A number of questions have been asked, most of which have been responded to in writing, but I will comment on a couple of them.
Medical and GP-only medical cards have proved to be significant issues for the committee. As indicated previously, staff working in the primary care reimbursement service, PCRS, which handles the €2.7 billion spent on demand-led schemes have been implementing plans to accelerate the delivery of services and reduce administrative costs. In the few months since we last appeared before the committee considerable progress has been made. The staff respond to the approximately 850 calls received each day in an average of 13 seconds. As members might have seen in the media recently, we have launched the on-line medical card-GP visit card application service. Applications for full cards made through this facility are being responded to and cards can be issued within 15 days if all of the necessary information is provided. This is a major improvement on the traditional approach, in respect of which there could have been a wait of six to 12 weeks. The public can still make inquiries and apply for cards through their local health offices if they choose to do so. However, nine out of every ten applications are straightforward and the on-line process is suitable. It is interesting that in the system's first three weeks of operation there were more than 3,000 applications, approximately 50% of which were made outside normal hours. This shows the appropriateness of our approach.
The second major issue is that of services for people with intellectual disabilities which has been topical recently. The annual HSE budget for disability services is €1.5 billion, of which approximately 80% goes to disability service providers in the voluntary sector. The recent media coverage of services for people with intellectual disabilities has shone a light on how these services are provided through multiple service providers and the costs involved. During 2009 we introduced new service level agreements with service providers, strengthened our relationship with these organisations and clarified their responsibilities. We will shortly be convening a working group which will, in the light of tightening budgets, examine how these service are delivered and how the many service providers might be able to introduce more streamlined processes to ensure they can maintain and increase front-line services. Approximately 280 organisations are involved. The group needs to examine opportunities for merging organisations, removing duplication of back office functions, reducing management structures and amalgamating and rationalising services relating to transport, estates management and maintenance. These changes are never easy and will create many challenges for the staff and managers working in that large number of organisations. However, such changes have been under way in many parts of the health service in recent years. If we can work constructively with the voluntary sector, the changes will present opportunities to ensure a more efficient use of the resources we are spending on these services.
As the Chairman mentioned, this is the last time I will appear before the committee as CEO of the HSE. I can speak for my colleagues in taking the opportunity to thank members for the way in which they engaged in this process. I say a particular word of thanks to the Chairman, as this is often a difficult environment in which to chair proceedings. Without being patronising, he has dealt with us fairly at all times. This is appreciated. While our exchanges have been challenging, it is important that we be held accountable. I have always asserted that we should try to give as much information as possible at these meetings.
Many health services across the world are facing the same challenges, namely, how does one provide more with less money, a question raised by the Minister. There is widespread acceptance internationally that the hospital dominated model of care, a model on which we were focused a number of years ago, is neither desirable for patients nor sustainable. "Sustainable" is a word I often used when starting out. More and more countries are focused on integrating hospital and community-based services to provide a more seamless journey for patients. This is a significant undertaking for Ireland and every other country, but we are well advanced along the road. Everything we will do now will be about integration. At a practical level, this means that, starting from the point of contact with a GP, therapist, consultant or home carer, all services will be funded as a single service. Prior to this, hospital and community services were always competing interests. A single source budget can make a major difference and is already doing so in parts of the country in which there are integrated services. When integrated services are provided, we find that even the staff are generally much happier in terms of their capacity to work for the good of the patient rather than protecting competing parts of the organisational structure. This could never have been achieved under the old model of providing more hospital beds or putting more people into hospitals.
The focus on integration applies equally to modernising personal social services. Areas such as child care have presented major challenges. There have been many arguments about whether they should even be provided through the health service model. If we do provide for proper integration with proper primary care team structures at the front line, this is an ideal structure in which to provide personal social services.
Today thousands of GPs and HSE staff are providing high quality care for almost 2 million people through primary care teams. During the coming years the range of services they provide will expand. We had to start from somewhere. They will continue to grow and become excellent one-stop shops in communities throughout the country. This could never have been achieved overnight; it will constantly evolve. As part of our programme to improve services for people with mental health difficulties, we are also aligning the provision of community mental health services to a greater extent with primary care teams. This is another major change for those who work in our organisation in terms of how they do their work.
Hospital reconfiguration is always challenging but must take place if we reconfigure services. To be fair, leadership has been shown, not only by clinicians and managers in reshaping services, but also by many political representatives in local areas. It has been very constructive in terms of our capacity. Yes, we have had battles about changes to local services, but politically, people have been constructive in engaging with us, discussing our data and, where possible, helping to explain these to local communities. Thanks to the significant leadership shown by many local clinicians and managers, we are reshaping hospital services. The reconfiguration which includes making it easier for community-based professionals to link directly with hospitals and for hospitals to link directly with community services is improving access, quality and convenience for patients. It is taking us in a direction that a few years ago we would never have thought possible. Two of the more advanced areas are Dublin north-east and the mid-west. In the mid-west, with the reconfiguration of services and the creation of a medical assessment unit in Limerick, we have seen a reduction in the number of acute medical admissions. In fact, the medical assessment unit only admits 16% of the patients it sees. We have also seen the establishment of three community intervention teams as part of that reconfiguration, as well as state-of-the-art cardiac intervention services and intensive care centres.
I give full regard to the development of clinical leadership which has been essential in driving change in the health service — health services across the world constantly struggle without it. People such as Professor Higgins are critical in driving change in health services. Significant change can be achieved, not only by doctors but also by nurses, therapists and others leading change. For the first time ever in this country — certainly for the first time in a long time — we have clinical leadership that can bring about that change. It would have been hard to imagine in 2005 that we would have so many clinicians who are active and willing in driving change and who even appear in public to defend it. The implementation of this change can be an example internationally.
We have had to work in a tightening financial environment and I am glad to say we have been able to reduce costs by €1 billion, while still increasing the services we provide. We are providing care for more people than ever before with less money. The building blocks are in place and the HSE is driving what I hope is unstoppable progress towards a fully integrated system, which is the only way forward. The system must be high performance in terms of quality and safety — in fact, quality, safety and effectiveness tend to go together. Actual performance measurement is now central to what this organisation does. Again, this is a major step forward. It will no longer be a case of providing funding for those who shout the loudest.
While solid progress has been made, it would be naive in the extreme for me to believe we do not still have a long way to go. New work practices must be bedded down in a difficult financial and HR environment. However, there is now a groundswell of support among professionals for our goal of achieving an integrated and predominantly community-based health care system. Coupled with the current roll-out of integrated service areas across the country which will empower local ownership, clinical leadership and decision making to areas the size of one to two counties, the HSE can deliver the high quality and consistent service the public deserves. We must remain focused on the need to build a service that is sustainable and designed, first and foremost, to deliver an optimal service for service users, rather than providers. Equally, we must continually and urgently challenge the rate of progress and the motivation of those who resist progress. Real change requires absolute tenacity and does take time. The quick fix approach can no longer be acceptable. For years we wasted huge resources on maintaining a 1950s model of care which seems at times to be still much loved by some professionals from a bygone era.
Ireland is now much more advanced than most countries in developing an integrated health care system. It will be at least another five years before the integrated model of care is fully embedded. Sticking with the change agenda is the vital challenge. There is no doubt that in another five to ten years another change programme will start because medicine is a dynamic process.
