Celtic Tiger economy has fallen from grace, the Republic of Ireland is upgrading its accident and emergency and medical evacuation services, with positive developments in both the private and public sectors of its health infrastructure. Robin Gauldie reports
First published in ITIJ 127, August 2011
Although its Celtic Tiger economy has fallen from grace, the Republic of Ireland is upgrading its accident and emergency and medical evacuation services, with positive developments in both the private and public sectors of its health infrastructure. Robin Gauldie reports
As a small country with a population of just 4.5 million people, an adequate transport infrastructure, a temperate climate (temperatures rarely fall below freezing or rise above 22°C), few geographical extremes and no intractable endemic diseases, the Republic of Ireland provides fewer challenges for insurers and medical evacuation providers than most travel destinations.
Even the political and sectarian violence that cost more than 3,000 lives across the border in Northern Ireland between the late 1960s and the completion of a lengthy peace process in 2010 hardly affected the Republic – although the UK’s Foreign and Commonwealth Office, erring on the side of caution, still advises British travellers that there is an ‘underlying threat’ from terrorism.
Ireland attracts more than three million tourists annually, with almost half of them coming from the UK and more than one million from mainland Europe (mainly from France and Germany), while the US is also an important market. However, tourism suffered severely in 2010, with a 15-per-cent decrease in visitor numbers and 500,000 fewer British visitors. Arrivals from the US and continental European markets also declined.
Ireland attracts more than three million tourists annually, with almost half of them coming from the UK and more than one million from mainland Europe
Public provision
Public health spending has increased dramatically over the last four decades, partly as a result of regional funds made available by the European Union (EU) since Ireland’s accession in 1973, but critics say the money spent has not necessarily translated into better care.
In 2005, public health provision was restructured with the creation of the Heath Service Executive (HSE). Reorganisation of the national health service is ongoing, not without encountering some criticism.
A review by PA Consulting Group, commissioned by the HSE, has warned that Ireland can expect a 60-per-cent increase in demand for healthcare by the 2020 and says that the country is over-reliant on acute hospitals.
“To develop a world-class health system, we have to replace outdated practices with modern ways of doing things that reflect the needs of patients,” said Prof. Brendan Drumm, the HSE’s chief executive officer.
“The review tells us that more resources are not the only answer to improving access and reducing waiting times. Hospitals can reduce waiting times by simply modernising the way staff manage the passage of patients in and through their hospitals.”
Without a new, integrated approach to reduce its dependence on acute hospitals, Ireland will need 20,000 public hospital beds by 2020. Meeting that need would call for a €4-billion investment and the opening of one new, 600-bed hospital each year until 2020. Given the country’s parlous financial state, that is simply not an option. Creating an integrated health system – by doubling the number of day case beds, reducing the time patients spend in hospital before and after operations, expanding community services and increasing the number of critical base beds by 25 per cent – would reduce demand for public inpatient care beds to less than 9,000 by 2020, say the review’s authors.
Currently, Ireland has 50 acute care public hospitals across the country, 35 of which provide accident and emergency services. Most public hospitals are directly managed by the HSE, but a significant number are run by voluntary organisations. In this overwhelmingly Roman Catholic country, most of these are linked to religious charities. The largest public hospitals, with around 600 beds each, include Tallaght Hospital in Dublin, University College Hospital in Galway and Cork University Hospital.
The number of hospital beds actually declined during Ireland’s boom years, from nine beds per 1,000 people in 1980 to five beds per 1,000 in 2005 – though this must be placed in the context of quality versus quantity, with more beds in better and more up-to-date hospitals, fewer beds in outmoded, smaller, local hospitals, and more modern medical techniques allowing shorter patient stays and more efficient use of beds.
Spending on hospital administration rose up to three-times faster than spending on beds, doctors and nurses, according to some sources, and in 2009 the HSE reported that there were 49,000 administrators within the public service for 62,000 front line staff.
In comments passed to the Wikileaks website and published in The Independent newspaper, the US Embassy in Dublin, reporting to the US State Department in Washington, cited overcrowded hospitals and long waiting times for accident and emergency treatment in Irish hospitals.
In 2005, the then-US Ambassador James Kenny reported to Washington that Ireland’s healthcare system had not kept pace with the country’s economic rise and criticised the mixed private-public healthcare structure. Kenny noted that patients with private health insurance enjoyed quicker access to treatment and benefited from ‘subsidised public facilities.’ “Public hospitals often ring-fence up to 20 per cent of beds for private use, even when uninsured patients on waiting lists have greater medical need,” Kenny said.
Inherent weaknesses in the system were highlighted in January 2011, when an outbreak of the H1N1 swine flu virus swamped accident and emergency departments across the country. At its peak, more than 560 patients were forced to wait on trolleys in hospital corridors and waiting rooms before they could be treated.
In 2005, public health provision was restructured with the creation of the Heath Service Executive
In June, the Irish government announced the creation of a new Special Delivery Unit (SDU), to be established during the second half of 2011. Tasked with cutting waiting lists, the SDU’s priority will be to tackle accident and emergency waiting times, according to health minister James Reilly. Waiting times in many A&E units are ‘unacceptably high’, Reilly said, and frequently exceed the current six-hour waiting time target.
However, there will be no new government funding for the SDU, which will instead be financed from the budget of the existing National Treatment Purchase Fund.
Meanwhile, the HSE has cut back accident and emergency services in mid-western and north-eastern regions and is similarly reconfiguring A&E departments in Cork and Kerry. It has recently denied that it will curtail A&E services at St Columcille’s (Loughlinstown) Hospital, one of Dublin’s main hospitals, by the end of the year, but health service employees’ representatives have warned of impending chaos in the public hospital system, citing a shortage of junior doctors and increasing demand.
Despite gripes about long waiting lists from Irish residents awaiting treatment within the public healthcare system, satisfaction with treatment, professional staff and facilities is generally high, with a survey conducted by the HSE in 2007 showing up to 90 per cent of patients were satisfied with the care received.
Costs for care and treatment compare favourably with many developed nations such as the US. Irish residents who are unemployed or earning lower incomes – around 30 per cent of the population –are eligible for the state medical card, which entitles them to free hospital care, but those on higher incomes, and visitors, must pay fees for some services. There is a flat €100 fee for patients attending accident emergency departments, and a flat fee of €100 per day (up to a maximum €1,000) for inpatient care.
All EU nationals carrying a European Health Insurance Card (EHIC) are entitled to same level of healthcare as Irish citizens, as are visitors from Switzerland and other European Economic Area states and – since 1998 – Australia.
Private options
Three major companies – Hibernian Aviva, Quinn Healthcare and the state-owned VHI Healthcare – offer private health insurance. Private health insurance premiums are subsidised, attracting tax relief at source at the standard tax rate of 20 per cent, and encouraging some 47 per cent of Irish people to take out private health cover.
While the public sector appears somewhat embattled as it attempts to come to terms with future trends, recent years have seen considerable growth in private healthcare provision in Ireland. Three of the country’s private hospitals are classified as ‘high-tech’ establishments, including Beacon Hospital, which was opened by the Pittsburgh-based global health enterprise UPMC in 2006. The following year, it opened the first emergency department attached to an independent hospital in the eastern region, and currently has 183 acute care beds and 14 dedicated critical care beds.
Dublin’s Blackrock Clinic will complete a five-year, €100-million investment in 2012, expanding to have more than 160 beds, to become the first major acute hospital in Ireland to accommodate all patients in single rooms. Mater Misericordia, with locations in Dublin and Limerick, claims to be the only private hospital in Ireland to offer integrated, 24-hour 365-day intensive care and anaesthetic service.
Ireland’s National Ambulance Service (NAS) was created in 2005, taking over from a patchwork of services operated by regional health authorities, and since then the NAS has been criticised for its failure to match up to international rapid response standards. The HSE’s own statistics show that only around one in four calls are responded to within eight minutes. Counter-intuitively, the problem is at its worst not in remote rural areas but in Dublin, Ireland’s capital city. In January this year (2011), Ireland’s Health and Quality Information Authority (HIQA) announced an initiative aimed at ensuring that emergency services should respond to ‘immediately life-threatening calls’ within eight minutes.
Waiting times in many A&E units are ‘unacceptably high’ … and frequently exceed the current six-hour waiting time target
“The absence of such a system in Ireland has been a major gap in what is needed for a safe, good-quality emergency response service,” according to Jon Billings, HIQA’s director of healthcare, quality and safety. According to the HSE, however, innovations such as the introduction of an ‘Advanced Paramedic’ training programme and a system of upskilling for the service’s 1,200 paramedics have produced ‘significant improvements’ in patient care.
In the Dublin area, the NAS is complemented by ambulance services provided by the Dublin Fire Brigade, and several private ambulance services also operate in tandem with the NAS. The longest established of these (founded in 1993) is Medicall, based in Dublin and providing nationwide coverage with regional stations in Cork, Galway and Monaghan. Through an agreement with the recently launched air ambulance operator AeroMedevac Ireland, Medicall also claims to offer a seamless transfer for air ambulance patients to hospitals throughout the Republic and in Northern Ireland.
Medevac matters
Currently, most emergency helicopter services are provided by the Irish Air Corps, with six AgustaWestland AW139s and two Eurocopter EC135s. Operating out of Casement Air Corps base at Baldonnel, southwest of Dublin, and with ranges of around 1,000 km and 745 km respectively, these helicopters can perform evacuations from all parts of the country, including remote areas and offshore islands. The Air Corps also has CASA CN235 and Learjet aircraft, which can be used for air ambulance duties.
Meanwhile, CHC Helicopter has won a renewed, 10-year contract worth €500 million to provide search and rescue (SAR) services for the Irish Coast Guard, starting from 2012 and operating from bases at Dublin, Waterford, Shannon and Sligo. CHC already operates SAR missions from these bases, but will provide enhanced services from next year, said CHC Ireland managing director Mark Kelly.
“Over the next decade, this contract will offer a number of service improvements, including the ability to deliver a paramedic to any SAR incident within an hour anywhere on our coastline,” Kelly said. CHC’s Sikorksy S61-N helicopters will be replaced by Sikorsky S92-A equipment, custom-configured for SAR work, from next year. Since February 2011, Coast Guard helicopter crews have been upgraded to full air ambulance/paramedic status, ensuring that all SAR flights have at least one trained paramedic on board.
Ireland’s health and emergency medical infrastructure is, in short, well fit for purpose
Until recently, Ireland had no privately operated air ambulance providers, a lack that was remedied in June 2010 with the launch of Dublin-based AeroMedevac Ireland (AMI). AMI operates a Cessna 500 Citation II aircraft configured around the PLUS modular advanced life support system and AeroSled trauma sled platform and based at Weston Airport, 13 km from the city centre. It serves nine airports in the Republic (including Dublin, Galway, Shannon, Sligo, Cork, Farranfore (Kerry), Donegal, Waterford and Knock, as well as Belfast and Derry, in Northern Ireland. The company is headed by Keith Trower, former director of managed care at AXA PPP Healthcare, where he was responsible for travel insurance and emergency medevac services. AMI is an approved air ambulance provider for several leading travel insurers, including MAPFRE Assistance, International SOS, Europ Assistance, and the international assistance organisation Eurocross Assistance.
One reason for the apparent shortfall in private sector air ambulance provision has been Ireland’s close proximity to the UK. With most of the Republic coming well within the operational envelope of fixed-wing aircraft and helicopters operating from England, Wales or Scotland, UK-based operators are able to meet the evacuation needs of British holidaymakers in Ireland, who can of course also be transferred by road across the border into Northern Ireland (part of the UK) for treatment under the British National Health Service.
Despite the financial vicissitudes of the last two years – and despite grumbles about waiting lists from Irish residents and the Irish media - Ireland’s health and emergency medical infrastructure is, in short, well fit for purpose as far as the international travel insurance industry is concerned, and looks set to make further real progress in the near future.