THE RECENT controversy over cutbacks at Our Lady’s Hospital for Sick Children in Crumlin has focused attention on financial pressures within the health service. The debate understandably has been emotive because it involves children who are clearly suffering as a result of delayed surgery. However cuts specific to children’s healthcare are likely to be replicated across the health spectrum as public sector budgets continue to be squeezed.
Having been under-funded relative to other western states, the Republic’s spend on health as a percentage of GDP has grown significantly in recent years. With over €15 billion devoted to health annually, the ongoing problems in healthcare here are systemic rather than monetary. However, we face a likely “perfect storm” of confluent events later this year: a second wave of the influenza A (H1N1) pandemic will put additional pressure on resources; and as next year’s budget is framed and the Government faces up to large scale cuts across the public service, hard decisions on health funding will be required. Spending 40 per cent of tax revenue on health and social care is unsustainable.
Rationing of healthcare is a complex and challenging business. It is not just about approving new medical treatments, which in itself has proven controversial. Revenue allocation in health is usually calculated on the basis of population, healthcare costs and the age and health status of the population receiving care. Dividing funding simply on a per capita basis is unfair, but even more sophisticated methods of establishing need are not without controversy.
Analysis of cost effectiveness compares the cost of an intervention with its benefits for health. The aim is to see whether or not it is worth spending money on the treatment or procedure, especially in the context of a resource limited health service. A common type of analysis – that of quality adjusted life years – assesses benefits in terms of the quality and quantity of life delivered by a given treatment when it is compared to the alternatives. In the Republic, health technology assessments, including measures of cost effectiveness, are carried out by the Health Information and Quality Authority. A recent example was its assessment of the effectiveness of screening for colorectal cancer. It has also pronounced favourably on HPV vaccination against cervical cancer.
With the rationing of resources, the process must now move on to the assessment of existing treatments and services. It represents the only transparent and evidence based method of making difficult decisions about how best to use finite health resources. However, the process must include input from patient representatives, for only patients can truly understand the impact of illness on an individual.
We are not alone in facing some difficult dilemmas. There have been calls for public debate on health resource rationing in Germany, Scandinavia and Australia. Without such debate, we face more health cuts of a crude and arbitrary nature.