The Hepatitis C Scheme relates to the provision of healthcare services to those infected with Hepatitis C through administration within the State of blood and blood products under the terms of the Health (Amendment) Act 1996.
8.9.1 Rationale, Objective and Continuing Relevance
The services continue to be provided to persons infected with Hepatitis C under the terms of the Health (Amendment) Act 1996, which Act required that appropriate services be provided free of charge without a means test to the cohort of people infected with Hepatitis C through the administration of blood and blood products within the State. In doing so it contributes to integrated care policy whereby the right care is provided in the right place to persons for whom the State has a duty of care.
The objectives are to continue to provide healthcare services to those individuals infected with Hepatitis C through administration within the State of contaminated blood and blood products under the terms of the Health (Amendment) Act 1996 through the hospital and primary care settings. These services include:
• General practitioner medical and surgical services, in relation to all medical conditions, by general practitioners chosen by the persons;
• Drugs, medicines and medical and surgical appliances;
• The service specified in section 61 of the Health Act of 1970 (home help);
• Dental, ophthalmic and aural services and dental, optical and aural appliances;
• Counselling services in respect of Hepatitis C; and
• Other services considered necessary, e.g. physiotherapy, chiropody.
Clients also avail of supports under the Hepatitis C Insurance Scheme (set up under SI 31 of 2007). Infected persons and their non infected relatives may seek compensation under the Hepatitis C Compensation Tribunal Act 1997. The Consultative Council on Hepatitis C (set up under SI 339 1996) (cost €150k pa) advises the Minister on all aspects of Hepatitis C and holds an annual conference on specific aspects of services.
Health needs of the group are increasing in an ageing population so the scheme continues to be more essential. Services are provided to eligible persons for the whole of their lifetime.
There are 1,485 eligible persons (with HAA cards), with approx. 680 accessing home support services. Services are provided under the terms of the Health (Amendment) Act 1996, so cannot be discontinued. The State has a duty of care to people who became infected.
8.9.2 Programme Effectiveness
Services must continue to be provided to those eligible persons. While the average age of those infected is 57, the youngest person (infected at birth) is a teenager. HSE is responding appropriately to client needs. Services are provided where possible within HSE contracted service providers (ie GPs, DTSS dentists, pharmacies and opticians). Rate of payments for home support reduced in January 2010 in line with reductions in overall available funding and payments to home help workers. Funding to hepatitis C support groups reduced in 2010 and 2011 in line with reductions to all voluntary funded agencies.
There are no similar schemes comparable in other jurisdictions. Annual Reports of Consultative Council provide updates on service provision and Annual Reports from the National Database on Hepatitis C give an overview of the health profile of the cohort.
8.9.3 Programme Efficiency
Table 8.16: Trend in Expenditure on Hepatitis C Scheme 2008-2011 2008
(€m)
2009 (€m)
2010 (€m)
2011 (budget allocated) ( €m) Pay
Non-Pay 21 (approx) 22.5 (approx) 22.5 (approx) 14.458
The above expenditure includes an annual allocation to the eight designated Hepatology units in the public hospitals (€8.2m approx annually since 2008) and funding for four hepatitis C patient support groups (€1.6m approx annually since 2008; this funding reduced by 5.5% in 2010 and 5% in 2011). The remainder of the expenditure is related to the provision of primary care services to approximately 1,485 eligible persons. Expenditure continues to increase annually in primary care spending, mainly driven by increases in home support costs. Approximately 65-70% of primary care expenditure relates to home support costs - this translated to €8.2m in 2010.
Table 8.17: Trend in WTE on Hepatitis C Scheme 2008-2011
2008 2009 2010 2011
5 5 5 4
Expenditure includes approx €0.3m in costs of 5 WTE posts. (National Co-ordinator, 3 fulltime Liaison Officers, reducing to 2 in 2011, and 1 CNM 3).
8.9.4 Conclusions
HAA cards continue to be awarded to eligible persons, albeit only 1 per month approx. The HSE is introducing improved guidelines on delivery of services especially in relation to home care services. In keeping with the guidelines, every eligible person will be offered a health and social care needs assessment to determine their needs. Eligible persons continue to have services provided where possible via HSE contracted service providers; however, this is not always possible. The subprogramme is delivered via HSE primary care services and network of Liaison Officers. It is important that each eligible person in the scheme continues to have access to designated Liaison Officers.
As outlined, delivery of homecare services is under review and standardised assessment of health and social care needs is being introduced. Improvements in delivery of home care services and specifically the assessment of need process in determining supports required will result in an improvement in effectiveness of services. There may be cases where services being provided will decrease following assessment but 60% of eligible cohort are not accessing home care services, so there may be increased demands on services.
There is no scope to raise revenue from the subprogramme as the services are provided without charge. The subprogramme has been subject to the Consultative Council on Hepatitis C review of services 2000 and 2005. The services continue to be provided under the terms of the Health (Amendment) Act 1996.
8.10 CONCLUSIONS, SAVINGS AND REFORM
An alternative scheme arranging the provision of health services would be required before the GMS and community drug schemes could be discontinued. Alternatively, the existing legal requirement to provide GP and medical services would need to be abolished by the Oireachtas. However, a likely consequence of discontinuing the schemes, without an alternative in place, would be the postponement by individuals of seeking needed primary care. This postponement would be likely to lead to greater future costs associated with delayed treatment within the primary care sector or elsewhere within the health system, such as the acute hospital sector.
Discontinuation of the Dental Treatment Services Scheme and the Community Optical Schemes should only be considered as part of a broader restructuring of the health service that will continue to provide services to medical card holders.
The Health needs of persons infected with Hepatitis C through the administration of blood and blood products within the State are increasing, and the Hep C Compensation Scheme continues to be essential.
Key Savings:
• Reduce prices for generic medicines: The Department is currently in discussions with the Association of Pharmaceutical Manufacturers of Ireland (APMI) to deliver price reductions in the generics area. Total Annual Saving: €10m.
• xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
• Reduce inappropriate prescribing: There is also ample evidence of inappropriate prescribing and wastage of pharmaceuticals within the health system. xxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
This would require the establishment of an appropriate team with a project leader, within the Department or the HSE, including the employment of additional pharmacists.
A range of measures would be involved including working with prescribers (both GPs and hospital consultants) to achieve more cost effective prescribing, rolling out a
“preferred medicine programme” (identifying designated medicines whose preferential use over similar medicines would promote clinically appropriate utilisation of pharmaceuticals in a cost effective manner without compromising quality of care), and de-listing and/or imposing conditions on certain products under the community drug schemes. xxxxxxxxxxxxxxxxxx
• Proceed with reference pricing and generic substitution: A Memorandum for Government has been circulated seeking permission to draft the necessary legislation.
The short-term savings from this measure have decreased following significant price reductions in 2010 and 2011. However, a number of high volume medicines are expected to come off-patent in the coming years and this measure will ensure that lower prices are paid for these medicines resulting in significant savings for taxpayers and patients. Reference pricing is estimated to generate €30m in savings over the 3 year period to 2014. Savings would also be expected as a result of price competition between pharmaceutical manufacturers. Generic reference pricing in other countries has been found to increase the number of competitors and decrease the prices of all products within a reference group. Total Saving: €30m.
• xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
• Probity: Continued and greater focus on probity measures particularly in relation to pharmacy claims where an inspection regime is now in place, dental services (where an inspection system is due to be established shortly) and the reasonableness and accuracy of GP out-of-hours claims. Total Saving: €5m.
• Tax Expenditure: The introduction of subsidised access to GP care, as provided for in the Programme for Government, should reduce the cost of tax relief available to those
who currently pay their GPs. It is considered that the estimated savings in this tax expenditure should be reflected in the expenditure allocation for the health service. An initial estimate of €20m has been included.
Key Reforms:
• GMS Contract: The GMS Scheme will be amended to facilitate GMS contracts being available to all suitably qualified and trained General Practitioners by Q3 2011.
• Access to Primary Care for LTI Claimants: The Programme for Government states that access to primary care without fees will be extended to Long Term Illness claimants. To achieve this objective, medical cards or GP visit cards could be provided to existing claimants. If medical cards are provided to existing LTI claimants, the additional cost of providing GP services without charge will be offset by the lower cost to the HSE of supplying medicines under the GMS scheme.
• DPS Threshold: The existing monthly threshold under the DPS (currently €120) applies to all non-medical card holders. One option that might be explored would be to introduce two thresholds – one for those on lower incomes and another for those on higher incomes. Another would be to introduce a lower threshold for persons with a chronic disease, possibly as part of the roll-out of chronic disease management programmes. Such a change would have to be approached with caution in order to avoid impacting on those most in need.
• High Tech Medicines Scheme: The HSE is engaging with drug manufacturers and wholesalers aimed at reducing the Executive’s stock risk and waste in relation “fridge items” under the High-Tech Medicines Scheme.
• DTSS: The National Recovery Plan 2012-2014 provides for changes in the existing range of dental services and supports provided through the healthcare and social protection systems in order to improve access to essential dental services for those most in need. This requires a fundamental review of the Public Dental Service, the Dental Treatment Service Scheme, the Dental Treatment Benefit Scheme, and tax expenditure on dental treatment in association with the Department of Social Protection.
• Hep C Scheme Homecare Services: The delivery of homecare services under the Hepatitis Compensation Scheme is under review and standardised assessment of health and social care needs is being introduced. Improvements in delivery of home care services and specifically the assessment of need process in determining supports required will result in an improvement in effectiveness of services.
CHAPTER 9
ACUTE HOSPITALS & PRE-HOSPITAL EMERGENCY CARE 9.1. INTRODUCTION & DESCRIPTION
There are some 50 publicly funded acute hospitals which deliver a wide set of services ranging from assessment, diagnosis, treatment and rehabilitation of complex conditions, to non urgent conditions. They range from acute tertiary level regional hospitals to small local hospitals. There are a number of single specialty hospitals for maternity, paediatrics and orthopaedics.
The national average number of acute hospital beds and day places available in public hospitals for the years 2006 - 2009 is set out in Table 9.1 below. Acute bed numbers in public hospitals are counted as an average of beds available over each year, given that the number of beds available in each hospital can vary over any year for operational reasons.
This data includes acute psychiatric beds.
The emphasis for the HSE in 2011 continues to be to make the most effective use of acute bed capacity through shorter length of stay, increased rates of day-of-surgery admission and more day surgery. In this way the acute hospital system can ensure that, within the level of resources available, it provides the maximum number of patients with safe, effective and efficient care.
Table 9.1: Available In-Patient Beds and Day Places 2006 -2009 Year
Total #
2006 13,528
2007 13,668
2008 13,584
2009* 13,310
# Data for 2006, 2007 and 2008 - Health in Ireland Statistics - Key Trends
* Data for 2009 supplied by BIU - HSE 9.2 PROGRAMME OBJECTIVES
The major objective of the Acute Hospitals Programme is to ensure that
• patients who need acute care can access it as rapidly as possible, in the most appropriate setting; and
• patients receive safe care, with optimum clinical outcomes.
The overall goal is to reduce reliance on acute bed capacity by moving to a Preferred Health system as defined in the Bed Capacity Report 2007. The Preferred Health System changes the role of the acute hospital. More patients can be cared for in the community or at home with support. This will diminish the current reliance on the hospital and therefore alleviate many of these pressures. Patients will only attend a hospital when necessary and when admitted will have a reduced stay.
This involves targeted initiatives to:
• reduce average lengths of stay in hospitals for key conditions/procedures;
• increase the day case rates;
• reduce the numbers of acute admissions to hospitals;
• develop more services in the community such as IV therapies to avoid the need for hospitalisation;
• improve the levels of surgical admissions on the day of surgery;
• improve the management of chronic diseases such as stroke, diabetes, COPD etc.