Committee Reports > List of Committees > Joint > 2001 > Committee on Health and Children > Report - A Comparative Analysis of Waiting Lists for Acute Hospital Treatment in EU Countries

HOUSES OF THE OIREACHTAS

Joint Committee on Health and Children

A COMPARATIVE ANALYSIS OF WAITING LISTS FOR ACUTE HOSPITAL TREATMENT IN EU COUNTRIES

(Rapporteur: Liz McManus T.D.)

January 2001

Table of Contents

Foreword

The Joint Committee on Health and Children was established in November 1997. The issue of hospital waiting lists was an item for consideration in Committee’s Work Programme for 2000.

At it’s meeting on 17 February 2000, the Joint Committee appointed Liz McManus T.D. as a Rapporteur carry out a comparative analysis of waiting lists for acute hospital treatment in EU countries. The draft report was considered by the Joint Committee at it’s meeting on 24 January 2001. The report, as amended, was agreed.

The Joint Committee is grateful to Deputy Liz McManus for her work as Rapporteur in researching and drafting this report.

______________________

Batt O’Keeffe T.D.

Chairman

24 January 2001

WAITING LISTS

A comparative overview

Only 24% of the Irish population expressed itself satisfied with our health services in a survey published last month by Eurostat, the statistical office of the European Commission in Luxembourg.¹ That compares to 70% in the Netherlands, 71% in Austria, 78% in Finland.

Waiting lists are clearly a major reason behind this low satisfaction rating.

The Eurostat data also records the highest death rate for males in the EU from both respiratory and circulatory diseases among Irish men. Among females, Irish women have the highest rate of deaths from respiratory diseases and the second highest for all cancers.

It is difficult to draw precise correlations between long waiting times and high death rates from cancer and respiratory and circulatory diseases. We are forced to conclude, nonetheless, that the link is more than purely coincidental.

A look at some facts

31,851 people are currently waiting for hospital treatment in this country. Many are debilitated by unnecessarily prolonged illnesses. Some die before they have the treatment.

This 31,851, however, indicates only part of the problem. Only those who have already seen a consultant and who have been diagnosed as needing hospital treatment are counted on waiting lists. In marked contrast to the practice in the UK and Northern Ireland, public patients here must also undergo a pre-list wait where they are undocumented for a period of three months as they wait to be added to the official list. This is often subsequent to an initial long wait to see the consultant.

What’s the point of waiting lists?

Waiting lists are used to ration health services, although supposedly only for certain non-urgent conditions. What happens in fact is that waiting lists are also used to apportion treatment to seriously ill patients—cancer and heart surgery, two of the biggest killers in Ireland and the UK included. The waiting list may ultimately be so long as to actively exclude access to specific services, because the patient dies or otherwise removes him/herself from the list, opting out of treatment altogether or seeking other avenues within the private sector.

Everyone has a statutory entitlement to free public hospital care in Ireland. Yet this entitlement cannot be met and is not met by public hospital services, as evidenced in particular by the existence of waiting lists.

We have reached the extraordinary point where 45% of our population is covered by private health insurance—quite simply to ensure (according to recently published ESRI research) that quality care can be accessed when needed.

How do we compare internationally?

We experienced significant difficulty in drawing a comparative picture of waiting lists across Europe because of the lack of available information. According to the office of the European Commission in Luxembourg, comparative data on waiting lists simply does not exist. We were therefore prevented from drawing comprehensively on the resources of knowledge and experience available within the Union.

In addition to Ireland and the UK, where the problems of waiting lists are most acute, we know, for example, that the Netherlands, Spain, Sweden, Finland and Denmark have each endured differing degrees of waiting list difficulties. Often, it is a regional and/or sectional problem—as opposed to a national problem across all areas in Ireland. Outside the EU, problems with waiting lists in Canada and New Zealand are often cited.

However, we also know that waiting lists are not an inevitable result of necessary rationing and prioritisation in public health care systems—as evidenced by the examples of France and Germany where, apart from organ transplantation, waiting lists as we know them do not exist.

So, all countries are not in the same boat?

Let’s look at the example of France

Recently assessed as being the best healthcare system in the world by the World Health Organisation, France does not have the problem of waiting lists. This is not to say there is no waiting period. Rather, under a “booking” system (similar to the system introduced in New Zealand in 1996), all patients are immediately given a date at which surgery will be carried out, thus reducing uncertainty and stress for the patient and family.

The French system copes with emergency surgery cases by running bed occupancy rates at around 75% so that the system runs, normally, under full capacity. Thus it can mange periods of peak demand without disrupting the booking system. In addition, the expansion of day care surgery has also helped in avoiding the problem.

To make some comparisons with Ireland: among French males, the death rate from circulatory diseases is 54% of that affecting Irish men (255 per 100,000 opposed to 465 per 100,000 in Ireland). Among French females, it is 52% of the rate affecting their counterparts in Ireland (146 per 100,000 and 279 per 100,000 respectively). Comparative death rates for men and women from respiratory diseases run at 46% and 32% of Irish death rates. In other words, France suffers less than half the rate of death for men and less than one third for women from respiratory diseases than we do in this country.

Close to 99.9% of the French population has medical cover through social security payments. Insurance is mandatory², whether employed, unemployed or self-employed and resources are not divided between the kind of two-tier system of health care we have in Ireland.

What’s the biggest problem with waiting lists?

Indisputably, the greatest problem with waiting lists in Ireland is the actual length of time spent waiting.

If we look at the examples outlined in the HOPE report on Measures to reduce surgical waiting lists (Appendix 1), in which regional initiatives in Finland and Spain and the national Waiting List Initiative in Ireland were examined, we see just how unfavourably the Irish situation compares. (Figures in this report were for the 1996-97 period).

(i) Finland

In 1997, the South Karelia region in Finland experienced waiting times ranging from 90 days for ENT procedures to 325 days for gynaecology (sterilisation). There was no waiting period incurred for cancer surgery, coronary bypass or minor orthopaedics (Appendix 1, HOPE Report, section 4).

(ii) Spain

In the Spanish study, covering a region of 15 million people which included the city of Madrid, 148,224 people were on waiting lists in December 1997. Of that number, only 826 waited more than 9 months (0.005%) while the average wait was just 98 days.

Those figures compared to 21,525 people waiting more than one year out of a total of 168,265 on waiting lists just 18 months previously (see p.8, Appendix 1). Average wait times for the earlier period had been 217 days.

These reductions were achieved by a number of measures including standardisation of waiting list registration systems, standardised criteria for placement of patients on waiting lists, prioritisation of list and selection of patients from lists and incentive payments to hospitals for day cases.

(iii) Ireland

In December 1996, just under 26,000 people in Ireland were on waiting lists. 74% of those waiting for cardiac surgery waited more than 12 months, as did 64% of those waiting for vascular surgery, 45% waiting for orthopaedics and 58% waiting for plastic surgery (see Report of the review group on the waiting list initiative, p.5). This was despite the additional £12 million invested under the Waiting List Initiative in 1996.

Target specialities in Ireland

If we look at what’s happened in Ireland since the HOPE report was written, with the implementation of target specialities for waiting time reduction in certain key areas, the stagnation within the system is even more apparent.

Table 1.0 below indicates significant increases since 1996 in the percentage of people on waiting lists who are forced to wait in excess of one year for each of the target specialities outlined—except for cardiac surgery where the situation has changed little in the four intervening years. This increases have persisted notwithstanding the increased funding and reform measures implemented since that date.

Table 1.0 percentages of total number on waiting lists waiting 12 months and above

So numbers haven’t actually come down under the Initiative?

Irish waiting list figures suggest that investing additional specifically targeted resources and providing incentive payments to hospitals, even with enhanced list management, reviews and prioritisation, will at best arrest the rate of growth or provide periodic drops in the total numbers waiting.

Despite a total of £124.57 million invested in the Waiting List Initiative since its inception in 1993 (see table 1.1 below), extraordinarily long waiting periods still persist.

Without structural reform of our two-tier system of access to health services with its in-built system incentives against rapid patient throughput (such as fear of going over fixed hospital budget or greater financial incentives to treat private patients) we will not solve the problem of waiting lists³.

Table 1.1 Waiting lists numbers and investment under the Waiting List Initiative

If it was simply a matter of extra cash and better management, much greater inroads would by now have been made on the numbers waiting.

What do these figures mean in real terms?

The attached report, Waiting lists for healthcare in developed countries—Initiatives for long term management, notes that “targeted funding such as this is a short term measure. Such initiatives will not address the underlying cause of the waiting list growth” (p.33).

The most recent figures available show a drop of one sixth, from 36,855 in December 1999 to 31,851 last month, achieved with the enormous investment of £34 million this year and concurrent list audit measures. Going on previous years, this rate of throughput will only be sustained if the same level of investment is sustained.

If we look at the history of funding under the Waiting List Initiative since 1993, the temporary nature of improvements effected with targeted funding is borne out—especially given increased waiting times and the increase in total numbers waiting by over one-fifth since December 1993.

In March 1993, waiting lists stood at 39,423. £20 million additional moneys were invested under the Initiative in 1993 and by December of that year, the numbers had fallen to 25,373. By December of the following year, with a further investment of £10 million, the lists numbered 23,772, a proportionately much lower decrease.

The net effect of the Initiative appears to have plateaud by 1995 when, despite another £8 million specifically targeted at waiting lists, they had actually risen to 27,752 by December. It would seem that problems of capacity also set in.

As noted in the Report of the review group on the waiting list initiative (p.i, Executive summary, Appendix 3),“some hospitals have reached full capacity with existing resources in relation to elective work”—whereby hospitals are simply physically incapable of increasing throughput even with the additional resources offered through incentive payments.

With £12 million invested in 1996, waiting lists fell again to 25,969 only to rise to 32,206 by December 1997, despite the £8 million invested that year. With another £32 million shared between 1998 and 1999, the numbers waiting had further climbed to 36,855 by December 1999—highlighting the very temporary nature of improvements effected.

So it’s not simply a question of money?

It is interesting to compare and contrast, in the attached report from the Irish Medical Times of December 1998 (Appendix 2) concerning “Health services in each of the EU member states”, not only differences in number of inhabitants per doctor, number of hospital beds per 1,000 inhabitants and total expenditure on health as a percentage of GDP across the EU, but also how health services are funded in these countries; in short to see whether we can draw correlations between infrastructural provisions and waiting lists⁴

We do not have adequate information to draw definitive conclusions on the relationship of health system structures to waiting lists. However, the apparent absence of waiting lists particularly in France and Germany, suggests that the equality of access underpinned by the social insurance model found in these countries may well contribute to more immediate care for everyone. In addition, the relatively high levels of per-capita spending on health in each of these countries must also be counted as hugely significant.

What about countries with waiting lists?

The attached report, Waiting lists for healthcare in developed countries—initiatives for long term management, takes three countries, namely the UK, New Zealand and Canada where waiting lists are or have been problematic

In Canada, waiting lists have resulted from a range of factors—from financial cutbacks to uneven levels of access to care across the country and poor list management.

In the UK, 75% of waiting list cases are concentrated among the five specialities of general surgery, orthopaedics, ear, nose and throat, gynaecology and ophthalmology. While considerable numbers of people wait for treatment under the NHS for unacceptably long periods of time, waiting lists also show significant local variations in the length of lists and waiting times.

Although only 10% of Britons access healthcare via the private sector⁵ (compared to 45% in Ireland), private medicine in Britain is also used as an avenue to skip queues in the public system—particularly at times when the public system is least able to cope with demands for its services.

As already indicated, waiting lists in New Zealand have been countered with the introduction of a booking system in 1996 for surgical procedures—preceded by investment of NZ$130m to clear surgical waiting lists. At the same time, priority criteria have been developed to encourage treatment of most needy patients first. Resulting in greater efficiency and more productive use of resources, this has also had the added benefit of encouraging greater integration between general practice and the acute hospital system as patients with less serious conditions are treated locally by GPs.

Why are Irish reforms not working in the same way?

Too often in our society, decisions on healthcare are made in the interests of the most powerful. Nowhere is this more evident than the disproportionate level of care paid for and provided by the state to the private patient.

A recent report by the Economic and Social Research Institute, Private Practice in Irish Public Hospitals, revealed that private patients in public hospitals have half their costs covered by the taxpayer; that their health insurance covers just 50% of the actual costs incurred. Although private patients only account for one-fifth of all in-patient stays in acute public hospitals, one quarter of the hospitals’ total expenditure on in-patient care is spent on them. Private patients are also subsidised by the state through tax relief on health insurance payments.

Public hospitals are allowed to take private patients up to certain limits. Even if public beds are closed, these limits are not affected. As public hospitals operate on fixed budgets, private patients enhance hospital earnings and thus under the current system they are unlikely to wish to reduce their number in favour of their public counterparts.

We cannot, however, lay blame on the private patient. This is quite simply how the current system works. It is the structure which needs to be tackled to enable equitable and timely access to necessary care as need dictates, irrespective of patient status.

The public/private mix—who benefits?

Both the attached document, Waiting lists for healthcare in developed countries—Initiatives for long term management) and a 1998 report prepared for Health Canada suggest that “greater access to private care appears to be generally associated with longer public sector queues—particularly where physicians operate in both sectors”⁶, as in the UK and particularly in Ireland.

We are fortunate in Ireland that the professionalism of our consultants has moderated the negative effects of the structure of our health system.

Over 80% of consultants in this country are engaged in both public and private practice. While contracts in the public service engage consultants for 33 hours per week, there is no limit on the time that can be devoted to private practice.

There is in effect an inherent incentive within the system for consultants to create waiting lists for treatment. Although everybody in this country has a public entitlement to care, those with health insurance will use it to pay for treatment, while those who do not will (if they can access the necessary moneys) either pay up front or take out health insurance in anticipation of future need. Such queue-jumping is now an integral part of the Irish healthcare system.

Private hospitals piggyback on cash-strapped state-funded institutions as they rely hugely on consultants from the public sector. Financial incentives available to consultants in the private sphere, coupled with the lack of monitoring of work carried out under public contract, leaves open the potential for disproportionate time to be spent with the lucrative private market, further shifting the balance against the public patient.

The government review group which examined the problem of waiting lists two years ago (and which included five consultants among its 12 members) commented: “some hospitals or consultants may find it attractive to maintain a public waiting list because a proportion of those waiting may opt to be treated privately”.

In 1989, the Commission on Health Funding said that some consultants did not fulfil their responsibilities to public patients because they could make so much more money in the private sector. The Commission recommended monitoring of consultants’ obligations to the public system. The Department of Health are still attempting to reach agreement with consultants’ representatives on a monitoring procedure.

Shortage of consultants

The negative effect of consultants dividing their attentions between the public and private sphere is compounded by the serious shortage in their number employed throughout the system. Nationally, we have more than twice the number of Non-Consultant-Hospital-Doctors (doctors in training, often young and inexperienced) as consultants, a fact which has serious adverse consequences for the health service, not least of which are waiting lists.

NCHDs actually keep many of our hospitals going. Supposedly in training, they regularly carry out unsupervised work tending to public patients on behalf of absent consultants. Inappropriate admissions via A&E by the less experienced NCHD often means that both treatment and discharge are delayed as NCHDs are understandably reluctant to take decisions necessary to progress patients through the system. Therefore, through no fault of his own, the public patient inside the system blocks admission for those still waiting on the outside by spending unduly long periods in in-patient care—evidenced statistically in the high number of bed-days used by Irish patients in comparison to their counterparts internationally.

Primary care

The Report of the review group on the waiting list initiative, (Executive summary, Appendix 3), said that “a satisfactory response [to waiting lists] must reach beyond the acute hospital services alone” and further called for an “improved flow of information between primary and hospital care regarding the status of patients on waiting lists”.

Apart from inevitable cost implications, the development and expansion of healthcare at the primary and community level, in line with our European neighbours, and a greater integration of primary and secondary care, will have significant follow-on improvements for more rapid processing of patients through the acute hospital system and therefore for the length of our waiting lists..

Conclusions

1.The lack of centrally collated data on waiting lists within the European Union points to a significant gap within our knowledge. It points to an urgent need for statistical research within this area. The generation of data-based knowledge will assist in moving towards basic agreed standards in care across Europe while respecting our rights as individual countries to provide a system of healthcare most appropriate to local needs, cultures and traditions.

2.As noted by the Report of the review group on the waiting list initiative (p.i, Executive summary, Appendix 3), “there are no simple short term solutions which, on their own, will have a significant impact”. In addition to the range of solutions outlined in the attached documents, as derived from international research and experience, we need to recognise that we will not solve the problem of waiting lists in Ireland until we accept, as legislators and as citizens, that our two-tier system of healthcare is a significant part of the problem. Built into its basic structure is an acceptance that public patients should wait long periods for care while private patients have fast-track access.

3.In the short term. greater investment, centralised control and management and prioritising and auditing waiting lists will help reduce the numbers still waiting for treatment. In the longer term, however, it is only by systematic, planned and gradual reform of our health system itself that we will ensure appropriate and timely access to care for all patients.

REPORT

Waiting Lists for Healthcare in Developed Countries–Initiatives for Long Term Management

Aodán Tynan

Health Services Research Centre

Department of Psychology

Royal College of Surgeons in Ireland

October 3, 2000

1. Introduction

Most, if not all, people when asked would undoubtedly say that waiting times for surgery and other medical procedures and investigations should be as short as feasibly possible. Yet waiting lists in recent times have become one of the focal points of the growing dissatisfaction with the Irish public healthcare system. To a degree waiting lists are a common feature of many modern public healthcare systems throughout the developed world, though differences do exist in the incidence of waiting lists within a system as well as in the relative size of the waiting list and length of waiting time. Ultimately waiting lists result from a mis-match between demand and immediate available supply and have been found to be a particular characteristic of publicly funded healthcare systems in which patients do not pay directly at the point of service. Given the nature of the commodity healthcare and assuming that the demand for medical procedures is related to clinical need, as determined by the physician, most initiatives implemented to address the problems of waiting lists in other developed countries have concentrated on the management of the supply side. Given the continued growth expected in the demand for healthcare it is clear that some of public healthcare rationing is unavoidable in the presence of limited available resources being available. This rationing should be carried out in an explicit, informed, efficient and equitable basis.

Waiting lists in themselves are not necessarily a bad thing. Indeed having waiting lists can, to a degree, help control costs in a publicly funded system. Certainly short waiting lists can improve efficiency by eliminating periods of inactivity associated with over-capacity. In addition a period of waiting can afford the patient time to reach a more considered decision regarding an interventions, particularly if there is a degree of risk and choice involved. However persistent long waiting lists and associated long waiting times for essential services and procedures go far beyond this and their existence questions a system’s ability to deliver quality care. It is the time and nature of the waiting that is at issue – unreasonable waiting times are what we should be focusing on.

Lengthy waiting lists do not reduce the actual cost of performing the procedure. Rather they result in the inefficient delivery of healthcare. Data from study of surgical centres in Canada reported only 51% of by-pass surgery as being elective. The remainder of the surgery was on patients who were deemed as being too ill to be discharged from hospital without surgery, (Barer M 1998). Current research being undertaken in Ireland shows a similar situation. A significant number of non-emergency patients remain in hospital until they undergo surgery. They have been told that if they return home there will be put on a long public waiting list, however if they remain in as an in-patient they will have a better chance of getting surgery sooner. What is of importance here is that these patients, while being priority cases, are not strictly emergencies. If they could be assured that they would be operated on in a timely fashion if they returned home and went on the normal elective list there would be a significant freeing up of resources. The fact that many these people have been on the elective waiting list prior to hospitalisation only further illustrates the inefficiency of having long waiting list for such procedures.

Often when we consider waiting in the context of public healthcare we tend to concentrate on waiting lists for elective surgeries such as coronary by-pass surgery, cataract surgery and hip replacement. This is typically due to the fact that these forms of surgery have a high public profile due to their emotional context and high impact on an individual’s quality of life. Waiting lists however are not confined to surgical areas. Individuals in the Irish public healthcare system can and regularly do wait significant periods of time for routine specialist consultations and diagnostic procedures. Thus an individual’s waiting experience can begin well before they are placed on a ‘formal’ waiting list. In addition there are areas such as organ transplant, which by its nature of uncertain supply, typically has associated with it a degree of waiting time – the organisation and management of such waiting lists is largely beyond the scope of this report though certain issues relating to list management are common across all waiting lists.

This report concentrates largely on waiting time for elective surgery as this is the most widely documented internationally. It first describes the situation facing developed countries and documents some specific experiences from selected countries where information has been available (Section 2). The report then briefly considers the possible effects of trends in demographics and healthcare expenditure on public healthcare systems (Section 3) before concentrating on the various policy initiatives which may be taken to address this problem based on the experience of policy implemented to date in other developed countries (Section 4).

It is important to note that waiting lists and waiting times, as they have been experienced in Ireland, while worthy of immediate attention are just as symptom of an underlying malaise. The issue of waiting is closely related to that of priority setting – we have already described how waiting lists can be viewed as an implicit form of healthcare rationing. It is widely accepted in the international literature that given the growing demand on health care resources some form of rationing is inevitable in the healthcare sector. While the question of how we prioritise healthcare is not directly at issue here it is certain that any solution of the waiting list/time problem extant within the Irish healthcare system would give a clear signal of prioritisation decisions regarding delivery of public healthcare. Prioritisation will have to be explicitly made not only across the lists for different procedures but also within individual lists. The first level of prioritisation should naturally reflect society’s values. To the extent that this is possible the agenda would be better set at a political level in consultation with healthcare managers and clinical professionals rather than leaving it up to ad hoc decisions made at local levels. Prioritisation within the various lists is at the core of the equitable and efficient management of waiting lists and as such will be discussed in section 4.

2. Experiences of waiting lists in other developed countries

2.1. General determinants of public waiting lists

As mentioned in the introduction, waiting lists for healthcare and the rationing implicit in those waiting lists result from a basic imbalance between supply and demand. In the case of organ transplants it is a case of commodity scarcity and typically people on the list are evaluated on the basis of medical condition weighted by time on the waiting list – this is a simple case of material scarcity. Far more serious are waiting lists for elective procedures resulting from fiscal scarcity and subsequent insufficient resource allocations in the face of such constraints. Clearly this is a form of rationing as it results from a lack of resources going to medical care such that not all care which is expected to be provided actually is provided. Fiscal scarcity within a system is not the sole cause of waiting lists. There may also be a persistent underlying scarcity of other resources such as facilities and staff. While shortages of facilities and equipment can be addressed through capital investment within a system, shortages of staff may be due to either unfavourable pay and working conditions, as we have recently seen in the case of nurses and junior doctors both in Ireland and the UK, or due to restrictive entry into the medical professions. While there is clearly a requirement to regulate medical practitioners ultimately such restrictive access is a determinant of high consultant costs.

In recent years waiting lists have become part of the landscape in the Irish public healthcare system, most notably in the area of cardiac surgery. There can be no question that, as a procedure, coronary artery bypass grafting (CABG) is highly beneficial, post surgery a return to a normal quality of life can be expected, without surgery quality of life generally continues to deteriorate and quantity of life is much reduced. A basic tenant to distributive justice is equal access for all or access independent of income. Having a private healthcare system in conjunction with a public healthcare system is natural as it gives further choice to those willing and able to pay. There is no evidence however that the quality and professionalism of medical care is in any significant way different across the two systems and typically we find many professionals working in both systems. Private healthcare can provide more ‘hotel comforts’ and offer a wider range of elective procedures such as certain forms of cosmetic surgery which would not reasonably be expected to be available from public funds. It can also allow consumers to avoid any waiting costs that they may experience in the public healthcare system. When waiting times in the public system are at clinically acceptable levels there is no significant inequity in this. However when waiting times are so great in the public system that individuals routinely deteriorate while waiting until they reach some emergency priority status or actually die while waiting then there is clearly inequity in the system. This is even before taking into consideration the psychological impact on the individual and their families of waiting for long periods for important interventions while facing an uncertain future.

We must ask then why have these waiting lists come about in the Irish context, to a certain degree their growth was insidious but expected given the cuts experienced in the 1980’s. During this the country was undergoing a period of fiscal rectitude. We can see from figure 1 below there were serious cuts in public healthcare expenditure from the beginning of the 1980’s through to 1988. At the beginning of 1980 Irish healthcare expenditure as a % of GDP was 8.7% at £1797 million (1995 prices) by 1989 it had dropped to 6.6% at £1295 million.

Throughout the 1990’s we remained significantly below the OECD average and somewhat on a par with the United Kingdom, see Table 1. Clearly in a period in which the national finances are in such a state, cutbacks are inevitable and public healthcare as a high expenditure area is an obvious target.

This reduction in funding coupled with the obligation of healthcare managers to manage their resources within budgets and give priority to emergencies was the cause for the growth of many waiting lists. Faced with such priorities it is difficult for managers to reduce waiting lists as available system capacity is absorbed dealing first with priority cases while elective cases present at a higher rate than they are being routinely treated. Essentially the state we find our healthcare system in at the present time is a legacy from the cutbacks in the 1980’s from which the healthcare system has failed to recover and which can only ultimately be addressed, given the current state of national health, through a significant and sustained injection of well managed funds targeting both system infrastructure and staff.

Table 1

Total Health Expenditure as a % of GDP

2.2 Report methodology

Public healthcare waiting lists are generally of internal interest to country/region. International data for waiting time for general procedures is not routinely recorded and published internationally, even by the World Health Organisation as part of their World Health Reports, (WHO 2000). However certain countries have been very active on a policy side in addressing the issue of waiting lists as they occur in their healthcare system and have become a greater issue of public concern and urgency. Typically there has been a concentration on high profile areas such as coronary artery by-pass surgery. An extensive literature search was conducted using medline and over 80 articles relevant waiting lists were identified, all of which were published since 1990. Of these 80 articles 70 referred to surgical procedures with the majority (40) as expected concentrating on cardiac surgery waiting lists. Articles referring to waiting lists for transplant surgery were not considered. The spread of articles over countries was as follows; Canada - 14, New Zealand - 7, United Kingdom -10, Netherlands -3, Australia -2 and general articles not referring to any specific country - 4. Thus our analysis of the experiences and responses to public healthcare waiting lists is significantly curtailed. The absence of supporting literature for a country does not imply that there is no waiting in that particular system. It is more likely that the absence of information on European countries has more to do with waiting lists being seen as an internal issue and discussed and debated internally rather than in international journals. It is of no coincidence that four of the five countries identified are all English speaking and that therefore their internal journals are more widely available for our investigation. It is also not surprising to find nothing on this area in the literature from America. The American system heavily penalises those without insurance coverage or independent means of payment. The American public healthcare system is relatively small and generally does not engage in large-scale elective surgery. An individual can either afford the treatment or can not. It would appear that there is little objective comparable information on waiting time and waiting lists in Europe or anywhere else.

2.3 Waiting experience – Canada

During the 1990’s Canada experienced significant structural changes to its healthcare system, with fiscal circumstances creating pressure on the system to do more with less. Their approach was to initiate widespread operational reorganisation largely focused on regionalisation and moving patients closer to home. This has resulted in growing concern within Canada about diminished access to care in certain regions which traditionally have not had good service coverage. In part this reorganisation has led to what has been publicly viewed in Canada as unacceptable lengths of time on waiting lists (Doogue; Brett, and Elliott 1997). However waiting lists in Canada predate the restructuring of the healthcare system (Barer M 1998) and are accepted to be as a result of an extended and prolonged mis-match of demand and supply compounded by poor list management.

Within the Canadian system there exists considerable differences in waiting times across regions due to lack of standards governing when a patient is placed on a list, methods in which waiting times are recorded and the method by which waiting lists are managed – usually at a individual physician or hospital surgical or diagnostic department rather than at a regional level or other co-ordinating agency(Sanmartin; Shortt; Barer; Sheps; Lewis, and McDonald 2000;Turnbull; Taylor; Hsiang; Salvian; Nanji; O’Hanley; Doyle, and Fry 2000). Canadians’ high approval of their healthcare system declined significantly during this period. However when we compare Irish waiting times for comparable procedures we find that even though the Canadian system perceived itself to be in crises and was rapidly losing public support their performance was significantly better than ours. For example from 1991 to 1994 the median wait for CABG in Canada was two weeks, the average was four weeks, a wait of over 6 months reported to be vary rare and there were low rates of death while on the list (Naylor; Sykora; Jaglal, and Jefferson 1995;Turnbull and others 2000). Similar concrete information for Ireland during the same period is difficult to isolate due to the fact that management of lists was not centralised. However from ongoing work being carried out in this area it is clear that the Irish system was not performing even at these levels, indeed it was not unusual for elective public patients to wait for over one year for surgery.

2.4 Waiting experience – UK

The United Kingdom has experienced considerable public discontent at the state of waiting lists within the NHS during the 1990’s, (Green 1999). There was, during this time, particular concern regarding the number of people on long-term waiting lists. To address this funds were targeted at these long-term waiters and lists were shortened. However these approaches often involved minimal extra resources with only a temporary redistribution of existing resources and on their own had little long term impact. Within the surgical waiting system it was documented that adding surgeons to a hospital had a short term effect on reducing the level the waiting list but that within two years the lists were back to their per-intervention level due to increased referrals,(Frost C 1980). In recent years the UK approach has concentrated heavily on list audit and list management as the primary method of controlling waiting lists, (White A 1998). They have also implemented a small degree of prioritisation concentrating particularly on patients who are reaching a pre-set maximum wait threshold for certain conditions. These maximum wait programs have also been implemented to a degree in Sweden. This issue of waiting lists remain a current problem within the NHS.

2.5 Waiting experience – New Zealand

The issue of waiting lists in New Zealand has been in the public domain since before the 1990’s. However as a part of the restructuring of their health system which began in 1992, with the stated aim of achieving greater levels of assessment and accountability in the publicly funded health system, they established a committee to advise the Minister of Health on the types and relative priorities of health services which should be provided by the public system. One of its first reports recommended, for surgical services, a complete move away from a system of waiting lists towards system of specific booking times based on formal prioritisation (White A 1998;Fraser G 1993). Priority would be given to patients with the greatest likely benefit. The principal goal of this undertaking was to achieve the maximum possible population health gain with the available funds. Since the publication of this report much work has been done in New Zealand on formalised priority setting for surgical procedures and New Zealand has been a fertile testing ground for such instruments. The net effect of these measures has had a dramatic impact on the nature of ‘waiting’ within the New Zealand system.

2.6 Waiting experience – France

Not all countries with large active public healthcare systems have experienced a waiting list ‘crises’ in recent years and as such they are more difficult to document. France however is a good example of a country, which for the most part, has not experienced significant waiting problems except in the area of organ transplantation.

All surgery is planned in France in a manner very like the booking system introduced in New-Zealand. A patient may have to wait a few months for surgery but they are given their surgery date immediately. This has the added benefit of reducing uncertainty and stress for the patients and their families. The French system copes with emergency surgery cases by running bed occupancy rates at around 75% so that the system runs at all times under full capacity. Thus is can manage periods of ‘peak demand’ without disrupting the booking system. The growth, due to technical advances, of day care surgery has been a feature of the healthcare landscape in many countries over the past 15 years. However it is certain that the dramatic expansion of day care surgery in France in particular has played a part avoiding the problem of unacceptable waiting times.

Ultimately it could be said that France has avoided waiting lists by having over capacity built into their system. They finance this though specific social security payments which are quite significant but these social security payments almost wholly finances the system.

In addition there is the method by which the French system has addressed the issue of manpower and skills availability. The necessary number of practitioners for every speciality is determined on a centralised basis by the Ministry of Health for every region and on this basis the number of students to be trained in any speciality is determined. This requires centralised planning and clearly there is a time lag. While it is less responsive that an ‘open market’ would be it does not suffer form the restrictive practices inherent in the Irish system.

All this being said, France does appear to have a slight emerging problem of waiting lists – mostly at the hospital level for minor complaints and investigations. As hospital care is free of charge at the point of use in France, low-income individuals have been presenting at hospitals with minor conditions rather than consulting a physician in the first instance thus skipping the ‘barrier’. This is largely not a problem for surgical waiting lists. In the short term public hospitals are implementing screening and selecting priority cases of this sort only. A long term solution recently implemented has been to educate the public about the universal insurance coverage system which has recently been introduced thus giving the disadvantaged access to all care without charge – thus encouraging them to go through a physician rather than initially presenting at a hospital.

Essentially therefore France has no significant hospital waiting lists outside of transplantation. They operate a booking system in which patients are free to choose any physician. By systematically running the system under capacity they allow for fluctuations in demand and avoid the problem of backlogs developing which would disrupt the booking system. Clearly all this comes at a price. Since the 1960’s France has been highest spenders on healthcare in Europe. They finance their public system largely through dedicated social security payments which accounted for 75% of total health expenditure and 93% of public health expenditure in 1996. These social security payments are supplemented by central funds. This level of direct expenditure on the healthcare system is certainly reflected in France’s premier position in the WHO World Health Report (2000).

3. Implications of future trends in healthcare utilisation

The demand for healthcare in developed countries, including Ireland is expected to rise in coming years partly as a result of demographic shifts, specifically ageing populations which will result in a significant increase in chronic diseases of old age (Hurst J 2000). Simultaneously healthcare costs can be expected to rise due the labour intensive nature of healthcare and the normal experience that sector specific wages tend to rise in line with general wage trends. This cost increase will be further exacerbated by the continuous growth in high technology medicine, particularly where focused on quality/quantity of life extension of an ageing population. Such a combination of rising healthcare demand and costs will probably result in an increase in public expenditure on healthcare as a % of GDP, which given the falling tax base associated with an ageing population can not be expected to be matched by an increase of tax revenue.

It is within such an environment that our healthcare system will have to operate. Current practice of implementing various waiting list initiatives are sufficient to cut numbers on various waiting list in the short term but can not be viewed as a long term solution. Formalised and centralised recourse allocation and prioritisation will have to become and integral part of our healthcare management system if we are to make best use of the limited funds available to us in the face of rising demand and expenditures. There is evidence that there potentially exists considerable cost saving within public healthcare systems without cutting back on service provision. These savings would stem from the application of a Total Quality Management approach to public healthcare which as well as ensuring quality of service would tackle unnecessary waste and duplication. Estimates from the manufacturing sector suggest that from 20%-40% of operating costs are directly or indirectly due to unnecessary waste (Joss R 1995). While implementing such as system would be a difficult and lengthy process and the costs of implementation would be significant, especially given the small scale of our healthcare system, we have to ask if we can afford not to in the long run. This is particularly true if we are to retain a viable public healthcare system which will be able to adequately serve the population in a responsive manner.

4. Policy instruments for dealing with waiting lists in the short and long terms

4.1 Centralised review/control and management of waiting lists

Part of the confusion when dealing with waiting lists is that there often is no formal management structure for regulating waiting lists. Individual physicians and hospitals manage their own lists and while there may be a degree of transference between physicians and hospitals it tends to be of an ad hoc nature. This is the main reason why we often do not know how many people actually on a list. There is generally no process of continual review to check if patients have moved off the list due to death, treatment in another system/region or simply no longer wishing the intervention. International data suggests that this may inflate waiting list by as much as 20%-30%. Related to this is the fact that we are generally unaware of the burden which waiting imposes on the patient in terms of health status, as well as in socio-economic and psychological terms. While in recent times there has been an effort made to audit individual lists it is not certain that a continual audit process has been established. The management and continuous review of the various waiting lists should be implemented on a more central level.

4.2. Targeting Funds

Additional funds to tackle waiting lists must be targeted. A good example of this are various waiting list initiatives implemented by the Department of Health and Children in recent years. Such an approach ensures that the funds address the correct area. However it is generally accepted that targeted funding such as this is a short term measure. Such initiatives will not address the underlying cause of the waiting list growth. Conversely international experience has show that targeted funding can spark a wave a new entrants onto the list which can actually result in the list increasing in size despite the funds allocated(Lewis; Barer; Sanmartin; Sheps; Shortt, and McDonald 2000). This occurs if physicians start placing patients on the list who the originally would have held back and managed in another way, knowing that they would not receive the intervention given their relative health status and the previous length of the list. At most targeted funds alleviate the major crises points while new structures are put in place to address the fundamental underlying causes.

4.3 Making use of the private sector

There is some merit in targeting funding to have procedures carried out in the private sector if the main constraint in the public sector is one of short term lack of capacity and the excess capacity exists in the private sector. This was the scenario in Ireland which has led to public patients being operated on in private hospitals. However such an approach can have a detrimental effect under conditions where there remains excess capacity in the public sector and when the underlying problem is one of insufficient funding alone and the if physician involved works in both systems. Under such conditions giving greater access to private care can be associated with longer public sector queues(Kingma 1995). This is particularly true when one has a market shortfall of human resources in healthcare where any formalised expansion of the private sector would be likely to further drain an entire spectrum of staff away from the public sector.

4.4 Selection criteria and prioritising waiting lists

It is essential that there should be some standardised method of selecting individuals onto a list to ensure equity in the public system across physicians/hospitals/regions. This again would require more centralised control while at the same time establishing a formalised method of selection onto the list. It is accepted that a degree of physician discretion should be an integral part of this system. While it is unacceptable to have someone waiting over 24 months for cardiac surgery should such an individual been on such a list in the first place? Formalised selection criteria might not have allowed this.

More critically once a patient has been accepted onto the list they should be prioritised in a formal manner and placed in the list on that basis(Shortt 1999). Queuing for healthcare is different. First come first serve should not be a basis of treatment unless we are treating like with like. Clearly we accept that those who are clear-cut emergencies should receive immediate attention. There exists however other levels of need and patients should be judged on these. Clearly clinical status would play a large part in the prioritisation process, however personal circumstances, length of time waiting to date and again some degree of physician discretion should be included. If the issue of unacceptable waiting lists is to be addressed in the long term such an approach is unavoidable. A further advantages of such a system of prioritisation is to give a level playing field to all patients regardless of their geographical location within the country.(Jackson; Doogue, and Elliott 1999;Rao and Burd 1997;Hadorn and Holmes 1997b;Hadorn and Holmes 1997a) In addition it takes pressure off individual physicians from colleagues or public representatives who may lobby on behalf of a certain individual to get priority treatment. Such pressure on a physician to favour one patient over others is an abuse and clearly inequitable if it were to have any effect on the physician’s decision.

The issue of within list prioritisation has been the focus significant levels of debate in recent years, mostly focused around the experiences in New Zealand and the potential adaptation of such a system within the NHS in the UK – trials of which are currently ongoing. The analysis of waiting lists with an emphasis on maximum waiting time and numbers on the list is alone is inadequate. A priority scoring system goes far beyond by attempting to place patients on the elective list in some uniformly recognised order of need.

The concentration in the media and the resulting political emphasis on the raw numbers on the waiting list and the length of time spent on the list erodes the physician’s ability to treat according to urgency. One of the potential problems of earmarking funds to specifically reduce waiting lists is that the incentive is to reduce the numbers on the list by targeting a greater number of the less complex cases. That those cases left on the list may be more cost effective based on potential changes in patient health status is not considered. This is a weakness of targeting funds in a short term ‘waiting list initiative’ which a priority scoring system would also address.

4.5 Priority Scoring Systems

The central argument in implementing a scoring system is that of introducing transparency and thereby equity into the waiting list system. As well as being used to determine a persons position on a list they can also be used as a ‘threshold’ measure of being initially accepted onto a particular list. A scoring system for healthcare procedures in not comparable to one for public housing. A entire battery of ethical, technical and managerial issues arise. Should scoring system should be tailored to each list individually or should common criteria be applies across several clinical specialities? What weighting is given to the various clinical and social variables? Whose prioritisation criteria should be used? For the successful implementation of such a scoring system the active involvement of healthcare professional and managers would be essential. It would have to be stressed to healthcare professionals that such a prioritisation system is not seeking to diminish their professional liberty but rather free them from undue pressure to favour individual patients. In this manner they loose little of their clinical discretion as they are actively involved in establishing the individual’s score.

The scoring mechanism would ideally be developed using a Delphi type technique where professional consensus has been achieved. It must be easily incorporated into routine clinical procedures and be replicable independent of the physician. The scoring system would provide a process which would be both fair and consistent across the various health bodies. Scoring systems are at the foundation of prioritisation and are also essential for the implementation of a booking system, they provide transparency and can assist in both the equitable and efficient management of lists.

4.6 Demand side interventions

Clinical need should be the only cause of an expressed demand. Priority scoring systems recognise this via the ‘threshold’ for acceptance onto the list. Regular auditing of the list and periodical reassessment of patients on the list where necessary will restrain demand to its ‘true’ level. For this to be effective centralised control of the waiting system is again required. Public health education also plays a significant long term role in affecting demand for healthcare through various health awareness strategies.

5. Summary

•Public healthcare systems require targeted funding to address underlying causes of waiting lists and reduce them in a sustainable manner

•Demand for healthcare is projected to grow significantly in the future. Mechanisms should be put in place at this stage to prepare for increased demand

•Private healthcare should not operate at the expense (financial and labour) of the public healthcare system

•More centralised control of waiting lists – control at a regional level rather at the individual consultant/hospital level

•List reviews should take place on a regular basis backed by sufficient information technology

•Explicit prioritisation and the general use of scoring systems should be used in the general management of lists

6. Reference List

1.Barer M, McDonald P Shortt S. waiting Lists and Waiting Times for Healthcare in Canada. 1998 Jul.

2.Doogue, M.; Brett, C., and Elliott, J. M. Life and death on the waiting list for coronary bypass surgery. New Zealand Medical Journal. 1997 Feb 14; 110(1037):26-30; ISSN: 0028-8446.

3.Fraser G, Alley P Morris R. Waiting lists and waiting time: their nature and management. 1993.

4.Frost C. How permanent are NHS waiting lists. 1980; 14, 1-11.

5.Green, N. Uk hospital pays dearly to cut waiting lists [news]. Lancet. 1999 Aug 21; 354(9179):660; ISSN: 0140-6736.

6.Hadorn, D. C. and Holmes, A. C. The new zealand priority criteria project. Part 1: overview [see comments]. BMJ. 1997a Jan 11; 314(7074):131-4; ISSN: 0959-8138.

7.---. The new zealand priority criteria project. Part 2: coronary artery bypass graft surgery [see comments]. BMJ. 1997b Jan 11; 314(7074):135-8; ISSN: 0959-8138.

8.Hurst J. Challenges to health systems in OECD countries. 2000; 76, (6).

9.Jackson, N. W.; Doogue, M. P., and Elliott, J. M. Priority points and cardiac events while waiting for coronary bypass surgery. Heart. 1999 Apr; 81(4):367-73; ISSN: 1355-6037.

10.Joss R, Kogan M. Advancing Quality. 1995.

11.Kingma, J. H. Waiting for coronary artery bypass surgery: abusive, appropriate, or acceptable?[Comment]. Lancet. 1995 Dec 16; 346(8990):1570-1; ISSN: 0140-6736.

12.Lewis, S.; Barer, M. L.; Sanmartin, C.; Sheps, S.; Shortt, S. E., and McDonald, P. W. Ending waiting-list mismanagement: principles and practice [comment]. CMAJ. 2000 May 2; 162(9):1297-300; ISSN: 0820-3946.

13.Naylor, C. D.; Sykora, K.; Jaglal, S. B., and Jefferson, S. Waiting for coronary artery bypass surgery: population-based study of 8517 consecutive patients in ontario, canada. The steering committee of the adult cardiac care network of ontario [see comments]. Lancet. 1995 Dec 16; 346(8990):1605-9; ISSN: 0140-6736.

14.Rao, G. S. and Burd, D. A. Problems and priorities of plastic surgical waiting list initiative schemes: an audit. Journal of the Royal College of Surgeons of Edinburgh. 1997 Apr; 42(2):128-30; ISSN: 0035-8835.

15.Sanmartin, C.; Shortt, S. E.; Barer, M. L.; Sheps, S.; Lewis, S., and McDonald, P. W. Waiting for medical services in canada: lots of heat, but little light [see comments]. CMAJ. 2000 May 2; 162(9):1305-10; ISSN: 0820-3946.

16.Shortt, S. E. Waiting for medical care: is it who you know that counts? [Editorial; comment]. CMAJ. 1999 Oct 5; 161(7):823-4; ISSN: 0820-3946.

17.Turnbull, R. G.; Taylor, D. C.; Hsiang, Y. N.; Salvian, A. J.; Nanji, S.; O’Hanley, G.; Doyle, D. L., and Fry, P. D. Assessment of patient waiting times for vascular surgery. Canadian Journal of Surgery. 2000 Apr; 43(2):105-11; ISSN: 0008-428X.

18.White A. waiting lists, a step towards representation, clarification and solving information problems. 1998; 76, 279-4.

19.WHO. World Health Report 2000. 2000.

Appendices

Appendix 6

Members of the Joint Committee

Appendix 7

Orders of Reference of the Joint Committee

Joint Committee on Health and Children

ORDERS OF REFERENCE

Dáil Éireann

13th November, 1997, (** 28th April, 1998),

Ordered:

(1) (a)That a Select Committee, which shall be called the Select Committee on Health and Children, consisting of 14 members of Dáil Éireann (of whom 4 shall constitute a quorum), be appointed to consider such—

(i)Bills the statute law in respect of which is dealt with by the Department of Health and Children, and

(ii)Estimates for Public Services within the aegis of that Department,

as shall be referred to it by Dáil Éireann from time to time.

(b)For the purpose of its consideration of Bills under paragraph (1)(a)(i), the Select Committee shall have the powers defined in Standing Order 78A(1), (2) and (3).

(c)For the avoidance of doubt, by virtue of his or her ex officio membership of the Select Committee in accordance with Standing Order 84(1), the Minister for Health and Children (or a Minister or Minister of State nominated in his or her stead) shall be entitled to vote.

(2) (a)The Select Committee shall be joined with a Select Committee to be appointed by Seanad Éireann to form the Joint Committee on Health and Children to consider—

(i)such public affairs administered by the Department of Health and Children as it may select, including bodies under the aegis of that Department in respect of Government policy,

(ii)such matters of policy for which the Minister in charge of that Department is officially responsible as it may select,

(iii)the strategy statement laid before each House of the Oireachtas by the Minister in charge of that Department pursuant to section 5(2) of the Public Service Management Act, 1997, and shall be authorised for the purposes of section 10 of that Act, and

** (iv)such Annual Reports or Annual Reports and Accounts, required by law and laid before either or both Houses of the Oireachtas, of bodies under the aegis of the Department(s) specified in paragraph 2(a)(i), and the overall operational results, statements of strategy and corporate plans of these bodies, as it may select.

Provided that the Joint Committee shall not, at any time, consider any matter relating to such a body which is, which has been, or which is, at that time, proposed to be considered by the Committee of Public Accounts pursuant to the Orders of Reference of that Committee and/or the Comptroller and Auditor General (Amendment) Act, 1993.

Provided further that the Joint Committee shall refrain from inquiring into in public session, or publishing confidential information regarding, any such matter if so requested either by the body or by the Minister in charge of that Department; and

(v)such other matters as may be jointly referred to it from time to time by both Houses of the Oireachtas,

and shall report thereon to both Houses of the Oireachtas.

(b)The quorum of the Joint Committee shall be 5, of whom at least 1 shall be a member of Dáil Éireann and 1 a member of Seanad Éireann.

(c)The Joint Committee shall have the powers defined in Standing Order 78A(1) to (9) inclusive.*

(3)The Chairman of the Joint Committee, who shall be a member of Dáil Éireann, shall also be Chairman of the Select Committee.

“That the Joint Committee on Health and Children shall have the power to send for persons, papers and records as defined in Standing Order 79. This Order shall cease to have effect on 30th June, 2001.”

Seanad Éireann

19 November 1997(** 30th April, 1998),

Ordered

(1) (a)That a Select Committee consisting of 5 members of Seanad Éireann shall be appointed to be joined with a Select Committee of Dáil Éireann to form the Joint Committee on Health and Children to considerC

(i)such public affairs administered by the Department of Health and Children as it may select, including bodies under the aegis of that Department in respect of Government policy,

(ii)such matters of policy for which the Minister in charge of that Department is officially responsible as it may select,

(iii)the strategy statement laid before each House of the Oireachtas by the Minister in charge of that Department pursuant to section 5 (2) of the Public Service Management Act, 1997, and shall be authorised for the purposes of section 10 of that Act, and

(iv)such Annual Reports or Annual Reports and Accounts, required by law and laid before either or both Houses of the Oireachtas, of bodies under the aegis of the Department(s) specified in paragraph 1(a)(i), and the overall operational results, statements of strategy and corporate plans of these bodies, as it may select.

Provided that the Joint Committee shall not, at any time, consider any matter relating to such a body which is, which has been, or which is, at that time, proposed to be considered by the Committee of Public Accounts pursuant to the Orders of Reference of that Committee and/or the Comptroller and Auditor General (Amendment) Act, 1993.

Provided further that the Joint Committee shall refrain from inquiring into in public session, or publishing confidential information regarding, any such matter if so requested either by the body or by the Minister in charge of that Department; and

(v)such other matters as may be jointly referred to it from time to time by both Houses of the Oireachtas,

and shall report thereon to both Houses of the Oireachtas.

(b)The quorum of the Joint Committee shall be 5, of whom at least 1 shall be a member of Dáil Éireann and 1 a member of Seanad Éireann.

(c)The Joint Committee shall have the powers defined in Standing Order 62A(1) to (9) inclusive.*

(2) The Chairman of the Joint Committee who shall be a member of Dáil Éireann.

“That the Joint Committee on Health and Children shall have the power to send for persons, papers and records as defined in Standing Order 68. This Order shall cease to have effect on 30th June, 2001.”

Appendix 8

Proceedings of the Joint Committee

AN COMHCHOISTE UM SHLÁINTE AGUS LEANAÍ

THE JOINT COMMITTEE ON HEALTH AND CHILDREN

Imeachtaí An Chomhchoiste

Proceedings of the Joint Committee

Dé Céadaoin, 24 Eanair 2001

1.The Joint Committee met at 11 a.m. in Room G4, Kildare House.

2.MEMBERS PRESENT.

The following members were present:

Deputies Batt O’Keeffe (in the chair), Michael Ahern, Paul Bradford, John Gormley, Cecilia Keaveney, Billy Kelleher*, Liz McManus, Dan Neville, Michael Ring and G.V. Wright.

Senators Camillus Glynn and Pat Moylan.

3.DRAFT REPORT

Deputy Liz McManus brought forward a report entitled “A Comparative Analysis of Waiting Lists for Acute Hospital Treatment in EU Countries”. The Report was read and amended. The Report, as amended, was agreed.

Ordered: To report accordingly.

4.ADJOURNMENT

The Committee adjourned at 11.24 a.m.

¹ Key data on health, Eurostat, September 2000

² 90% have cover through state medical insurance programme; remainder through other welfare bodies.

³ The private patient population in Spain and Finland is negligible in comparison to Ireland—e.g. in Finland, only 0.5% of patients are private.

⁴ See also Appendices 5 and 5a for OECD health system structure comparatives and analysis of Irish system within that perspective.

⁵ Fallen recently from 11% due to NHS reforms

⁶ Available on the internet at: www.hc-sc.gc.ca/iacb-dgiac/nhrdp/w1sum5.htm

² Senator Kathleen O’Meara was appointed in place of Senator Pat Gallagher on 4 November 1999

³ Deputy Liz McManus was appointed in place of Deputy Róisín Shortall on 4 November 1999

⁴ Deputy Gay Mitchell was appointed in place of Deputy Alan Shatter on 29 June 2000

⁷ Deputy Michael Ring was appointed in place of Deputy Deirdre Clune on 29 June 2000

* The following motion was passed by Dáil Eireann on 12 December 2000:

* The following motion was passed by Seanad Eireann on 13 December 2000:

* in substitution for Deputy John Dennehy