I thank the Chairman and members of the committee. I welcome the opportunity to set out some of my views on the future direction of health policy. We all know the challenges that we face in the area of health and that these issues have been with us for many years. We also know that it takes time to give effect to reforms in the health service. I believe that, for a variety of reasons, there is a certain amount of reform fatigue, one of which is certainly the absence of a long-term plan founded on the consensus necessary to have confidence in its delivery. That is why I was so strongly supportive of the commitment in the programme for Government, the commitment of all parties in the Dáil and, in particular, that of the Chairman, Deputy Róisín Shortall, to establish this committee to avail of the considerable advantages in having broad political consensus on the strategic direction of reform. Of course, the Minister of the day has responsibility for setting policy and should be and is accountable to the Dáil. However, if we can achieve consistency of approach at a high level for a period of years, we can improve the position for patients, their families and the many dedicated staff who work in the health service.
I await with great interest the outcome of the committee’s deliberations. As members know, there are certain issues such as those related to system governance and the finalisation of a five-year HSE service plan, mentioned in both the confidence and supply agreement and the programme for Government, on which I have deliberately not moved until I have the benefit of the committee’s work. However, I have now been Minister for the best part of a year and have a strategic perspective on these and other major issues which I would like to share with the committee in the hope that it will be of assistance. Genuinely, it is in that spirit that I am here. While I wish to share my views and perspectives, what is most important to me and all members of the committee in the work they have been doing is that we arrive at a political consensus. For what they are worth, these are my views, but reaching political consensus is of paramount importance.
The report of the committee and the work that will follow will be significant for the country. This is the last chance for a generation to get it right. We all know the compelling reasons we have to make the most of this chance. I will elaborate further in the course of this statement on each of the priorities which I believe need to underpin the future direction of health policy, but, broadly, they include a shift in the model of care towards more comprehensive and accessible primary care services; an increase in health service capacity in the form of physical infrastructure and staffing to address unmet needs and future demographic requirements of citizens; exploiting the full potential of integrated care programmes and eHealth to achieve service integration based on the needs of patients across primary, community and acute care services; strengthening incentives for providers to respond effectively to unmet health care needs by ramping up activity-based funding; empowering the voice of clinicians and providing them with opportunities to contribute to the management of health services; further developing hospital groups and community health organisations, aligning them geographically and, as they develop, devolving greater decision-making and accountability to them; following this with the provision of a statutory basis for hospital and community health organisations, operating as integrated delivery systems within defined geographic areas; and, once statutory responsibilities and accountability have been devolved from the centre to hospital and community health organisations, dismantling the HSE and replacing it with a much leaner national health agency. In the interim, because we cannot wait for all of this to happen, we need to reform the existing legislation within which the HSE operates to improve its governance structure.
It is important to place Ireland’s experience of health service delivery within a comparative international context and take a long-range view. That is not to say, however, that we can simply adopt another country’s health service, but through comparisons we can learn about ourselves and our strengths and weaknesses. In the past, attempts have been made by reputable international bodies with health expertise to rank health systems. I have referenced a number of comparative exercises in my full statement which I will take as read.
First, we compare well on health status. In particular, life expectancy has increased by five and a half years over the past two decades in this country. Second, we have relatively high levels of reported unmet needs and the main reason for this is the cost of health care. I believe this is confirmed by our own experiences as public representatives. The biggest challenge facing our health service relates to coverage and access.
Over the past few months, I have made no secret of the frustration that I felt, and I am sure members of this committee feel, at some of the problems our fellow citizens face in accessing health and social care. I say health and social care because problems of access are not confined to surgery or unscheduled hospital care. Access is also an issue in respect of community-based services.
In line with the key theme that has emerged from this committee’s consultations, I believe we must find a way of bringing about significant improvement in access. We should do so without losing focus on other crucial goals such as patient safety, efficiency and cost-effectiveness. The overarching objective must be population well-being and disease prevention or what we now refer to as the healthy Ireland agenda.
In devising a strategic way forward, we must also have three other factors in mind. First, every country faces challenges in this area. As we live longer, as technology changes, as new treatments are developed, and as people’s living standards improve, the demand on our health service will probably always challenge the level of provision. At any given point in time there will always be limited resources available. That is just a reality and a statement of fact. I think we will all agree that we need to do better than we are doing at present. To do so, we must have better systems in place to guide us in setting priorities and allocating finite resources. Over the next decade we need to get past the stage of constant firefighting to a place where we can have a mature debate on how to set priorities and where to develop our services.
The second point I would make is we are not starting from a blank page. It is always tempting to sketch the perfect system on a blank piece of paper but health policy is not just an academic exercise. It is about trying to develop, reform and build a system while at the same time providing services day in and day out to the people who need them. That is part of what makes this a unique and demanding challenge.
The third point I would make is that there are many disparities in the way in which we, as citizens, experience health care. Health inequality is a major issue. It will become even more marked in the years ahead unless we find ways to serve all of our people better. This will require us to pay greater attention to addressing differences in access and outcomes as a central part of ongoing performance evaluation and to work with other sectors, nationally and locally, to address underlying social issues that impact on health and well-being.
I mentioned at the outset that I have not moved ahead with structural change or changes in HSE governance in deference to this committee's work. I am not a believer in structural change just for the sake of doing so and it has not proved a panacea in the past. However, if our structures are not best serving patients, then change they must. I must stress that when I talk about HSE structures not serving patients or others in need of services, I am not talking about HSE staff. In fact, I know from my interactions with staff that they suffer negative impacts by structures that place too many layers between health service leadership and front-line staff.
Just as important as the design of structures is how we bring them into operation. Improving a system while simultaneously delivering services places a premium on a planned approach. For example, this requires the development of the actual capability to discharge functions before they are transferred or devolved to another. A benefit of a ten-year horizon is that it provides a context for carefully planning the evolution of structures so as to avoid unduly disrupting the primary focus on improving care delivery.
The key entities for managing service delivery that are now in place in the Irish health service are hospital groups and community health organisations. These are at different stages and both require significant further development. This will bring decision-making closer to the point of care delivery and will provide a counterweight to the over-centralisation of decision-making and accountability that impedes service responsiveness.
I am convinced that hospital groups and community health care organisations, CHOs, should be geographically aligned. Due to considerations of specialism and critical mass, hospital services generally require to be organised across larger populations than community services. Therefore, I do not believe that in the first phase it is necessary to have the same number of hospital groups and CHOs but a hospital group should ideally cover the same geographic area as one or more CHOs. Having hospital groups and CHOs operating on this basis will facilitate collective performance and accountability arrangements based upon pre-agreed and shared goals, budgets and incentives.
The next stage would be to provide a statutory basis for hospital groups and community health organisations. Rather than do this separately, it is my view that we should legislate for integrated delivery systems within defined geographic areas that, for now, I might refer to as hospital and community health organisations. What I am outlining here is a clear journey towards a more devolved, responsive and integrated delivery system, although I acknowledge it will require time and careful planning. An integrated approach will enable us to move beyond the silo mentality and structures that often exist in the delivery of current health services.
My Department is on the record as saying that the current HSE directorate governance arrangements, as set out in legislation, need to be reviewed. While this committee is developing a ten-year vision for the health service, and this may, I would imagine, and I hope will result in significant change, including legislative change, in a number of phases, I respectively suggest that more immediate improvement in existing national governance arrangements is merited. Subject to the committee’s report, I intend to ask my Department to come forward with proposals to improve governance arrangements for the HSE for so long as the HSE continues in its current form. This will include examination of the current vesting of governing authority in the HSE directorate, including the fact that the director general is currently responsible to the directorate for the performance of his or her functions. Many members of the directorate, however, are actually subordinate to the director general. We really need to take a new look at this matter. I do not think we need to wait for the end part of a ten-year strategy to move ahead with this matter and I hope that we can develop a political consensus on that. However, with the development of stronger, more accountable and geographically aligned providers, the opportunity will arise to begin to more fundamentally consider organisational arrangements at national level. The overall HSE project initiated in 2005 can be legitimately criticised in a number of areas but the need for national arrangements for planning and sharing of expertise and services for a population of less than 5 million people cannot.
We have gained much in recent years through national initiatives in areas such as the cancer programme, the integrated care programmes, the fair deal scheme, eHealth and other areas. We need to retain such capability and avoid reverting to stand-alone geographically based organisations in the mould of the old health boards. However, the national health capability that takes the place of the HSE is likely to be a much slimmed down body. In my view it is likely to be more equipped to lead than to directly control and, accordingly, with fewer management layers between the top and the front line.
There is also a question as to the respective roles of such a body and the Department of Health. In some countries of not dissimilar size, such as Scotland, the Department itself commissions services from regional providers but in others, an organisation at a remove from Government of the day, and the Civil Service, plays this role nationally. I genuinely have an open mind on the question of where such a national agency should sit in terms of the Department. I would appreciate input and guidance from the committee in that regard.
The challenge in any set of proposals is to devise a clear set of principles and a framework of accountability that ensures better and more rapid decision-making and responsiveness. They must also fully recognise the demands of parliamentary accountability.
I am sure all members are familiar with the demographic and epidemiological challenges this country faces. These challenges are common to the vast majority of developed economies. I shall not go over this matter in detail this morning, although I have elaborated a little further in my full speech that has been circulated. As things stand, the annual increase in the number of people over the age of 65 in Ireland is approaching 20,000. The overall number in this age group is expected to increase by more than 36% between 2016 and 2026. What this all means is that the nature of the demands that the health service must provide for has changed. Today, the great challenge is the management of chronic disease. These are long-term conditions that can be treated but not cured. In some respects, chronic disease is simply a feature of living longer but in many other cases the onset of disease is influenced by lifestyle factors such as diet, exercise, smoking and alcohol consumption.
As chronic diseases are often managed rather than cured, this shift in the burden of disease requires a shift in the way that health care is conceived, provided and managed. Traditionally, health services have been structured to provide episodic care but we now need a far greater emphasis on continuous care. That is why the World Health Organization has placed so much emphasis on the development of person-centred and integrated care, which is care that is organised around patients and not just around groups of conditions or around health facilities such as hospitals.
Ireland faces particular problems in meeting this challenge because, historically, our health system has been highly hospital-centric with a comparative underdevelopment of primary and community-based services. In effect, the challenge we face is to develop a new model of care that is better suited to the needs of our population now and into the future. We need our hospitals to work more effectively, we need to develop primary and community care and we need all of the components of the system to work in a more integrated and co-ordinated way.
Many of the necessary features of the new model of care are already apparent and some are already being put in place. First, because chronic disease is related to lifestyle, we need to drive ahead with the healthy Ireland agenda.
As a country, we have made considerable strides in tobacco control, and there is a growing consciousness of the need to have healthier diets and take more exercise. However, we cannot be complacent; we must drive ahead with implementation of our strategic approach. This includes public health measures targeted at discouraging harmful levels of alcohol consumption.
Second, because chronic disease is continuous, care and management of patients with these diseases must also be regular and continuous. It must begin with better information and self-management but must also be provided and supported to a far greater extent through primary and community care. I know this is an area that has been discussed in detail as part of the committee's deliberations. The programme for Government seeks to achieve this decisive shift of the health service to primary care with delivery of enhanced primary care in every community. I suggest that this is not a politically contentious point because both Government and Opposition have supported this goal over recent decades. However, successfully implementing such a strategy is not as straightforward as saying we support it.
As we look to develop more comprehensive and integrated primary care, we need to consider the challenges which experience has shown us we are likely to encounter. Achieving a high level of teamwork across diverse professionals with different employment and contractual relationships, priorities, cultures and approaches has proven to be challenging. It has not always been easy to combine the efforts of salaried HSE staff and general practitioners paid through capitation for medical card holders and fee per visit for others. Coverage and eligibility have also been issues. For example, how can the role of primary care in population health, disease management and hospital avoidance be fully realised when the State's financial support is predominantly concentrated on paying for access for the one third of the population on the lowest incomes? Also, in introducing improved primary care facilities, we now have examples of very successful primary care centres but we have faced problems in some areas with GPs locating in such centres.
While these challenges are closely related to our existing organisational, contractual and eligibility arrangements, all health services seeking to promote primary care face the twin challenges of achieving successful team-based, multidisciplinary working and enhancing the status of primary care professionals within the overall health service. Let me be clear: despite these challenges, augmenting primary care services is central to any successful strategy to address health care needs and to promote population health. I will be very interested to hear the committee's considered views on how the vision of enhanced, more integrated primary care can be achieved and the challenges in doing so overcome.
I suggest we can build upon important developments in the primary care arena in recent years. These include the extension of eligibility for GP cards to children under six years, the development of the diabetes cycle of care and the ongoing investment in the physical infrastructure of our primary care. Over the next ten years, however, we will have to significantly expand the scope of our ambitions as to what can and should be delivered in a community and primary care setting. This will involve investment in people, buildings, diagnostics and training as well as, crucially, expanding the scope of eligibility for primary care services on a phased and prioritised basis, taking account of resources and capacity within primary care. If we do not address this, we will continue to have a primary care system whereby the State's crucial link is to provide cover for a third of the population but not to provide financial support for the other two thirds.
As the committee is aware, we are at the early stages of negotiation of a new contract for GPs. This is an important piece of work but is by no means the only element of the transformation we must effect.
My Department will shortly launch a consultation paper on the future development of community nursing. In line with the recently concluded proposal put to both the INMO and SIPTU, we are planning to introduce new advanced nursing posts operating across primary care and acute hospitals. These initiatives have the potential to support the delivery of multidisciplinary care, including active case management, through the introduction of greater nursing expertise in the community that until now has been located solely in the acute hospital setting.
We are also undertaking a significant programme of work in the area of home care. We will launch a public consultation process in the coming months to allow those who have views on this issue to have their say, most particularly older people and their families. We need to provide much better access to home care and we will seek to bring as much certainty to this access and the associated financing arrangements as we currently have for nursing home care.
We must also consider how services which are currently hospital-based can be deployed in community settings. Community intervention teams and the maternity strategy are two good examples, and there is a little more on both in my full written statement.
Hospital groups will enable better configuration of hospital services with benefits in respect of safety, quality, access, cost and sustainable medical staffing and recruitment. Hospitals working together will be able to support each other, providing a stronger role for smaller hospitals in delivering less complex care and ensuring that those who require critical emergency or complex planned care are managed in larger hospitals.
The evidence for how hospital services should and can be organised in a manner that achieves quality and sustainability is now being confronted by health systems the world over. Medical technology and practice and global competition in training and retention of highly skilled health practitioners are all reshaping our hospital services. However, as politicians, we have on many occasions been hesitant in interpreting and reconciling these unavoidable factors with the existing understanding and expectation of the public we serve.
We cannot simply rely on clinicians to explain to the public how the reality of hospital care is changing and set to change further, not just in Ireland but in every health service committed to achieving above all else excellent patient outcomes. The committee had the benefit of hearing from the very eminent professor Tom Keane, who contributed so much to the progress we have made in cancer care. Professor Keane gave very well-deserved credit, in my view, to the political leaders of the time who initiated and provided crucial support for these reforms. Such credit is overdue because some of these political leaders were at the time the subject of unrelenting criticism in this House and outside from a range of political parties, including my own. I believe the committee, through its final report, has an important opportunity and, I would respectfully suggest, a duty to explain these developments so that future Ministers for Health have greater support than heretofore to do the right thing on the basis of sound health policy. In the era of "new politics", without such support, the change necessary to deliver ambitious improvements in our health service as envisaged by the committee risks being severely hindered. The recently completed report on the Northern Ireland health services, called Systems, Not Structures, summed up the challenge as follows:
The choice is not whether to keep services as they are or change to a new model. Put bluntly, there is no meaningful choice to make. The alternatives are either planned change or change prompted by crisis.
That is the view in Northern Ireland. I believe the setting up of this committee was a vote for the former on our part.
I talked earlier about the importance of comparative analysis of the strengths and weaknesses of the Irish health service. The extent to which public and private are interwoven in our health system is one of its most distinct and sometimes controversial aspects. Our publicly funded hospitals deliver care to both public patients and private patients. As far back as 1999, in the White Paper on Private Health Insurance, the potential drawbacks to this mixed system were outlined and these concerns expressed. Nevertheless, in the interest of putting all the facts on the record, the White Paper also identified certain advantages of the coexistence of public and private practice in public hospitals. These are set out in my full written statement. In the intervening period, concerns about the allocation of scarce public hospital resources to private patients have grown. This is partly attributable to the heightened concern about access for public patients generally. It may also be indirectly influenced by the growth in private health insurance coverage from 1.5 million people, or 42% of the population, in 1999 to 2.1 million people, or 46% of the population, in 2015. Over the intervening years, there have been proposals to eliminate private practice in public hospitals entirely on the one hand and, on the other, through mandatory competitive private health insurance, to extend private insurance to the entire population. Whatever the direction of change, it requires careful consideration as it is likely to have a very extensive implication for hospital costs and resourcing as well as contractual and remuneration arrangements for hospital consultants. Other more detailed aspects of current arrangements are worthy of consideration, including the misalignment of financial incentives, as between public and private patients. At the moment, public hospitals receive a block grant for public patients and a per diem rate for private patients.
Movement to activity-based funding for public patients will see public activity remunerated on a per-case basis. It would make much sense and is certainly worthy of consideration in this context to introduce a case-based charge for private patients and to equalise the tariff for public and private patients based on the efficient economic cost. This would eliminate a concern expressed by many that the hospital would have an incentive to accommodate more private patients. Full alignment of incentives would also require a movement away from fee-for-service payments to hospital consultants for private patients towards an annual remuneration inclusive of both public workload and the permitted and planned level of private activity.
I offer these as examples of how the detail of any change proposed in current arrangements will need to be thought through carefully because of provider issues, not least the fact that almost half the population has private health insurance and very many people with such insurance currently receive their care in public hospitals. Wherever the political consensus lands is appropriate, but we do need to make those decisions in the context of these facts.
Wider consideration of incentives suggests that the introduction of stronger provider incentives for responsiveness and productivity can assist in addressing the widespread concern about access issues.
A strength of our primary care system compared to some others is that there are generally no delays in accessing GPs, although there can be issues in some parts of rural Ireland and some deprived urban areas in this country. The responsive nature of general practice owes something to the strong financial incentives under the capitation-based choice of a doctor scheme for medical card holders and the fee for service for private patients.
In contrast, the traditional block grant approach to hospital funding entails very weak financial incentives for productivity.
I hope the committee will concur that activity-based funding should continue to be used to promote stronger performance incentives for acute providers. Much of the technical work is now in place to allow activity-based funding for hospitals to be significantly ramped up over the period ahead, with further work potentially undertaken to incorporate measurement of quality and appropriateness.
A crucial aspect of quality and appropriateness is integrated care. As we change hospital services and strengthen primary and community services, we will be challenged to ensure services are designed around patients, rather than the institutions that provide them. Across the world, health services are grappling with the question of how services can be integrated in order that patients' needs are managed holistically and in as seamless a manner as possible. This will not be easy to achieve - there is no magic wand for integration - but we are working to find the right path for the future. In this regard, I refer to the integrated care programmes. As members will be aware, the HSE is developing a number of integrated care programmes, which are focused on piloting new ways of working within the health service. The integrated care programme for older people has put in place a number of local initiatives on pilot sites. The integrated care programme on chronic disease is developing four projects which include asthma, chronic obstructive pulmonary disease, COPD, heart failure and diabetes models of care, again focusing on multidisciplinary teams. As insight is gained from these projects, translating those lessons into the broader health service will be one of the big concerns of the next decade. The integrated care programmes are a great example of the benefits of clinical leadership in reshaping our health services.
As a society, we greatly value clinical judgment in relation to our personal health and that of our family. It flows from that value that we must ensure we empower the clinical voice within the health service and facilitate a greater clinical role in health service management. Clinicians in management roles should not be the exception to the rule but rather one of the legitimate options for management of our hospitals and health services. This will involve the development of a range of opportunities and pathways for clinicians to get involved in management. I am struck, when visiting health services, by the palpable frustration of clinicians who feel their voices are not heard in hospital decision-making structures.
A significant amount of the work done in the health service consists of collecting and using information, yet the health service is a long way behind other sectors in society in using information technology. I am aware the committee has given this matter serious consideration and we are making progress on the individual health identifier and electronic health record. A clear strategy and programme of work are now in place and I look forward to these interacting with the outcomes of the committee's deliberations.
I refer again to the issue of capacity. I have repeatedly made clear that increasing capacity is a priority. This includes physical capacity, the staffing capacity to support this and harnessing untapped potential in the system. My Department is managing a large capital programme, much of which involves the necessary replacement and upgrading of existing buildings, rather than adding to the capacity of the system. This is an unfortunate consequence of the age of our health service facilities. While managing this problem, we must also address the question as to what is the level of capacity required into the future, which is the reason my Department is working on a capacity review. Unlike previous reviews, this capacity review will extend beyond acute hospital beds and will examine issues such as the provision of additional capacity in primary and community care. This is the right approach which is also in tune with the thinking emerging in the committee. While we need to have a view on capacity, it cannot be divorced from the need to shift the model of care that is more integrated and continuous, person-centred and delivered at the lowest level of complexity consistent with patient safety. It misses the point to argue that more hospital beds are the exclusive answer. It is within this context that the capacity review will be undertaken.
I am also on record as stating there is no point in increasing physical capacity if we do not have the necessary staffing. I acknowledge the intensive efforts of staff, management and the HSE who work daily to ensure those in need of services receive the highest possible quality of care. I am acutely conscious of the challenging staffing environment our health services are facing. Many initiatives are under way to improve staffing levels and we will continue with these efforts. Increasingly, we operate in a highly competitive market for attracting and retaining many health professionals who are in short supply globally. This is obviously relevant in assessing both pay and tax rates. However, it also means we must enhance the attractiveness of the work environment with ongoing learning and career opportunities. In return we should expect approaches to flexibility and change which are comparable to those demanded of health professionals in other health care systems, both abroad and in the private sector. All of this will be required to achieve the vision set out on the establishment of the committee. Whatever our direction of travel, the capability of our health workforce - health professionals, administrative staff and managers - will be essential to the success of the committee's proposals.
While I appreciate I have covered a wide agenda at some length, it is difficult to do so in a shorter time. Having followed the work of this committee for a sustained period, I wanted to share with members my insights from my perspective. The work of the committee to date has highlighted the considerable consensus around some of the key building blocks and we can all accept that this will require transformational as opposed to piecemeal change. The challenge for the committee now is in determining the implications of each of its recommendations, what can be achieved realistically in the time period and in what sequence. This involves prioritisation and, where progress will be resource-dependent, consideration of cost. This is no small ask but, through success, the committee will provide the reference point for successive Governments and Dálaí in implementing real change in how members of the public experience health services.
I wish the committee well in its final deliberations and, once again, I offer it my continued assistance and that of my Department as it finalises its work. I sincerely thank the Chairman and members of the committee for the non-partisan and dedicated way in which they have gone about their work to date. This is also the way in which I try to go about my work. I thank members for the opportunity to present my views today.