Getting health care right for good future jobs and care

December 20, 2019

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by Phil Ni Sheaghdha, Irish Nurses and Midwives Organisation

The Carnegie UK Trust-TASC Ensuring Good Future Jobs essay collection describes many of the key challenges faced by workers in Ireland today, and proposes a series of policy and practice changes to ensure good future jobs. First published on 28 November, as a coordinated response to the Irish Government’s first Future Jobs Strategy, this blog series showcases the contributions by key social partners in Ireland to the collection.

Health care jobs aren’t going anywhere. Our population is ageing, we’re living longer, and treatments are becoming more effective – but also more complex. The future will doubtless see major changes in health, but due to the importance of human care and interaction, it is a sector uniquely resistant to the much-predicted automation which so often features in discussions on the future of work. Even if robotic medics are an unlikely prospect soon, health care remains the subject of much debate and scrutiny. This is a good thing! One key aspect of ensuring good (current and future) jobs in the healthcare sector is for policy makers to understand and invest properly in a fit for purpose healthcare service.

Getting the Model Right

Health care and its provision is complex and expensive. We aspire in Ireland to universally available care based on need, not on ability to pay. Happily, this is where the arguments usually begin. There is a strong political and public consensus for the availability of health care for all, but in practice access to the health system is a major problem, leading to many of those with private health insurance jealously guarding their privileged rights to speedier access.

It’s all down to trust. The concept and principle of equal access to health care is sound and achievable. However, the way government approaches policy change – particularly the roll out of Sláintecare – indicates that the change will be slow, segmented and only when matched with financial and political expediency. You can’t blame the public for being sceptical. When it comes to healthcare and political promises, they’ve heard it all before. Political pledges on health grow, but so too do waiting lists, trolley counts, and the numbers of people who can’t even register with a GP.

Change doesn’t come cheap, and while the government rhetorically support the universal Slaintecare plan, they have still not set out a transition fund to begin the switch. Such funds are needed to clear legacy overruns and shift from a bloated, bureaucratic management model to a more agile, dynamic one. The proposed six new regional health areas are a welcome start on that and could help deliver services closer to where the need arises, “delayering” the system.

Short-term budgeting

Healthcare workers’ recruitment and patients’ needs are not perfectly contained in single financial years, but inexplicably our budgeting system acts as if they are. The Sláintecare plan sensible suggests multi-annual budgeting, but unfortunately, our government does not agree. Instead, they continue with the old-fashioned annual budget system in health, with its clear negative impacts on staff, recruitment, and retention. Another consequence of annual budgeting is a tendency towards short-term, often counterproductive, thinking. The current HSE recruitment “pause” is a perfect example – restricting the number of staff hired or promoted based entirely on arbitrary financial controls, rather than patient or service needs.

In the short run, these policies are unlikely to save money. To provide essential services, the switch to more expensive agency staff is inevitable. In the long run, we know there are serious staffing consequences too. The recruitment moratorium introduced at the end of 2007 left a bitter taste in the mouths of many health professionals when they were forced to leave Ireland to seek employment – despite their skills being clearly needed here. This “bitter taste” is a significant hurdle in efforts to attract those professionals back to Ireland. In that context, it is not surprising that the HSE’s much-trumpeted ‘bring them home campaign’ did nothing of the sort, enticing less than 100 nurses and midwives back over two years. A recruitment pause causes fundamental changes in health service provision. The failure to consider optimum long-term staffing can be summarised in a single statistic: Ireland has fewer nurses and midwives working in its public health service in 2019 than it did in 2007.

This statistic is particularly galling given the increased demand on the health services in an Ireland which is both growing and ageing. And, of course, as patients from 2007 can testify: we didn’t have enough staff then either. Thankfully the recent nurses and midwives’ strike delivered agreement on a funded plan to measure patient dependency and set staffing levels based on that. When piloted in Ireland, this model reduced the length of hospital stays, cut patient mortality, reduced staff burnout and saved money for the exchequer. It was a win-win – and a clear sign of how the future must be.

Up to this point, there has simply been a failure to evaluate the staffing requirements to meet the demands of a growing population. Internationally, Ireland’s penny-pinching, stop/start approach to recruitment just won’t cut it anymore. Worldwide there is a grave shortage of health care professionals – by 2030 there will be an estimated shortage of nine million nurses. Ireland is thus in increasing competition with the UK, USA, Australia, Canada and others as we to try to entice nurses and midwives from India and the Philippines. The idea that we would introduce a recruitment pause at home, forcing newly qualified professionals to leave, while furiously trying to recruit staff from abroad is like trying to fill a bucket with water that has a large hole in it. The drive to stay within the annual budgetary requirements and the foolish application of a recruitment pause indicates that the system will be slower to change than we would hope.

Technological change

Health services are heavily dependent on qualified and competent professionals. While advancements in technologies are undoubtedly of great benefit to health services, they rarely reduce the requirement for skilled professionals. Technology is extremely important in driving efficiencies in relation to patient records, remote access to case conferencing and expert review of diagnostic scans. It delivers efficient, faster, less invasive procedures and more accurate diagnostic services. It clearly improves patient outcomes but does not lower the need for staff. Unfortunately, it is not always the case that these technologies are available, particularly in community health care provision settings: this is inexcusable in the 21st century. Regardless of technological development, the need for staff is likely to remain a constant demand in modern healthcare.

The Commitment

Health care workers deliver an incredible service in short-staffed, under-resourced services. But I know from daily conversations with nurses and midwives that they are tired of apologising to the patients and the public for delayed services and overcrowded environments. Innovations and changes are not a problem for these employees. Healthcare workers are typically the first to embrace innovation. It is a feature of their daily work and a feature of health research and innovation. If you want to see the depth of their commitment, merely look at the endless new qualifications they secure, the shift to nurse and midwife-led care, the transfer of duties traditionally performed by doctors, the on-the-job mentoring, or the lifelong learning to ensure up to date data and research is utilised correctly. Much of this is done in their own time or at their own expense.

What is needed is a reciprocal commitment from policy makers to implement the very practical recommendations of Sláintecare: invest in front-line staff, invest in staff planning and recruitment, replace bureaucracy, and move services that can be delivered by community services to the community services. Getting this right will allow healthcare workers to get on with what they came into the profession to do – deliver quality diagnostics and care. In such a system, private health insurance will truly then become an individual choice – not a necessary safeguard to secure timely access to the health service. Demands on that service will only continue to grow. Qualified health professionals are up for the challenge: now it’s time for policymakers to get the system right.