I will pick up on several issues which arose during my last appearance before the committee in February. I will address the role of the Department and, in particular, the issue of performance evaluation and the Office of the Minister for Children, given that the committee is examining Vote 41.
The Department has recently published its statement of strategy for 2008 to 2010. The Department's mission is "to improve the health and well-being of people in Ireland in a manner that promotes better health for everyone, fair access, responsive and appropriate care delivery, and high performance".
The Minister for Health and Children is politically accountable for developing and articulating Government policy on health and personal social services, and for the overall performance of the health service. The Department's mandate is to support the Minister and the four Ministers of State by advising on policy development and implementation, evaluating the performance of existing policies and service delivery, preparing legislation, and working with other Departments, the social partners and international organisations.
One of the Department's functions is to develop and refine a system of performance evaluation which helps the Minister to assess the performance of the health system. Given the committee's role, it would be useful to focus on this issue.
Much of the public debate about health tends to focus on inputs — the need for extra funding, beds, consultants, nurses, etc. We expend a lot of energy debating what we should invest in health. However, even when funds are plentiful, we must get the most from what we put in.
The NESC has suggested that Ireland could make much better use of the existing resources being devoted to health. It stated, "... we need to rely more on the improved use of resources to make the case for additional resources, rather than the other way around...".
The OECD's recent study of the public service stated, "Instead of focussing on inputs and processes, more information needs to be gathered on outputs and outcomes and what has actually been achieved".
It is already clear that we are unlikely to see the same rate of increase in health spending over the next few years as we have in the recent past. This makes it all the more important that we deliver maximum benefit for patients from whatever resources we have.
This is not about balancing the books. It is about delivering the best possible service in terms of access, quality, effectiveness, etc. to those who need our services. I also want to emphasise that safe and effective care is also good value care. Poor quality care, in addition to its impact on individuals, leads to complications and the need for additional care, which raises costs substantially. International evidence suggests that good hospital management, for example, usually results in efficient use of resources and high quality patient care. Very often, the immediate reaction to a problem with our health services is to call for more investment and more staff for a particular service. We need instead to ask how the existing resources are being used, to find out what is actually being delivered in terms of outputs and outcomes, and whether there is a better way of providing the service. If we can show that we are getting the best from the existing investment in a particular service and still have a clear service deficit then we are in a much better position to make the case for additional investment.
There are many examples of good practice across the health service. One of the projects at the HSE's recent innovation awards ceremony was the St. James's Hospital physiotherapy department. I understand that the waiting times for a physiotherapy appointment at this hospital have been reduced by making better use of existing capacity. The non-attendance rate for outpatient physiotherapy had been as high as 21% a month. Some 290 patients a month did not attend their scheduled outpatient appointments. The outpatient physiotherapy hours were extended — they now run from 8 a.m. to 6 p.m. — allowing greater patient access and choice of appointment. A text message reminder service to patients attending physiotherapy was introduced and the non-attendance rate was reduced to a low of 10% a month. As a result, it was possible to reduce waiting list times and patients now wait no longer than six weeks for a physiotherapy appointment.
One of the winning projects at the same innovation awards ceremony was St. Vincent's Hospital's neurology department. Previously, the department saw fewer than 3,000 outpatients a year and had long waiting times. Regular cancellation of elective admissions meant many patients with neurological problems ended up being referred to the accident and emergency department and spent long periods on trolleys. The department now runs nine public neurology clinics a week and has put in place a web-based general practitioner direct referral service. In 2006-07, almost 5,300 patients were seen in the clinics. The waiting time for a new patient has fallen from 18 months to less than ten weeks. The time each patient spends with a doctor has doubled. More people are now treated in the clinic instead of being admitted. Fewer patients end up in the accident and emergency unit.
We need to acknowledge these positive service developments and encourage others to adopt similar innovative solutions to make the best use of existing capacity. The total number of outpatient attendances in 2007 was more than 3 million but there was a very high rate, more than 18%, of people who did not attend, while the ratio of new to return attendances is too low — only 1:2.8. This suggests there is already capacity within the system that could be used more effectively.
To drive this type of improvement, we need to empower local decision makers — doctors, nurses, other clinicians and managers — and provide them with good information. Although much of the debate about health reform in recent years has concentrated on structural matters, information is even more important than structures. Among the recommendations about the health service made by the OECD in its recent report about the Irish public service were the following. There needs to be better performance and budgeting information, more activity-based costing and better data collection and utilisation generally across the system. Key performance indicators need to be identified by the Department of Health and Children with the HSE which can incentivise local management and staff to deliver the best solution to improving patient experience while not imposing a major administrative burden on the system. There needs to be a focus on longer-term outcomes, such as improvements in life expectancy, survival rates for cancer treatment or transplants, the number and age profile of elderly people living independently or with limited support in their own homes.
Good information is essential to drive improvements in safety, efficiency, quality, effectiveness and sustainability, and to evaluate the performance of the health system. At national level, we need to continue to improve the service planning process. We need more transparency about spending on specific programmes and care groups and good baseline information about existing services such as waiting times. At local level, we need to provide clinicians and managers with comparative information on actual performance to encourage, support and ultimately require them to deliver better services. The focus has to be on patient services and helping the professionals providing them. One of the critical shortcomings of modern health care around the world is the lack of a consistent ability to get critical clinical information to the doctor or health professional at the point of care. The availability of accurate and timely information is also essential for the Department to be in a position to plan, formulate policy and assess the performance of the health system.
On the subject of the office of the Minister of State with responsibility for children, OMC, and other offices in the Department, the OMC was established within the Department of Health and Children in early 2006. It is designed to bring together policy issues that affect children in areas such as early childhood care and education, youth justice, child welfare and protection, children's and young people's participation, research on children and young people, and cross-cutting initiatives for children. It also has a general strategic oversight of bodies with responsibility for developing and delivering services for children. Its core aim is to ensure an integrated approach to the development of policy and delivery of services for children and, as a result, support the delivery of better outcomes for children.
Following on from the success of the OMC, the Government announced in January this year the establishment of two other offices within the Department: the office for older people and the office for disability and mental health. The main functions of the office for older people will be to develop and support the implementation of a strategy for positive ageing and to bring greater coherence to the formulation of policies affecting older people as well as developing policy and supporting the delivery of health and personal social services for them.
Although substantial progress has been made in recent years in the areas of disability and mental health, much remains to be done. In particular, there is a need to improve co-ordination and communication across different Departments and agencies in their delivery of services to this client group. This will be the main focus of the office for disability and mental health in the coming months. In its recent report, the OECD said that the use of networks within and across organisations will be increasingly important in an integrated public service. It went on to say that Ireland had "made inroads in developing a network approach" through the establishment of the Office of the Minister for Children and, more recently, the office for older people and the office for disability and mental health. In the case of all three offices, the focus will be very much on outcomes and results, on establishing what works best and on encouraging other Departments and agencies to use their existing funding streams and adjust existing services as necessary to get the maximum benefits for the different client groups.
There is evidence of significant improvements in our health services and in health outcomes but we clearly have much more to do. The problems and pressure we face are not unique to this country. The best way of improving services is through a combination of better performance targets which are readily understandable to patients and health care professionals, better information and greater clarity about authority and responsibility at all levels within the health system.
