I am pleased to have the opportunity to put in context the investment and reform programme the Government has been promoting since the launch of the national health strategy in November 2001.
It is a matter of record that there have been significant increases in public investment in the health services in recent years. In 2003 the Government is investing €8.9 billion of current and capital expenditure, representing an overall increase of 154% since 1997. As a percentage of GNP, gross non-capital health expenditure now stands at 7.45%. The more than doubling of investment in health spending over the period 1997 to 2003 marks a significant achievement.
The range of services provided within the health system is almost unique by international standards, covering everything from health promotion, disease prevention to acute hospital treatment and a wide spectrum of personal, social and community services. One of the problems in showing effectiveness and outcomes of investment in the health area at the macro-population level is the time-lag between the investment and the measurable effect in terms of life expectancy and/or premature mortality. However, there are improvements to be pointed to in the system and it would be remiss of me, and unfair to our highly skilled and committed workforce, not to illustrate some of these achievements.
The overall aim of the health strategy is to improve the health status of the nation. That means helping people achieve their full health potential. This may mean medical interventions aimed at cure or the putting in place of supports to improve individuals' health, personal well-being or quality of life.
Immunisation is an area where effectiveness is relatively easy to measure and the outcome can be seen in a matter of a few years or even less. Recent successes have included the introduction of the haemophilus influenza type B vaccine in 1992, given its role as a significant cause of meningitis. Since the introduction of this vaccine, the incidence of this condition has reduced tenfold and is close to the point of eradication. An immunisation campaign against group C meningococcal disease was launched in October 2000. The aim of the campaign was to immunise all children and young people up to 22 years of age against the disease. The result has been impressive. In 2002, 14 cases of group C meningitis were reported, compared with 139 cases over the same period in 2000. This represents a 90% reduction overall. However, this success did not come cheaply. The costs of the group C meningitis programmes were in the order of €80 million for initial start-up and €10 million ongoing revenue funding.
This clear and quickly obvious link between intervention and outcome is the exception rather than the rule. There are areas where the full health impact of investment is less easy to measure. However, it is important to understand the impact of investment and the capacity of the delivery system before we begin to talk about system efficacy.
A particular feature of policy development over recent years has been the development of highly focused disease or condition specific action programmes. Leading examples include the cancer and cardiovascular strategies, addressing the two main premature killers.
Since 1997 there has been a cumulative investment of €400 million in the development of cancer services, well in excess of the £25 million initially envisaged in 1996 to implement the national cancer strategy. This funding includes an additional €29 million allocated in 2003 for cancer services this year. That investment will ensure that this year we continue to address increasing demands in cancer services in areas such as oncology/haematology services, oncology drugs and symptomatic breast disease services. This substantial investment has enabled the funding of 80 additional consultant posts, together with support staff in key areas such as medical oncology, radiology, palliative care, histopathology and haematology.
There has also been investment in the development of symptomatic breast disease services. A total of €30 million has been invested in these services alone since 2001. The benefit is reflected in the significant increase in activity which has occurred, with in-patient breast cancer procedures increasing from 1,336 in 1997 to 1,829 in 2001, an increase of 37% nationally. We can also show dramatic increases in chemotherapy and radiotherapy services throughout the country.
The increase in activity levels has been quite dramatic in all these fields over the past few years and one has to ask how we were treating cancer before this level of investment. The bottom line is that previously we were not treating cancer adequately – and that is not to say we do not have more to do. Obviously increased investment is necessary.
We have introduced a national breast cancer screening programme, BreastCheck, on a phased basis and have achieved an uptake of over 70%, which exceeds international standards in programmes of this kind. We are also putting symptomatic breast cancer clinics of excellence in place with attention to geographic spread.
We anticipate that the reports of the National Cancer Registry Board will enable us to show, over time, the link between the type of treatment provided and outcomes in an Irish context. I hope to return to the House to debate the evaluation of that cancer strategy or the formulation of a new one. We will have an evaluation of what happened over the past five years. The critical issue is outcomes, survival rates and reduction of mortality.
Heart disease is the single biggest killer in Ireland. The implementation of the cardiovascular health strategy will have a significant impact on heart disease, an everyday reality for thousands of Irish people and their families. The Government has committed a cumulative €54 million towards its implementation since 2000.
This has supported a wide range of new regional services and initiatives and created almost 800 new posts, four out of five of which are professional staff. The process of appointing 17 of 25 new consultant cardiologists is also under way. This will bring the total number of consultant cardiologists up from 29 to 46. The range of services being sponsored from within this funding is broad, including health promotion, primary care, pre-hospital care, hospital care, cardiac rehabilitation as well as information systems, audit and evaluation.
There have also been substantial improvements in acute services. Of the 3,000 beds committed to in the strategy, 520 were funded in 2002 and the remaining beds will be brought into use shortly. Based on provisional figures provided to my Department by health agencies, for the first 11 months of 2002 there was an average of 12,219 acute hospital in-patient beds available. Considerable progress has been made in reducing waiting times for public patients in 2002. The total number of children waiting for more than six months for in-patient treatment has fallen by 24% between June and September 2002. On the points made by Senator Feighan about cardiac surgery for children, we have made dramatic progress by sending children abroad, with the agreement of the consultant in Crumlin hospital, to Johns Hopkins Hospital in the United States and to England. That has resulted in a dramatic erosion of the waiting list, particularly for children awaiting cardiac surgery, while we are building up capacity in Crumlin in terms of the additional operating theatres.
The total number of adults waiting for more than 12 months for in-patient treatment in the nine target surgical specialties covered by the waiting list initiative has fallen by 15% between June and September 2002.
The hospital system has continued to improve its productivity. A total of 968,000 people were treated last year as either in-patients or day patients in acute hospitals. That is an increase of 5% over the 2001 figure, which was an increase of 6% on the 2000 figure. Since 1997, the number of patients treated in our acute hospitals has increased by 23%. An internationally accepted measure of acute hospital efficiency is the proportion of day cases and the picture in that regard is impressive. In 2002, day cases were up 14% over 2001. Since 1997, day cases carried out in Irish hospitals have increased by 44%. Some of our Dublin teaching hospitals have passed the 50% mark and are now treating more patients in a day case setting than as in-patients. In this regard we are up with best international practice.
While the waiting list initiative will continue to fund additional elective activity, the dedicated national treatment purchase fund is being used to target those waiting longest for treatment. Funding of €43.8 million has been provided in 2003 for the waiting list initiative and a further €30.75 million has been provided for the national treatment purchase fund. To date, approximately 2,300 long waiters have received treatment under the national treatment purchase fund.
In 2002, a primary care task force and steering group were established to drive implementation of the model. In 2002, the task force selected ten locations throughout the country for the putting in place of implementation projects in line with the primary care model. The projects will enable the new model of a multi-disciplinary based primary care team to be demonstrated in action and refined as necessary. Funding totalling €8.4 million is being provided for the projects in 2002 and 2003. As the ten projects are developed, more than 80,000 people will benefit from having direct access to an improved range of services provided by their primary care team.
To complement the primary care model, it was envisaged that in the short term, general practice co-operatives would be established on a national basis so that effective out of hours services would be available in all parts of the country. The funding provided for out of hours co-operatives in 2002 totalled €17 million. Each health board region now has GP co-operatives in place and these are being progressively extended board-wide. Negotiations are ongoing on further expansion this year.
There has also been substantial investment in continuing care services since 1997. For older people this has meant enhancement of nursing home subvention schemes, the provision of additional home helps, improving community-based services and services provided in community hospitals and day care centres, additional respite care and support for carers. For people with intellectual disabilities and autism, service developments provided for included, in 2002 alone, over 100 new residential places, 75 new respite places, 600 new day places and the continuation of the programme to transfer persons with an intellectual disability or autism from psychiatric hospitals and other inappropriate placements. For people with physical disabilities, in 2002 alone investment was provided for the enhancement of home support services, therapy services, up to 100 additional posts as recommended in the sector's service audit, 500 rehabilitative training places and 15 guidance-assessment staff in the health boards in the area of rehabilitative training.
We all know that there are benefits to be gained from investment in the health service in terms of overall economic development. However, assurances that money is being spent effectively and efficiently are crucial. The strategy recognises that further spending can only come in the context of improved efficiency and that investment decisions have to be based on sound information and evidence.
The introduction of the service planning framework has provided an opportunity to enhance the way in which health services are planned in terms of addressing changing needs and ensuring the best possible quality of care is provided for the resources available. This is a major advance in the health system, linked as it is to statutory accountability.
Last year saw a set of performance indicators conjointly agreed between the health boards and the Department being put in place to enable better performance and accountability in the delivery of health board service plans. These indicators will be built on in moving towards a stronger focus on performance at all levels in the health system. A high level steering group and project team made up of representatives from the Department of Health and Children and the health boards were recently established to further develop and enhance service planning and performance measurement in the health service.
This framework provides a foundation for further reform but it needs to be enhanced. In isolation it cannot achieve the order of reform necessary to really improve overall system functioning. Much more needs to be done.
One of the issues which came to the fore during the consultation process on the health strategy was the complex structure of decision-making, roles and responsibilities within the health system – many involved in the national consultation process which led to the strategy commented on this. Other issues included the many layers and intersecting roles, and the lack of consistency in the development of systems and the application of schemes.
It has to be acknowledged that the present structures in the health system evolved from a model developed over 30 years ago. During that time the size, range of functions and complexity of managing the system have all grown dramatically. There have been significant enhancements to the original health board model through the Health Acts 1996 and 1999 as well as considerable changes to the internal structures of the Department of Health and Children and the health boards. A number of new advisory and executive bodies have also been established in recent years.
One of the main conclusions in the strategy was that while the system had served us well in many respects, some significant concerns remained. These include the need for stronger co-ordination and integration of functions and services; greater consistency in access to and delivery of services; and greater clarity around levels of decision-making in the full range of organisations, particularly, vis-à-vis the role of the Department and the requirement for “whole system” effectiveness.
A number of strands of reform are being formulated in respect of the health system – first, the undertaking of an audit of structures and functions in the health system, to which there is a commitment in the health strategy. The audit will also deal with the commitments in the strategy in relation to the establishment of a national hospitals authority and a health information and quality authority.
A second strand of analysis relates to the work of the national task force on medical staffing. This review is concerned with preparing a plan for the medical staffing of acute hospitals based on the recommendations of the report of the medical manpower forum in 2001 and the report of the national joint steering group on the working hours of non-consultant hospital doctors in 2001. Part of its work is concerned with examining the practical implications of moving to a consultant-delivered hospital system that would dramatically change and improve the quality of service to patients. This is likely to include reference to the future configuration of hospital services – in other words, deciding which hospitals will provide what services in a consultant-provided context.
A third strand of reform to be drawn together with these two is the work of the commission on financial management and control systems in the health system being undertaken on behalf of my colleague, the Minister for Finance, who established the commission, on which the Department of Health and Children is represented.
I will elaborate on the work in relation to the audit which is now at an advanced stage. Action 114 of the strategy was intended to support organisational development in helping to clarify roles and co-ordinate the work of different organisations. Specifically, the audit was commissioned in order to ensure clear lines of accountability and communication between each part of the system; no overlap or duplication between organisations; and a proper alignment of the structure as a whole to the vision and objectives outlined in the strategy.
The outcomes sought are to ensure the structures in the system are the most appropriate and responsive to meet current and future service needs; constitute an adequate framework for overall governance of the health system; achieve an effective integration of services across all parts of the system; adequately represent the views of consumers in the planning and delivery of services; and focus on the principles of equity, accountability, quality and people-centredness and the national goals of the strategy.
My Department commissioned Prospectus Strategy Consultants in June 2002 to undertake the audit. The preliminary response of the consultants was to identify the need for the consolidation of structures within the health system. It is important to acknowledge that the findings and recommendations of the consultants must be considered in the context of the considerable achievements of the system I have just outlined. These achievements are an indication of the commitment at individual, professional and corporate level within the system. It is important to be clear that the findings relate to systemic problems and in no way reflect the considerable expertise, skill and dedication of the workforce.
In summary, the consultants found a number of barriers to achieving the improvements sought in the strategy. They also identified the need for strengthened frameworks for governance and accountability as well as the need to develop and enhance supporting processes to secure improved planning, integration, delivery and evaluation of services.
While a final draft of the report is pending, it is already clear that the need to significantly reform the existing delivery structure will be put forward as a major proposal. This will include the development of a unitary delivery system involving considerable consolidation of existing agencies; the configuration of services into two broad pillars, one centred on acute service delivery and the other on primary, continuing and community care; and the development of large-scale shared services. This unitary system is being advanced as the most appropriate way to support the individual strengthening of each pillar within the system, while at the same time providing for a more structured approach to integration processes.
The proposals also include the development of an improved system of governance and accountability which clarifies and creates appropriate boundaries between the delivery system and the Department of Health and Children. This is intended to allow the Department to focus more actively on its role in policy development, population health planning and the monitoring and evaluation of the impact of the delivery system on health status. The proposals emerging will support the commitments made in relation to reform of acute hospital services and the likely changes required, in terms of configuration, anticipated in the health strategy. They will provide a more adequate unitary approach to the delivery of hospital services which, in turn, will support the more even and consistent introduction of consultant-delivered services.
It would also be imprudent to suggest that the gains from changes in system structures and function changes can be achieved without continuing investment in the health system. There are several reasons for this, the principal one being that healthcare is expensive. We need only look at the increased frequency and volume of MRIs in recent years as a classic illustration of technological advances in healthcare There are also an ageing population and higher levels of public knowledge and expectations, combined with pay and non-pay inflation, which make it expensive just to stand still. From a cost viewpoint, there is a cruel paradox in the fact that the more successful the outcome, the more expensive it gets. When we appoint an oncologist, the service will improve and the treatments increase, as will the expenditure. That is what is happening in many of our acute hospitals.
Important factors to be considered include demographic projections for Ireland which suggest that by 2011 the population aged 65 years and over will have almost doubled to an estimated 767,300 and constitute 16.4% of the population. This is a factor of major significance in planning for the provision of acute hospital services.
Demand for health care is increasing as a result of better education, increased expectations, economic prosperity and technological advances in health care permitting earlier and improved diagnosis and treatment. Many successful medical interventions are now made in middle years, yielding longer life expectancy but also, typically, dealing with the onset of further illness later in life.
The need for continued investment relates to the current deficits in the system which must be improved to achieve the changes we seek. Hundreds of millions of euro have been invested in developing infrastructure under the national development programme –€2 billion has been committed between now and 2006. Notwithstanding the significant funding of capital projects in recent years, there is still significant investment required to upgrade facilities such as the Central Mental Hospital, Our Lady's Hospital in Crumlin, radiotherapy services and a variety of other facilities, especially those providing care for older people.
The full development of information and communication technology capability is identified as a prerequisite to improving monitoring and evaluation of services, improved health impact assessment, and, in turn, better value for money. Report after report has identified this as a major system deficiency. There is a need for up-front support of structural reform of the nature being contemplated. A national reform programme will result from the current proposals and that will also require investment. We must continue to invest in the system if we are to keep pace with the changes and at the same time deliver the potential yield from the radical restructuring of the system.
The Government is committed to taking early and decisive action on reform of management structures and financial accountability. The first stage is the finalisation of the two key reports, the audit of structures and functions and the report of the commission. The Minister for Finance and I will be submitting the reports to Government for decision in an integrated manner.
I am confident that there are gains to be made from a radical restructuring of the system in terms of efficiency, effectiveness and value for money. The proposals now being advanced, however, are a considerable challenge to everyone in the system. I will not understate the enormity of the task ahead. There are no quick fixes for the change we envisage undertaking in the coming years. In addition, I must reiterate that the potential of the system can only be realised if we continue to invest as we reform.