Plans to almost double the €75 million palliative care budget and build nine new hospices may be shelved as the HSE's own budget comes under severe pressure. MICHAEL KELLYreports
THE IRISH HOSPICE Foundation will meet the HSE and the Department of Health and Children (DoHC) this Thursday in an effort to clarify the status of the HSE’s National Action Plan for Palliative Care Services 2009-2013, in light of the deteriorating economic situation.
The plan identified priorities and actions required to address the deficits in palliative care service provision.
The unpublished plan, seen by The Irish Times, contains plans to almost double the €75 million annual palliative care budget, build nine new hospices and increase the number of hospice beds from 153 to 356. It requires a capital investment of €237.34 million over the five-year duration of the plan.
The HSE produced the plan with input from key stakeholders such as the Irish Hospice Foundation, the Irish Cancer Society, the Irish Association for Palliative Care (IAPC) and the Hospice CEOs group.
However, there are now growing concerns that so called “action points” in the plan may be delayed or even shelved as the HSE’s operating budget comes under increased pressure.
Of the 41 action points identified, seven are due to be completed this year, but according to the HSE’s assistant national director James Conway, the HSE is still awaiting feedback from the Department of Health and Children on the document.
In response to a query from The Irish Times, the HSE has stated that the title of the document was changed from National Action Plan to Palliative Care Services – Five Year Development Framework before it was submitted to the DoHC.
“We want to see the five-year plan published and we are concerned that the seven actions that were due to be completed under the plan this year are delayed,” says Irish Hospice Foundation chief executive Eugene Murray.
“We recognise that the country is facing challenging economic times and in these circumstances, all expenditure is being controlled.
“However, we feel that an investment in hospice and palliative care is a strategic and cost-effective option as people using palliative care use fewer resources than those receiving ‘usual care’.”
Increased spending on these services would be more than offset by the savings in the €2 billion we currently spend on caring for the 30,000 people who die in Ireland each year, according to Murray.
“There is overwhelming international evidence that investment in comprehensive hospice services will save the Government money,” he says. “The economic downturn only strengthens the case.”
Hospice and palliative care services are provided to patients at a stage of a serious illness where the focus has switched from finding a cure to administering treatment aimed at ensuring quality of life.
A multidisciplinary team including doctors, nurses and therapists work together in a specialist facility or in the home, to ensure a patient is comfortable and pain-free in the final stage of their lives. Because symptom control is better organised, patients tend to live longer and live out their days in greater comfort and dignity.
While the majority of people want to die at home surrounded by their loved ones, the current reality is that more than two-thirds of Irish people die in hospitals.
There is considerable variation in the availability of palliative care throughout the State – three of the former health board regions (south eastern, midlands and north eastern) for example, have no inpatient hospice facility. “Whether you get hospice care in Ireland, is totally dependent on where you live,” says Murray.
It may be argued that this is inequitable, but according to research it is also a profound waste of taxpayer’s money. A US Medicare study in 2007 found that patients in hospice care consume 25 per cent fewer medical resources than those in the “standard” care system.
A palliative care programme in Barcelona resulted in a 61 per cent decrease in the use of hospital resources.
“Proximity to death, not age, is the biggest factor influencing health services consumption,” says Murray. “People in the last year of life comprise only 1 per cent of the population and yet they account for 30 per cent of all hospital expenditure.
“The spend per person on healthcare over a lifetime is approximately €300,000 and 40 per cent of that spend is typically consumed in the last month of life,” he says.
“Fewer people die in hospitals in those regions that have comprehensive hospice services. In Limerick, for example, there is a 30-bed hospice, which is one bed per 10,000 people in the county,” says Murray.
“The vast majority of people in Limerick are cared for at home and they are comfortable at home knowing that they can go in to the hospice for symptom control if required,” says Murray.
“The percentage of people who die in hospital in Limerick is 31 per cent and 69 per cent die at home, or in the hospice. The opposite is the case in places like Waterford or Wicklow where they don’t have comprehensive hospice service,” says Murray.
According to a recent Irish Hospice Foundation report, the southeast is regarded as a black spot in terms of hospice service. It says the area has no inpatient hospice facility and argues that, based on existing Government policy and its population size, it should have a 30-bed hospice.
The foundation also claims that spending on palliative care in the region is just €7.90 per capita as opposed to €35 per capita in the northwest.
“We have had a home care team operating in Waterford for 21 years,” says Des Kelly, a director of the Waterford Hospice Foundation, “and it is better for people to be kept at home if they can, but the people who can’t stay at home are dying in the public wards of hospitals.
“That is not right. To round off our service, a hospice building is required so that we can provide for the physical, mental, spiritual and emotional needs of a patient and their family.”
The National Action Plan contains a provision for the development of a 20-bed inpatient unit in Waterford (as well as facilities in Kilkenny, Tullamore, Drogheda, Cavan, Castlebar, Tralee, Wicklow and Blanchardstown) which is due for completion in 2013 assuming the National Action Plan is implemented in full and on schedule.
That now appears unlikely given the delay in implementing the seven actions for the current year.
In many cases, local groups are raising sizeable amounts of money to go towards hospice- building programmes. The Waterford Hospice Foundation, for example, can contribute €2 million of the €16 million capital cost of a new hospice, according to Kelly.
“It is the running costs that are the key problem – it will cost €6 million a year to run the hospice, so we can’t part with a penny of that €2 million until the Department of Health and the HSE have agreed to fund the running costs.”
A 2006 Irish Hospice Foundation study found that Wicklow has the most under-funded palliative care community service in the Republic.
The county has no hospice facility and just four palliative care nurses, three of whom were appointed only this month.
Based on the recommendations of the 2001 National Advisory Committee on Palliative Care, a comprehensive service in Wicklow would comprise a 12-bed hospice with a consultant-led palliative care team of 12 specialist nurses, a community team of five palliative care nurses and a team of multidisciplinary professionals.
“The situation in Wicklow is dire,” according to Murray. “They have no hospice beds and a year ago they had no homecare nurses. The county doesn’t have an acute hospital either. Seventy per cent of Wicklow people die outside the county, most in Dublin hospitals.”
The recent appointments are just the start of what’s needed, according to Miriam McGrath, who is secretary of Wicklow Palliative Care/Hospice Campaign. “The next step is to get a consultant-led palliative care team in operation and then we need to get working on the hospice building.”
“A US Medicare study in 2007 found that patients in hospice care consume 25 per cent fewer medical resources than those in the ‘standard’ care system. A palliative care programme in Barcelona resulted in a 61 per cent decrease in the use of hospital resources.
People in the last year of life comprise only 1 per cent of the population and yet they account for 30 per cent of all hospital expenditure