Dáil Éireann díospóireacht -
Thursday, 29 Sep 2016

Vol. 922 No. 3

Report of the Committee on the Future of Healthcare: Motion

Deputy Róisín Shortall

I move:

That Dáil Éireann shall consider the Interim Report of the Committee on the Future of Healthcare, copies of which were laid before Dáil Éireann on 4th August, 2016.

It is a great pleasure to present the interim report of the Committee on the Future of Healthcare. This committee had its origins in a motion passed by the Dáil on 1 June last. It was a historic motion. While health is a matter of concern to every Member of the House, and they represent the concern of the community, I am not sure if at any stage we, as representatives of the public, have come together to decide on the best type of health system the country can have to meet the needs of the people. In many ways, our health system has developed in an ad hoc manner since the foundation of the State. We have never taken an objective view of its strengths and weaknesses and where it should go in the future.

The purpose of the motion agreed by the Dáil on 1 June was to recognise the fact that there are serious difficulties in the health service. Given the spend on the system, a total of €19 billion, it is certainly not providing the type of modern accessible service we should aspire to have. A big element of that is the nature of the service and the fact that it is a two-tier service which is very expensive for everybody involved, be it the 46% of people who are paying for expensive health insurance or the more than 40% of people who are public patients and are left waiting for long periods to access services. That is the backdrop. We are all conscious of the shortcomings in the health service. I believe there is a genuine shared aspiration to do something worthwhile to make our health service fit for purpose and to take the key strategic decisions which will enable us to move from the current somewhat dysfunctional two-tier health service, with all of its problems, to having a modern, accessible, single-tier health service. That is the desire of every Member of the House and it reflects the desire of the public which has expressed its views very clearly not just in the last election but also in several opinion polls over the years and through contacts with public representatives. People strongly feel that a good functioning health service is key to a modern republic. That is what we must achieve for this country.

That was one of the key provisions of the motion passed by the House. It sought to develop a consensus at political level on the future of the health service and the funding model, based on population health needs and the need to establish a universal, single-tier health service where patients are treated on the basis of health need rather than ability to pay. The motion also recognised that the best health outcomes and best value for money can be achieved by reorienting the model of care towards primary and community care, where the majority of people's health needs can be met. We determined that the Oireachtas would work to establish a ten-year plan for the health service, based on political consensus, that can deliver all of those changes to achieve a modern reformed health service.

The committee was established on foot of that motion, with 14 members drawn from all parties and groups in the House. From the start there was unity of purpose among the members and a clear determination and commitment to work together as best they could to put together a strategy for a ten-year plan for the health service, recognising all of the challenges involved but also recognising the importance, once and for all, of coming together at political level, setting past political differences aside, looking at the evidence relating to best practice, identifying the problems and roadblocks to modernising the service and making it more accessible and considering in an honest and genuine way the best type of funding model that would deliver a single-tier, accessible, equitable and modern health service. I pay tribute to the 14 members of the committee. I am pleasantly surprised by the level of commitment displayed, the attendance at meetings, the work that members had to do aside from the weekly meetings in terms of reading the volumes of material the committee received and their real engagement in the complex issues involved in moving from the current system to a new and better system. I appreciate the commitment and enthusiasm of the members in that regard.

The committee was established on 1 June and held its first meeting on 23 June. We met weekly at the end of June and through July. Initially, we sought to have private meetings at which we were given detailed briefings from some of the main players. We received very good briefings from the Department of Health and I acknowledge the full co-operation and support of the Minister and his senior officials for the work we have undertaken. We received a briefing from the HSE. We are also conscious of the huge amount of research that has been done already, the policy papers that have been drawn up and the examinations of different aspects of the health service, both at international and national levels. Indeed, we are very much of the view that this area has been researched in minute detail over many years. What we must do now is take decisions at political level and move into the implementation phase of what needs to be done to reform the health service. A vast amount of research has been done already.

We received briefings on much of that research from the ESRI and the Department of Public Health and Primary Care, Trinity College Dublin.

We were also very conscious of the project management role that is necessary. It is not just a case of producing a report. It is about implementation. How do we ensure we deal with those cultural issues within our health service that prevent us from moving ahead, modernising and streamlining the service and making it more responsive to patients' needs? Dr. Eddie Molloy has done a lot of work in the area of implementation and we are very conscious of the work he has done in the public and private sectors. We invited him in for a briefing session, which was extremely worthwhile. He got a spontaneous round of applause at the end of his briefing, which is a first in my experience at a committee. Members were very impressed by his knowledge of this area and his stressing of the importance of cultural change and commitment to implementation.

That is the work we did prior to the summer and it is referred to in the interim report. We began a public consultation process in July. We issued invitations for submissions from members of the public, service users, patient groups, people working in the health service, different professional groups and so on. The closing date was the end of August. We were very encouraged by the fact that we got some 160 submissions, which were very detailed and thoughtful. We also received requests from many people to meet the committee. Those submissions are being evaluated and summarised. The secretariat of the committee is working through them preparing them for the committee and making recommendations to us on which of those groups or individuals we should invite in to make oral submissions. We have taken a number of those decisions so far. After the August break, we went straight back into weekly meetings. Two groups of individuals or service users or representative groups come in and present to us every Wednesday morning. This has been really worthwhile. It has produced a huge level of thought-provoking activity in the committee and has challenged us all possibly to revisit some set views or preconceived notions we may have had. It has challenged us to learn from the evidence presented to us and in particular to learn from best practice elsewhere.

We have identified 11 different work streams at an early stage. They involve the future vision and strategic challenges involved in what we are doing; the funding model on which a lot of work has been done by the ESRI to date; the related areas of primary care, integrated care and chronic disease management, which are key; access to care; quality and safety; resource allocation, which is emerging as a very big issue; organisational reform; workforce planning; and the key issue of implementation and monitoring. I think I am speaking for all members when I say that we are determined that when we produce our final report, it will not be just another report on the health service. An implementation plan will be part and parcel of that. I hope the current Minister and future Ministers over the next ten years will subscribe to it and take it very seriously and that it will be the programme of work for future Ministers for Health.

In respect of the various groups that appeared before us before the summer, which is referred to in the interim report, our priority was to ensure the voice of patients and service users was heard. There are very loud voices in health, including very loud commercial interests. In some cases, one could even talk about vested interests. Too often, they are the voices that dominate. We said from the beginning that this is about serving the patient and that we were determined to put the patient front and centre of all that we do. That was the reason why our first public hearing involved the Health Reform Alliance which represented a number of different groups of service user representative bodies and which made an excellent presentation to us.

We have been meeting every Wednesday with groups since then. There is no doubt that to date, very common themes have been coming through. There is an extraordinary level of agreement across the board regardless of whether it involves service users, patient groups, professionals working in the area or researchers. There is a significant amount of agreement. I will very briefly run through those areas. They are the importance of the patient voice, inequality of access and the fact that we have a two-tier system, the geographical lottery that applies because of the unequal distribution of resources, moving from the hospital-centric model we have currently to putting far greater emphasis on health and social care within the community, the traditional under-resourcing of primary care where there are huge gaps not only in GP services and practice nurses but in other critical allied professionals who do such an important job at community and primary care level, access to diagnostics for GPs in particular where there is a sense that they are locked into a system where diagnostics are only available in hospitals, the lack of direct access for GPs and the logjams that creates, the question of multiple morbidities and ensuring that the next contract for GPs recognises the important role of chronic disease management - key to that is recognising the fact most people with chronic illnesses have multiple chronic illnesses and the need for a model of care that addresses to be reflected in the contract, staff shortages and the recruitment and retention of staff across the board which is a major challenge with morale emerging as a key issue because people do not feel valued in the service, and organisational structures which is an issue that is emerging as a significant problem relating to the organisation of hospital groups and the fact that we have six hospital groups and nine community health organisations that are not aligned and the difficulty that causes in terms of integration.

An Ceann Comhairle

The Deputy must conclude because we are quite limited in terms of time.

Deputy Róisín Shortall

This is a very brief overview of what we have been doing to date. There is excellent ongoing work and there is huge potential for political consensus in producing our report in the coming months. I pay tribute to the exceptional work done by staff supporting the committee in its work.

Minister for Health (Deputy Simon Harris)

When I spoke in the Dáil on 1 June last about the Government motion to set up the all-party committee, I said that I regarded this as one of the key health initiatives of the new Oireachtas. Four months on, I am even more convinced of the need for a long-term consensus on the direction of health policy. We can make, and I contend that we are making, improvements to our health system but the task that faces us is one that requires substantial and sustainable efforts underpinned by a long-term common purpose.

At the outset, I acknowledge the work being carried cut by the committee. It is so encouraging to hear the positive update, in particular the leadership role taken by Deputy Shortall both in the establishment of the committee and now as its Chair. I am genuinely excited about this project. I think we are on the verge of potentially achieving something really lasting in terms of our health service. Much work is already underway, as set out by Deputy Shortall and as set out in the interim report. I understand and am pleased to hear that there has been a large response to the committee's call for submissions. I have had the opportunity to read a number of submissions that have been sent directly to me and to meet with a number of groups that made submissions. The volume of submissions does say something about the huge level of interest in this fundamental societal issue.

The committee has set itself a very ambitious work programme. This includes work packages on the funding model, integrated care, resource allocation, access to care, primary care, chronic disease management, organisational reform and workforce planning, among others. I appreciate the breadth of this agenda and I do not think anyone in this House underestimates the challenging agenda that the committee has taken on. I reiterate my pledge to continue to support and assist the work of the committee in any way I can.

The central objective of the new Government, as reflected in the programme for a partnership Government, is to use the strengthening economy to make life better for the Irish people. As Minister for Health, that means improving the public services that people depend on and that really matter to families and communities across the country. We all know that the health service faces many challenges.

Moreover, the programme acknowledges that we now have an ageing population which, thankfully, is living longer and whose needs will become greater and more diverse. As well as an ageing population, we also have the highest birth rate in Europe. Most immediately, there are problems for patients trying to access services, whether from emergency departments or waiting lists, severe pressures on very dedicated staff and increasing demand and pressure on resources.

As citizens, all of us at some point in our lives will need to access health services. Therefore, we all have a common interest in finding a common way forward for improving and developing our health services. During debates of this nature, it is important to note that the health service has been changing and it would be only right to acknowledge where improvements have happened. For example, life expectancy in Ireland has increased by 2.5 years since 2004, to a place where it is now above the EU average.

There has been a decrease in the average length of stay in our hospitals and significant progress in reducing tobacco consumption. Progress has been made in many health areas and it is important to recognise that progress, along with recognising those who work so hard at the front line. I spent the summer visiting hospitals and other local health care facilities around the country and I was again struck by the many positive things that are happening but are rarely seen. The television programme "Keeping Ireland Alive" has gone some way to shine a light on the real story of health services in Ireland. It is a remarkable combination of skill, professionalism and care, often in extraordinarily difficult circumstances.

There are long-standing challenges that need to be addressed. Deputy Shortall outlined some of them. They include health inequalities and the geographical lottery. The Government and Oireachtas are clear in their objectives. We are committed to a goal of universal health care and working with others in the Oireachtas, in particular the Committee on the Future of Healthcare, to achieve the single tier health service that best suits Ireland.

The phrase "best suits Ireland" is key. We need to take account of the Irish context. In the past, we have considered the idea of lifting a model from another country. We do not need to do that do that. Rather, we need to do what is best for Ireland. While we can examine how others do things, we cannot simply transplant something that works somewhere else to here, nor does the health system in any country operate in isolation from the rest of society. Housing, education and employment are major parts of the universal health care equation. Therefore, this requires a whole-of-Government "health in all policies" approach and this is echoed in the healthy Ireland framework.

The committee has been established to allow us to reach consensus on an overarching vision and fundamental principles for the health system. There are three significant areas that need to be examined in this regard, all of which have been identified by the committee in its work programme. They are: the model of care; universal health coverage; and the funding model. Before we consider the financial implications of health care or how we manage it, we should first consider what kind of care we should provide and what the best model of care for the future is.

We can, and should, all support the need for a decisive shift within the health service towards primary care and the effective delivery of primary care in every community. The more intervention we can have for patients at the earliest possible stage and as close to home as possible, the more likely there will be a better outcome for patients. To do this, it will be necessary to build up GP capacity to respond to patients' needs and to expand chronic disease management in general practice. GPs want to do more and are able to do more but they need to be empowered to do so. That has to be the purpose of the GP contract negotiation due to begin this year.

We need to continue to embed social care and mental health and disability services within the community where appropriate and to support people to live as independently as possible. My view was echoed by the Chairman of the committee. There is a disconnect between the acute and the community and it is causing a problem. In terms of delayed discharges, there is a focus on acute hospitals and what we are doing about the pressures in them. Often, the solution lies in the community but a person in an acute hospital does not have the levers to release the solution in the community. That lack of integration is causing a real problem and adding to our delayed discharges in a very real sense.

The campaign of prevention and health promotion also needs to be continued and stepped up. I do not wish to be the Minister for ill; I am the Minister for Health. We all acknowledge that better integration across our health service is key to achieving a better patient experience, improving health outcomes and unlocking efficiencies within the system. In developing models of person-centred, co-ordinated care, we can draw on the work of national clinical programmes, in particular the piloted integrated care programmes.

Through the work of the committee, I hope we will be able to clearly articulate our desired model of care, the implications of moving towards it and how it can be achieved. I agree that we do not need a report to sit on a shelf. Rather, we need a model that we can get on with actually implementing.

The second area I have referred to relates to universal health care. As an overall goal to improve our health services, universal health care involves four main objectives, as set out by the World Health Organization, namely reducing unmet health needs, reducing inequalities in access to health goods and services, improving service quality and improving financial protection, which means patients must not face catastrophic or impoverishing levels of spending as a result of seeking health care. The WHO notes that no country fully achieves all the universal health coverage objectives for 100% of the population, 100% of the services available and 100% of the cost without waiting lists. However, it believes that every country can improve efficiency, reduce waste and increase value from its health spend. This is especially true in Ireland, where we know there are many challenges across the health system.

The Government is committed to a health service where all people can access the health services they need in an integrated and timely way, of sufficient quality to be effective, while ensuring that the use of these services does not expose them to personal financial hardship. Among the key building blocks for universal health care that are currently being advanced are the following important initiatives: the strengthening of primary care and improved management of chronic diseases; the creation of hospital groups and community health care organisations; implementing Healthy Ireland; the introduction of more efficient payment systems such as activity-based funding; the introduction of a wide-ranging package of patient safety reforms, which is a very important agenda; strengthening the ICT capacity within our health service; and the maintenance of a vibrant and sustainable health insurance market.

Work is progressing on these various reforms. As well as representing major building blocks for universal health care, they comprise important initiatives in their own right with the potential to drive performance improvement and deliver significant benefits in terms of timely access to high-quality care.

In striving for the optimal single-tier health service for Ireland, there are inevitable policy trade-offs to be confronted. These trade-offs often involve tensions between efficiency and equity or between comprehensiveness and cost control. In all countries, not only Ireland, the trade-offs centre on three basic dimensions of the health service which must be confronted when designing a health service. These are the proportion of the population to be covered, the range of services to be covered and the proportion of the total costs to be met. Through the committee, I hope we will be able to more clearly define our ambitions for universal health care and the means by which it can be achieved.

One of most important features of any country’s health service is how it is funded, in terms of the amount of money required and the manner in which it is financed. These are difficult questions to answer and will clearly be central to the deliberations of the committee. Making changes to funding levels and financing methods takes time and requires careful management, not least to avoid disruption to vital existing services. That is one reason it is important to take a long-term view, such as a ten-year plan, of how the health service can be developed.

I am not making major structural reforms in this area while the committee does its work, as we have to be serious about building consensus on how to fund a shared vision of universal health care. As a new Minister, my first step was to put the health service on a sustainable financial footing through an additional €500 million in funding. I have also met the HSE and all hospital group CEOs to stress that I want to see results for patients and management controls to stay within budget. This additional funding allowed new commitments to be delivered, such as an additional €40 million for home help services and €31 million for people with disabilities, restoration of the ring-fenced mental health budget and funding for the recently-launched winter initiative to address emergency department overcrowding.

While the committee deliberates on some long-term issues, life goes on and so does the health service. We have pressing challenges we must continue to work towards. My focus is on delivering practical, achievable improvements for patients and meeting key programme for Government commitments. The Ministers of State, Deputies Finian McGrath, Corcoran Kennedy, Catherine Byrne and McEntee and I have been putting in place a number of initiatives designed to create further improvements for our people.

I was glad to be able to launch an initial waiting list action plan this year and began reactivation of the NTPF with the endoscopy initiative 2016 to treat an extra 3,000 people, and reduce waiting lists and times in this area. I have confirmed plans to deliver more than 10,000 medical cards for children with disabilities whose parents are in receipt of domiciliary care allowance. The HSE published details of the winter initiative 2016-2017 which will increase the availability of community care, facilitate timely discharge from hospital and increase hospital capacity using an integrated care approach. I am especially pleased that we can do something under this plan to reduce waiting lists for orthopaedic, spinal and scoliosis patients.

The Minister of State, Deputy Finian McGrath, is establishing the task force on personalised budgets to empower people with disabilities to live independent lives. We have to move away from the unaccountable block grant system of delivering our disability services.

The Minister of State with responsibility for mental heath and older people, Deputy Helen McEntee, has established the national task force on youth mental health to improve the mental health and well-being of children and young people in Ireland. Crucially, the national patient safety office will be established in my Department this year. We are also co-operating and co-ordinating with other Departments to deliver key health commitments. A recent example is the Health Innovation Hub Ireland which I launched earlier this week in Cork and which is the first national innovation hub in the area of health in this State. It is a key element of the action plan for jobs 2016 and the programme for Government as well as being good for our health services. The action plan on housing and homelessness includes additional healthcare support services for people who are homeless, enhanced in-reach primary care services and additional funding to support the voluntary and community sector to make sure we are putting in place those wrap-around services that people who have been homeless need when they are housed. The Minister of State with responsibility for communities and the national drugs strategy, Deputy Catherine Byrne, has launched a public consultation on the new national drugs strategy which will be action based and published in January. Last week, the Minister of State with responsibility for health promotion, Deputy Corcoran Kennedy, and I launched A Healthy Weight for Ireland - Obesity Policy and Action Plan 2016-2025 which announced the intention to establish a healthy Ireland fund to allow for further joined-up working between Government Departments. Obesity is a ticking time bomb with regard to the health and well-being of our people. There is much more to do. However, these are important improvements already under way on which we can and must build.

Establishing the Committee on the Future of Healthcare was one of the first programme for Government commitments to be actioned and was one of the first motions before the House. I am very grateful to Members on all sides of the House who worked with me to allow the committee to be established without delay. It is important too that the process does not just create another report to go on the shelf - to echo the words of Deputy Shortall - but that it does actually lead to something tangible that we can all get behind, regardless of future governments or future election outcomes. Universal health care is not just something to implement, it is a direction and a journey. Ultimately, how far and how fast we proceed in the direction of universal health care is a question of choices and how we make them. In this regard, I look forward to the committee’s findings and recommendations, and the evidence on which these are based. The work of the committee will mean that members of the public, patients and those working in the health services can have a sense of certainty that there is a long-term strategy and vision agreed by political consensus, and I hope a societal consensus, about our direction of travel for a universal health service that will not change no matter what the make-up of the next Dáil. This is, I believe, an essential element that has been missing in reform efforts up to now and I look forward to working with people on this. We now have an unprecedented opportunity to achieve something that has never been achieved before in Irish health policy, namely, a long-term political consensus on fundamental guiding principles. As a nation, when we have set our mind to it, we have achieved great things such as the peace process and meeting economic challenges through the decades. We now need to decide, collectively, to work together to achieve that consensus and to meet that challenge in health. As Minister I will do my very best to work with all Members to make that consensus real.

Deputy Michael Harty

I thank the Ceann Comhairle for the opportunity to contribute to this debate on the interim report on the Committee on the Future of Healthcare. Deputy Shortall referred to the work of the committee and I also want to compliment the members of the committee. We have had a very positive debate at each weekly session on how we should go about changing our health service. I am a great believer that being in the right place at the right time is far more important than all the policy background decisions that one can make. We are in the right place at the right time. There is now an understanding of how we should move towards a universal, single-tier health service where people get care based not on their ability to pay but on their need. Putting the patient first should be kept on our minds whenever we are speaking about this because it is a health service for the patient and we should wrap the service around the patient, rather than the patient trying to accommodate to the health service. That is the way the service is currently going; it is an ad hoc service which tends to be self perpetuating. Many parts of our health service are working very well. We all tend to be critical of our health service when we see the accident and emergency trolley count and the waiting lists. The problem is getting in to the service. Once a person gets into it, the service works very well. It should be acknowledged that many parts of our health service work very well.

Rather than looking horizontally, we need to look vertically down on our health service in a bird's eye view to see what is happening, why is a patient in one place when they should be elsewhere or why is a particular system not working. Looking at it vertically rather than horizontally we should be able to see where the problems, the roadblocks and the challenges are. We have a great opportunity to drive change.

With regard to the political input into health care, as the Minister said at the committee this morning, there needs to be a political input into the policy of health care, but once the policy is devised - we hope we will have a ten-year policy - then it should be taken out of the hurly burly of political change such as the change of Government or the change of Minister. The plan should be there and it should be implemented irrespective of who is in government.

Time after time, the theme that comes though from each witness to the committee is the need to transfer from secondary care to primary and community care, particularly for chronic disease management. Secondary care should be a specialised service for complex and acute medicine. It should not be there to look after the day-to-day illnesses that people develop which should be looked after in primary care. We can keep people out of hospital if primary care is properly resourced. Once people go in to hospital the meter starts ticking. It is a hugely expensive way of looking after people. Coupled with resourcing of primary care we need also to integrate primary care with secondary care. Resourcing primary care on its own is no good as there has to be integration between it and secondary care. There needs to be a streaming of patients into secondary care in a constructive manner.

It is unfortunate that our accident and emergency departments are a catch-all for everything. Trauma, addiction, alcohol overdose and all the social problems that occur in our society end up in the accident and emergency department. Patients should be streamed away from the accident and emergency departments and into medical or surgical assessment units or to addiction or psychiatric services and the accident and emergency service could be kept for what it is meant to be. We need to integrate our services. Last week the committee spoke about integrated local care committees where GPs, consultants, management, nurses and all the various elements that go into supplying our services sit down as equals around a table and thrash out the problems. There should be no inequality in how we plan our service. That would be true integration of our services. I am a little worried about the community health organisations. They are coming from the top down and they have not been explained properly. We are worried that they may not be the answer to the integration of services; it should come from the bottom up with local integrated care committees. The role of community health service is that we want keep the majority of people in their homes. It is not just about GP services. Public health nurses, community intervention teams and all the other elements need to be bolstered within primary care to keep people out of hospital. This would allow hospitals to look after complex and acute cases.

We need to challenge existing work practices within general practice and in hospital services. There are work practices which, if they were streamlined and integrated with primary care, would act much more efficiently. It is important that the committee starts in the right direction. If we head off in the wrong direction we are going to be in serious trouble.

While activity based funding is important we need to move to a model of outcome based funding. Rewarding lots of activity which may not be productive is not the way to go about it. We should reward productive activity. The committee has also spoken about the inverse-care law where people who need health services most get them least and those who need them least get them most. In deprived rural or urban areas the services are not available to match the need while in affluent areas there are more doctors and GPs. I am not saying that those people do not also require health services but they are probably less in need of them than people in more deprived areas. We must consider how we populate our general practice and our health services in general with regard to supplying for the need rather than for the numbers of patients.

In general terms, there are a number of things we need to do to improve our health service. One of them is the recruitment and retention of staff such as GPs, nurses and senior and junior hospital doctors. We need to create a health service that attracts these people and keeps them in Ireland. We are producing fantastic health professionals but we are letting them leak away because they have trained in a service they do not like, is overburdened with work and offers no job satisfaction. They are leaving. We need to change that and to address it very quickly. We need to increase our bed capacity and to utilise our beds better. As the Minister suggested, delayed discharges are a problem. Shorter bed stays and people not being in hospital at all by being looked after in the community instead are solutions.

We need to increase access to diagnostics, which has been a very common theme in the debate. Diagnostics in hospitals tend to operate between 9 a.m. to 5 p.m. five days a week. We need availability to ultrasound scanning, CT scanning and MRI scanning seven days a week. It makes no sense that the diagnostic services close down on a Friday evening at 5 p.m. We need to bolster our diagnostics because it keeps people out of hospital. If we can diagnose a problem without sending people to a hospital service, we keep them away from the hospital and only send them if it is necessary.

As I said earlier, we need to alter our work practices. That is crucial in the integration of primary and secondary care. We need to streamline our practices in order that unnecessary work and duplication of work are not undertaken. Integration of primary and secondary care with nurses, primary care teams, community intervention teams, adequate home help hours and home care packages is crucial in taking people out of hospital and preventing delayed discharges.

HSE management is difficult to understand at times. It is convoluted, complicated, disjointed, opaque and difficult. We in the medical profession see decisions and cannot understand why they have been taken. The reason we cannot understand them is that we have not been involved in the process of making those decisions. Integrated community teams will get over that and iron out problems before they develop.

We need to develop and improve IT, which was referred to again yesterday. We also need to improve communication. We need to have access to patients' records in the cloud, as I referred to it this morning, in order that the GP, the hospital consultant, the junior doctor and the public health nurse, while taking data protection into account, can access a patient's record and maybe prevent unnecessary admissions to hospital and unnecessary access to diagnostics. Communication is the key on that.

This is a wonderful committee and when the report comes out in January, I hope it will be revolutionary in changing our health service.

Deputy Louise O'Reilly

I wish to start by thanking Deputy Shortall for proposing this committee. It was a good idea and the fact that it was embraced by people from all parties very quickly is a testament to that. Nonetheless, it did take someone to start the conversation. On behalf of myself and my party, I thank Deputy Shortall.

I wish to reiterate what I said only a few short months ago on the establishment of this committee. Sinn Féin is committed to the realisation of a world-class system of universal health care accessed on the basis of need, free at the point of delivery and funded by progressive taxation for the Irish State. However, as it was then, it still is now, my grave concern with this process is that the report, the recommendations, the expert opinion, potential models and stakeholder engagement will be discarded if it is seen to run contrary to the Minister’s agenda for health, as stated in the programme for Government. Can the Minister advise on whether this is going to be a worthwhile exercise? I hope that we are not tying members, stakeholders, academics and others into a process that will have a few days airing in the Dáil but ultimately end up being consigned to a library.

I note the Minister's comments on primary care being a building block and I would not disagree with him on that. While we are discussing the importance of primary care and the need to focus on it after having hearings about it, the bricks and mortar are going into primary care but the staff are not. The Minister, I am sure, will be aware that Sinn Féin has repeatedly questioned his Department and the HSE on this and they keep coming back with the same answer as to the number of additional staff that are going to be supplied for the primary care centres. It is a nice easy figure to remember: it is a nice big round zero every time. That is not good enough and does not fill me with hope that the report of this committee will be adopted.

Yesterday, our committee continued its hearings as part of our work plan and work stream. We were fortunate to have taken part in a video conference with Professor Allyson Pollock, who is an expert on universal single-tier health systems and who could draw on the experience of the NHS to point us in the direction that we should take our health system. One of the most striking points that she touched on was on the issue of hospital trusts, the various experiences in England, in particular, and how the establishment of these trusts may actually be detrimental to the establishment of a universal single-tier health system.

In that regard, I was struck by how her comments and warnings on these trusts needed to be heeded in terms of the programme for Government. To refresh Deputies' memories, some of the pertinent parts from the programme for Government document in this regard are:

We will advance progress made on Hospital Groups before strengthening their capacity to be stand-alone statutory Trusts. Hospital Trusts will gain greater autonomy (own their own assets, manage recruitment) while also ensuring accountability... Hospital Groups/Trusts will be required to develop strategic plans to re-organise services within their group of hospitals... We will provide for the temporary transfer of management of hospitals to another provider where there are consistently poor outcomes, patient experiences and financial management... Service providers who fail to meet their targets, and who do not fully engage with the new Unit will be obliged to use their own budgets to ensure targets are met with the assistance of private sector providers.

The Minister is smiling because he knows exactly what is coming next.

Deputy Simon Harris

I do.

Deputy Louise O'Reilly

Re-reading this after our meeting yesterday really set the alarm bells going in my head. In 1990 in Britain, the direct management of health services by health authorities was ended and replaced with purchasers and providers, turning hospitals into trusts with borrowing powers, their own finance, human resources and public relations departments. Good luck with that if the Government tries it here. Professor Pollock noted in her contribution that since the duty of the Secretary of State for Health to secure and provide comprehensive health care was removed, the rate of privatisation and closure of NHS services has been accelerating. This cannot be allowed to happen here. This is not how we build a foundation for a universal single-tier health care. It will do nothing only undermine it. Handing over control of our hospitals and services to stand-alone hospital trusts is a highly inefficient way of delivering health care and has the danger of introducing new costs that are not experienced in public systems. Performance, it is noted, will be key in these new trusts but the level to which this relates to quality of care leaves a lot to be desired. With all the programme for Government talk of financial management and private sector providers, these trusts are at risk of becoming wrapped up in looking at income and finances rather than integrating with health services, health outcomes, prevention and primary care. These trusts will essentially have the power to generate income privately and, as a result, may choose to use their beds, staff, capacity and resources solely for that purpose. They can feasibly enter into ventures with corporations, sell land and buildings and lease them back. What will be created from these programme for Government proposals is a substantial redesign of the health services towards the private sector - a health service franchise opportunity, more or less. Universal health care does not sit comfortably with the creation of these trusts and the long-term reliance on the private sector to address health inefficiencies. We cannot create a situation where the use of these services does not mean increased patient choice but rather increased choice of patient. In research undertaken by Graham Kirkwood and Allyson Pollock on private provision inequalities in Scotland, it was found that use of the private sector in Scotland was associated with a decrease in direct and in-area NHS provision and may have contributed to an increase in age-related and socio-economic inequalities. Instead, the claim made by NHS Scotland's 2003 white paper that the additional use of the private sector would provide sustainable local solutions to long waits, which might sound familiar to some people here, is not supported by the evidence.

On the contrary, the level of local provision by NHS boards decreased, while boards which made the greatest use of the private sector for elective surgery experienced the largest reductions in direct NHS provision. It will not be necessary, therefore, to reinvent the wheel in this area.

In this State previous waiting list initiatives and injections of cash to the system had a localised or short-term effect but failed to challenge structural inequality. This cannot be allowed to continue. We cannot continue to use the private sector indefinitely to alleviate pressure on waiting lists as this is neither a permanent nor credible solution. The Minister has stated previously that we need sustained investment in waiting list initiatives. The solution to the crisis in public health care is investment in the public system. The Minister seems to believe the National Treatment Purchase Fund is the solution to this deepening problem. Outsourcing is not a long-term solution to the problem and privatising more health care services will simply not work, as the research to which I referred proves.

The real solution to the crisis lies in the recruitment and retention of staff and the reopening of beds closed in hospitals by successive Fianna Fáil and Fine Gael-led Governments. Investment in the public health service is needed, not only to provide more resources and capacity but also to directly challenge and eliminate structural inequalities. Building adequate capacity across the health system and eliminating unequal barriers to access will require significant and sustained public investment. The private sector will not do this because it is not interested and does not have the capacity to do so. If we rely on the private sector to fix the problems in the health service, we will be on a hiding to nothing.

It is important to be clear in our deliberations that authoring a blueprint for a ten-year vision for health care and delivering a universal health care system is not just a question of funding but also one of political will and determination. Irrespective of the good will and hard work of the committee and what it may produce collectively or separately, the co-operation and backing of the Minister and the Government will be required. I do not mean that members should be given a pat on the back or a star in their copy books for their efforts but for a significant political buy-in.

The committee is fortunate to have high calibre delegates appearing before it. If the Minister and the Government proceed with their plans while the work of the committee is in its infancy, this will be a futile exercise. For my part, I would like to take on board the counsel of the committee's delegates when producing our recommendations and I sincerely hope they will form part of the Government’s plan.

There are very large swathes of the programme for Government to which I cannot sign up. I do not know how anyone could sign up to it, but that is the Government's business. I will not sign up to an agenda for privatisation, whether it be an outright process or takes place through the backdoor. Privatisation is completely at odds with the realisation of a universal health care system. If he is serious about the committee coming together to work collectively on a vision for the health service, the Minister must clarify that any move to privatise the health service in the form of the programme for Government plans must be shelved. The committee cannot gain legitimacy and respect or develop a comprehensive programme of work if it is precluded from doing its work by the Minister and the Government pursuing contrary plans.

Deputy Joan Collins

I thank Deputy Róisín Shortall for proposing the establishment of the Committee on the Future of Healthcare. This is the first time I have been involved in a committee that has collectively tried to grasp the complex nature of the health service. Finding out about its various parts and the way in which it operates is like going into a minefield. At recent meetings of the committee I have been struck by the number of professionals and researchers who espouse the principles of universal health care, including access to services based on need, free care at the point of delivery and equal access to care for all. This is the message the committee has heard from the Irish College of General Practitioners, nurses and others. We will see how the position develops in this regard when we meet other professionals in the health service.

Members have also been struck by the need to use general practitioners in primary and community care services to reduce pressure on hospitals. Many patients should not be in hospitals which should provide surgery, chronic care services and so forth. If care was provided in the community and services were configured correctly, the health service would be transformed. While general practitioners are up for such a change, as the committee heard, 33% of GPs are aged over 55 years - the figure for County Mayo is 55% - which means that a swathe of general practitioners will retire during the lifetime of the future ten-year plan. This puts the spotlight on the crucial need to address the issue of GP training and retention. We must put in place a policy that will take account of geography, deprivation and so forth and encourages and inspires GPs to stay in the country and play a role in the health service. This will require us to think outside the box. We must ensure the doctors we train are not grabbed by other countries because their training is so good and they conduct themselves so professionally. This is a strategic issue that the committee will have to address and it may mean, for example, waiving education fees for general practitioners who stay in the country for 15 years after graduation and buy into the system.

The Irish College of General Practitioners emphasised the need to use electronic medical records. This will be crucial if we are to achieve an integrated health service with information flowing between hospital consultants, general practitioners, practice nurses, physiotherapists and other health professionals.

The Minister will be aware of the special task force set up in the Carlow-Kilkenny area which has been working very successfully with a local hospital. The committee was informed that four or five years ago diabetes patients referred to the hospital for checks had to wait for months. The task force worked with the chief executive of the hospital and others to reduce waiting times. As a result, diabetes patients are now seen within two weeks of being referred to a hospital consultant by a general practitioner. The system has been transformed in four years because hospital consultants have worked closely with local GPs and agencies. The team meets regularly to discuss how to overcome problems. The committee will need to investigate how this approach can be extended to other areas. Hospitals and GPs need to engage with the Carlow-Kilkenny model. Sometimes, however, people protect what they have and do not want to move out of their boxes. This approach will mean that everyone will win if it is done right. Patients will win, which is crucial, as will general practitioners because they will assume responsibility for the overall health of their patients.

Most GPs know their patients from birth and are familiar with their background, their parents and their health history, including their mental health. They also know how active their patients are and have a great deal of knowledge that can be joined up if a patient develops a chronic disease. This is important.

According to Professor Allyson Pollock, the committee must base its work on evidence. Deputy Louise O'Reilly made a point about trust. Professor Pollock pointed out that British hospitals spent 16% of their income on servicing debts.

A further 3% is spent on public relations and a certain amount more will go on staff in the hospitals who work to raise money to pay back the debt. It is a waste of money but that is where it goes. I agree 100% with Deputy Louise O'Reilly that we should be moving away from that trust model. The programme for Government should consider slowing down the process in regard to the proposals from the committee.

The key thing Professor Pollock said was that it has to be underpinned by legislation. In the UK in 2012, following two decades of market incrementalism, the British Government abolished the universal public model by removing the duty on the Secretary of State to provide key health services throughout England. From that point on, there has been a crisis in the hospitals. In England, 75% of foundation trusts are in serious financial deficit. In contrast, no hospital in Scotland is going to the wall because the latter did not implement this and kept hospitals under the health boards. The key point Professor Pollock made was that national health service legislation has to be introduced by any country that seriously wants to drive a universal health model. That Bill will have to be brought through the Dáil and enacted first, not last, so there is a commitment from the Parliament that the necessary legislation will be in place. It is the first step in the ten-year plan. This also came up with GPs in regard to their contract, namely, there has to be legislation in regard to that contract in order to solidify the services they provide. Although I could say more, I will conclude on that point.

Deputy Billy Kelleher

I welcome the opportunity to speak on this issue. Normally, when we have had health debates in this Chamber over the years, by and large, they have been partisan and contentious and were often used for political point-scoring. Deep down, however, everybody would still have strong views on health and the health services available to the people. Therefore, while people are partisan and politically motivated, it is a fact that health comes into play for every citizen at some stage in his or her life and he or she will come into contact with the health services.

Traditionally, people would have expressed varying views on how we fund the health care system. It has evolved over many years and no political party can say that we have the ideal health system or that we will get to it in a short period. The establishment of this committee will give us an opportunity to remove the partisan approach that is very often taken to health debates in the House and allow us to come up with a substantial document that can reflect a real advance in how we see our health care strategy developing in the years ahead.

Of course, while we talk about a ten-year strategy, with the best will in the world, and even with a lot of resources, it will take us a long time to get to where we would like to be in terms of capital investment and increasing the number GPs, allied health professionals and clinicians. Therefore, it is not just about developing a strategy but about underpinning it with real resources in the coming years. I would instance the issues of training, education and expanding capacity to ensure we have enough clinicians to do the work and underpin the strategy as it evolves.

The motion that established the committee stated we are talking about a universal health care model. Of course, when we talk about universal health care, we have to define what that is, which is difficult. What does the term "universal" mean? Will everybody be entitled to everything? What will be free and how will it be funded? The universal concept would suggest that this would be the case but if one looks at most countries that have tried the universal model, very quickly there is some form of rationing or there are delays in the process, the service is underfunded and under-resourced and waiting lists increase. While universality is the concept, unfortunately, the position with regard to delivery is very different. We will have to be honest in terms of the type of system we want and how we commit resources to it and fund it. Will the system be funded out of general taxation with a direct subvention every year to whatever health agency will be running it? Even the most affluent countries in the world that have moved towards universality, such as France, have found it exceptionally difficult to consistently fund the health services to the standard they would like.

Regardless of whether we like it, almost every country in the world rations health care. Decisions are made that mean some people have to wait or are unable to access all forms of health care. This morning, the Oireachtas health committee discussed medicines and the high-tech drugs coming on stream. In that context, there is now a pharmacoeconomics unit that effectively assesses the impact medicines will have on the longevity of an individual patient and makes a decision on whether that person should receive the relevant medication. While receiving the medication could extend a person's life, decisions are sometimes made that do not allow the medicine to be made available to an individual. That is a severe form of rationing of health care to individuals who will die if they cannot access certain forms of medication. That is the extreme but we ration health care on a daily basis. It is a tragic reality of living in a world where we do not have enough resources to fund the health care system we would like.

The committee will report at some stage. I hope it will take a broad view of where we would like to go in terms of a universal health care system. A difficulty will then arise as to how we fund it and how much it will cost. As a country, Ireland is quite good at developing policy and already has quite a body of health care policy. Our difficulty is ensuring that we follow through. Whatever comes out of the committee's final report, if the recommendations are accepted by Government and the wider Parliament, some implementation body should be put in place to monitor the ability of whatever Government is in office to move towards that.

The committee has outlined 12 work streams, some of which will clearly be more important in terms of how the patient will experience health care in the years ahead. To take primary care, we have a very fine document, the primary care strategy, in respect of which there is broad buy-in regarding what we need to do to ensure that the vast majority of health care is provided in the least complex areas, at the lowest cost and in a way that is most beneficial to the patient. We all accept that. However, we have not moved the budgets and resources accordingly since the primary care strategy was conceived in order to ensure that primary care has the capacity to do what was intended under the policy. A major shift in resources is required but also a change in mindset at governance level in the HSE and the Department of Health to ensure that acute hospitals are not always front-loaded with funding while we starve primary care. This inevitably feeds the cycle of patients ending up in the acute hospital system because primary care cannot cater for them. Primary care, integrated care and chronic disease management are critical components in moving to a system where primary care has the capacity to deal with many of the issues in the community setting.

Some of the evidence we heard in the presentations today was very interesting. Much of it is not novel thinking; it is just very logical thinking in terms of how we deliver care. One area where I would like to get advice and a view from the Minister is in regard to the hospital groups and hospital trusts. The Minister said he does not want to take any more decisions on structural changes.

How far down the road are we going in terms of hospital groups and the establishment of hospital groups? Are we now moving to a situation whereby we will establish hospital trusts? During the committee discussions hospital trusts have not come to the fore in terms of something that is needed. They should be established immediately. Are we to delay the commitment on the roll-out of hospital trusts in order that we do not have to pare back on something that has just been established? I urge the Minister to examine the matter and to ensure we do go down the wrong road in the view of the committee. If we had to reverse engines in a short time it could create difficulties in terms of the final recommendations of the committee.

We should take the ideological element out of the discussion on health but I worry that might not be possible because some people refer to private health care as unable to provide the service that is needed. To be honest, much primary care is provided privately. GPs are not employed directly by the State. That is an issue that must be examined. In negotiating contracts we must bear in mind chronic disease management, community care, social care and the demographic changes that will happen in the near future. All of those issues must be taken into account. While the unions are negotiating on the GP contract it is important that the Irish College of General Practitioners should examine the contract negotiations from a clinical perspective. I urge the Minister to take note of the point. I raised the issue with the college last week and its spokespersons were of the view that they should have some say in the matter also. The motivation from the union's perspective will be to try to achieve the best outcome for members, although I accept that the patients will be foremost in their mind. That said, there could be slight conflicts of interest in terms of what is good for the patient versus what is good for the doctor. The Irish College of General Practitioners should have at least an oversight role in terms of the broad clinical issues that might arise out of the contract.

I compliment and congratulate Deputy Shortall for the part she played in having the committee established by the Dáil. I acknowledge the work that has been done by the staff. It is clear that the committee is a significant undertaking and it might take a little longer than we anticipated. However, we have a deadline and we are determined to meet it.

Deputy Caoimhghín Ó Caoláin

The establishment of this committee was most definitely a positive development and I too commend Deputy Róisín Shortall on her initiative. The terms of reference rightly recognised the severe pressure on the health service and the need to establish a universal single-tier service where patients are treated on the basis of health need rather than on ability to pay, something my colleagues and I in Sinn Féin have long been calling for.

While I welcome the fact that the work of the committee to date is before the Dáil, this particular interim report lacks substance and content. That said, I understand that many of the engagements and dialogue with the various stakeholders have yet to take place. However, with the budget looming, this provides us with an opportunity to focus on a number of issues which need to be addressed as part of the committee’s work and indeed, as part of the Government’s budget for 2017.

On Tuesday, I, as Sinn Féin spokesperson on disability rights, launched our disabilities document as part of our alternative budget 2017 entitled, Rights, Respect and Inclusion. The fact that this document was launched on the first day of the Dáil’s resumption reflects the importance we place on the issue of disability rights. Disability is a societal issue, affecting people of all ages and their families, directly and indirectly. We want to see a society in which all citizens, including those with disabilities, can play a full and independent part in all aspects of life, relying, as far as possible, on mainstream services for health, education and employment but with the support of tailored disability services where necessary.

As part of our alternative budget for 2017 we would invest an additional €54.812 million in the prioritisation of disability services. That would employ 600 additional front-line staff, including speech and language therapists, occupational therapists, physiotherapists and psychologists. We would provide 500,000 additional personal assistance hours. We would invest in neuro-rehabilitation teams and transitional services and would provide an increase of 20% in respite care services.

We have also provided €19 million to ensure that all children in receipt of domiciliary care allowance would be automatically entitled to a medical card. We would address the high cost of prescription charges and medicines by investing €56 million. The overwhelming body of evidence shows that charges for drugs can lead to higher costs on the health budget in the medium to longer term, not to mention the serious strain and ill effects they can have on the health of many who need medications. Prescription charges for medical card holders were originally introduced under a Fianna Fáil-led Government and were subsequently increased by Fine Gael and the Labour Party, despite pre-election promises to reverse them. Specifically, we would reduce prescription charges by €1 per prescription and lower the drug payment scheme monthly limit from €144 to €132.

Those are all costed, credible, necessary and most important, achievable measures that would have a significant, positive impact on the lives of so many, including those living with a disability in Ireland. For too long the most vulnerable in society have been used as easy targets with cut after cut imposed on them. That must not be allowed to happen again. The measures I have outlined are only the tip of the iceberg. Sinn Féin has long been committed to the realisation of a world-class system of universal health care, accessed on the basis of need, free at the point of delivery, and funded by progressive taxation.

Back in June, and on the establishment of the committee, I said that I hoped the committee would not simply provide a talking shop but rather would be a gathering of people with ideas, vision, and most important, solutions, to bring about the changes that are so desperately required in the health system today. That hope still stands. I wish all involved the best of luck with their work in the time ahead and I look forward to the final report in the coming months, and not too much beyond that because, as Deputy Kelleher suggested, the report might take longer to produce. Ádh mór ar an obair iontach agus tábhachtach.

An Leas-Cheann Comhairle

I advise the House that Deputy Shortall and the Minister have kindly agreed to take five minutes each so that all Members who are present will have an opportunity to contribute. The next speaker is Deputy John Brassil. He has about eight minutes.

Deputy John Brassil

I probably will not need all of the time. I welcome the opportunity to speak on the issue. Like other speakers, at the outset I compliment the Trojan work done to date by our chairperson, Deputy Róisín Shortall, who has gone far beyond the call of duty to the committee. It is a pleasure to work with her and to see the work that is being done by every member of the committee. It is refreshing for somebody like me, as a new Deputy, to be involved with 14 people working together, all with the same objective, to produce what will, I hope, be a revolutionary change to the way we provide a health care system. Deputy Ó Caoláin mentioned the possibility of the committee being a talking shop, but that will not be the case. It will take political consensus to see the work through and to deliver on the recommendations of the report.

As other speakers have alluded to, the primary care element of the health system is critical and getting that right will play a huge part in the future of health care provision.

We have had many contributions to date from people involved in primary care, and it is becoming increasingly clear to me, and I hope to all the members of the committee, that if we get primary health care sorted out, get our doctors, practice nurses, physiotherapists, occupational therapists, pharmacists, counsellors and so on working and funded, the pressure that will take off the system further up the line will result in our hospitals and accident and emergency departments being able to function properly and general elective surgeries and so forth working. There is also the need for proper step-down facilities to look after people who are well enough to be taken out of hospital but not well enough to go home. A combined strategy on those fronts will result in a much better health system.

Regarding the funding of such and where we get it, many models and possibilities are discussed. There is talk about Canadian models, the UK model, the NHS system and the Scottish model and so on. We must look at the Irish model because no one health system in one country will suit another country. There was mention yesterday in our presentation of the Canadian model, which is basically a public health system which is free to all and in which each citizen is treated equally. A person's public health card allows for treatment in every hospital regardless of income or background. That is a fantastic system and certainly something that we should strive to achieve. However, on looking into the Canadian system further, such elements as prescriptions, dental care, home care and physiotherapy care are not free. I imagine that if we tried to adopt that type of model in Ireland, took away the medical card from people and told everybody they had to pay for their prescriptions, it just would not work. There is a need therefore to develop a model that is specific to Irish needs. We have the ability and the wherewithal to deliver a health care system that suits and will work in our country.

There is constant criticism about morale in our health system and our hospitals. We must reflect that many people in the health system do very good work, and sometimes that needs to be recognised. I will share my own experience a few weeks ago. My mother is elderly. I finished visiting her at the accident and emergency department in University Hospital Kerry at 2.30 p.m. on a Sunday, and by 6 o'clock she was diagnosed, in a bed and being looked after. She is now home, healthy and improving. Things like that happen every day, and that must be recognised in order that people working under extreme duress see the fruits of their hard work. I have no problem saying in the House that people who do such good work need to be recognised and thanked for it. It is up to us to provide the system and the funding that works for them.

The establishment of the hospital groups is something we need to look at very carefully. It seems like it might be something that could work. However, there seems to be no onus on the individual hospitals to work together. For example, in University Hospital Kerry, there is one geriatrician doing outstanding work. There are 13 geriatricians in Cork University Maternity Hospital. That does not balance up. Cork University Maternity Hospital, University Hospital Kerry, South Infirmary-Victoria University Hospital, Mallow General Hospital and hospitals in Waterford are all part of the one group. I do not think a geriatrician in Cork can be told that he or she needs to go to Kerry and assist with the lack of services there. We have to deal with that. We have to establish contracts with our consultants and doctors that make sure every part of our geographical spread is covered properly. Part of this work needs to ensure we take control and get proper cover and care in all parts of our country.

I look forward to the next three or four months. It is an immense workload. I hope we can get our work done in the timeframe allotted to us. It is certainly our ambition to do so. Nothing focuses the mind better than a deadline. I hope that when we report - I think our full report is due to be published before Christmas - we will get the consensus and the buy-in because difficult decisions will have to be made if we are to buy into this. Every politician in here will have to make some difficult decisions. I hope we are up for it. The committee on which we are working certainly is. I believe we will produce a report that can transform health care in this country. It is up to the rest of us to row in behind it and support it. From this time forward, I hope we can look back at this as the start of the time when we got our health services straightened out in this country.

Deputy Mick Barry

I am a member of the committee. We have heard a range of very valuable and interesting witnesses. I will talk in this session about a key witness from whom we heard this week, namely, Professor Allyson Pollock, the professor of public health research and policy and the director of the global public health unit at Queen Mary University of London. The committee asked Professor Pollock to make some observations on the direction in which health care is being taken in this State. Specifically, we asked her about the provision in the programme for Government for the establishment of hospital groups, the formation of trusts and the ability of trusts to raise private finance and to contract in. She felt that was very reminiscent of the US health care model and of the privatisation measures that have been introduced in the UK since the early 1990s. She felt the experience in the UK in particular has completely discredited those ideas and has left hospitals and hospital groups with major debts. Some 75% of trusts in the UK are now in debt and 15% of their income is now allocated to servicing debt over the next 30 to 60 years. In fact, the majority of private finance initiatives have been forced to do a U-turn and go back in house again to get the best services. Another major problem was that the top priority for those groups became income generation rather than health care provision.

She made a very sharp observation which I want to read into the record of this House. She said, in respect of a single-tier health care system, "It is important to note that no country in the world has delivered [a] universal [single-tier] health care [system] through the market, for-profit provision or private insurance." That is a particularly important quote. I want to read into the record of the House another quote from Professor Pollock, "My understanding is that given the committee's commitment to articulating a vision for a universal single-tier health service, [a national health service] Bill for Ireland is the essential first step in a ten-year plan."

The reason she said it was a first step was that moving towards it slowly over a period of five or ten years would give time and space to powerful vested interests to campaign against it and to wreck it. Therefore she recommended a Bill for an Irish national health service as a first step.

She suggested that such a Bill should include placing responsibility on the Minister to deliver universal single-tier health care and should name the services that would be provided by the State in a basket that could be added to over a period of time, funded by general taxation which, she remarked, the World Health Organization had stated is the best way to fund such a service.

The role of private health insurance came up in that discussion. She made an interesting observation that in the UK less than 10% of the population availed of private health service insurance because of its National Health Service, NHS. There is not a need such as we have in this country where 44% of the population avails of private health insurance.

She raised interesting points about developments in the health service in Canada where private health insurance has effectively been banned. She felt there was a powerful case for that because it diverts resources from the public health service. In this State, for example, 20% of beds are private, diverting services in terms of not just beds, but also staff from the public system. That could not be done without providing a proper public system on the basis of a national health service.

Interesting points came up, not just from Professor Pollock, about the funding for such a model. While in some ways extra funding would be needed, in other ways huge savings could be made. For example, private health care is more expensive than public health care because of administration, invoicing etc. In the US between 30% and 50% of costs are down to administration whereas in the UK under the old NHS model, that was 5% to 6%. Therefore, it is not necessarily the case that a national health service would mean a massive increase in funding.

In some ways Professor Pollock's contribution yesterday has raised very sharp questions for members of the committee. Opinions will need to be formed and decisions made in the not too distant future as to whether there is agreement on the idea that we need an Irish national health service and a Bill to introduce it as the immediate first step. I am convinced of that argument. I have long been a supporter of that argument. The committee will now need to address that issue as part of its deliberations in coming weeks.

Deputy Richard Boyd Barrett

This debate, the committee's deliberations and more importantly coming out with a real strategy and plan to deliver a health service that works for all our citizens could not be more critical.

One has to put a human face on these things. I know everyone has cases and people they have to deal with. I have tabled several parliamentary questions over the case of a young man, Mark O'Brien, and indeed his father, William O'Brien. I believe he was on national radio recently describing his situation. This is a young man with a very rare disease and as a result has strokes constantly. He is very severely debilitated by this condition. It is acknowledged that he has a need and he is looking for home care hours.

When we send the parliamentary questions to the Minister, we get the reply that the budget for home-care hours is at capacity; that is it. He has a desperate need. Mark's father, who is much older and also has a very bad heart condition, and his wife have to travel on a train when their health is not up to it from Shankill to Dún Laoghaire to look after their son. As Melisa in my office said when William, the father, is going to see his son Mark because he does not have the home care and he comes into our office to plead with us to try to get these home-care hours, he is completely out of breath because he has a bad heart and lung condition himself and indeed probably needs somebody to look after him rather than have to go and look after his son, but the budget is at capacity and that is it. They are actively seeking money. This is just not acceptable.

When hearing these debates and the different categories of issues in the health service one's head can get fried and one can get drawn into thinking, "Well, I'm not an expert; I don't really know. It's all very complicated. How do we solve this? It's going to take a long time. There are so many different things to balance."

What Professor Allyson Pollock said is absolutely fantastic. She said that we have to start from basic principles. If the basic principles are right, everything else will fall into place. She said it starts here in this Parliament passing legislation to the effect that we will set up a national health service and the health services will be delivered on the basis of need and not on the basis of budgets or money and trying to balance private interests against the public system and so on.

In preparing my interventions on the health debate over the past five years, I have been lucky enough to have a doctor, who happens to be a member of our party, giving me advice. I would always be looking for the complex stuff from him and saying is it not really much more complicated. He says no, it is really simple; we just need a national health system. There has to be a commitment for that. It needs to be provided for free and delivered on the basis of need. If that principle is established and that is legislated for, everything else will follow. In the long term it will save money or certainly will not cost more. There may be more upfront costs to get this established, but it will actually work out cheaper.

In her comments Professor Allyson Pollock, a very eminent person, underlined all the points we have been making in the past five or six years. She explained it in simple and clear terms. She said, "no country in the world has delivered a universal single-tier health care system through the market, for-profit provision or private insurance." No country in the world is capable of delivering it and yet we still cling on to that system. She went on to explain why:

That is because it is in the nature of markets to operate through selection and exclusion. They transfer risks and costs back to service users and inevitably deny care to those who need it most. Risk selection and exclusion is built into the design of market bureaucracies.

She went on to cite the US system as the worst example of this where health expenditure represents 8% of GDP - much more than countries that have a national health service model such as the UK. The US spends much more than any other country but it denies one in five of its population access to health care. She said:

Overtreatment and denial of care, healthcare fraud, catastrophic costs and spiralling health expenditure are [features of the] US healthcare [system] ... more marketisation, higher administration and transaction costs, the greatest inequalities in access and health outcomes, [a] lack of coverage and the highest out-of-pocket payments.

All of these could be comments about our two-tier system. We have €3 billion in out-of-pocket payments because of user charges in accident and emergency departments and prescription charges. Some €2 billion of Irish health expenditure, which is one of the highest, goes to the private health insurance companies. We have all the unnecessary billing, all the administration, all the advertising and all the profit taking. It is all waste and money that should be going into the national health system. If we adopt the principle and legislate for it, all of those resources can be diverted into delivering the public health system that we need.

I agree with the emphasis being placed on primary care, integrated care services and so on, but let us not allow this to be the reason we do not provide more resources in hospitals. The reality is that acute hospital bed numbers per head of population here are way below the European average. Building up primary care services should not happen at the expense of investment in the provision of staff, beds and resources in hospitals.

My final point is on the wider question of capacity if the two-tier system were to be changed to a single tier system. I have previously made the point that all over Ireland there are private health care facilities that are empty or unused while there are people on lengthy waiting lists or waiting on trolleys in public hospitals. If we were to nationalise these facilities and makes them part of a single tier, publicly controlled universal system, we would have the capacity, beds, staff and resources to deliver the type of health service people need and want.

Minister of State at the Department of Health (Deputy Helen McEntee)

I am pleased to have the opportunity to contribute to the debate on the interim report of the Committee on the Future of Healthcare. The work of the committee, with cross-party agreement, has the ability to make a lasting impact on the future health care needs of citizens. There is little doubt that Ireland needs a concrete long-term plan for the delivery of health services. Notwithstanding this, it is important to acknowledge the hardworking staff who contribute greatly on a daily basis to the delivery of front-line services. Much of what is said about health services is negative, but it is important to acknowledge the fantastic work being done. To do justice to all those staff and the people, we must approach our planning and funding of health services in a manner that is cohesive and based on sound principles. A solid plan and a commitment to change will result in the delivery of a health service of which we can all be proud.

Universal health care is an overarching goal of health systems across the globe. Developing a pathway towards universal health care is a key element of A Programme for a Partnership Government and the Government is fully committed to it. The committee's work will define what we mean by universal health care in the Irish context and provide a roadmap to achieve it. This, of course, includes the funding model that will underpin it. There is an onus on us all to engage constructively with this process and use the opportunity to demonstrate that cross-party consensus is most definitely achievable.

When people are ill, all they want is easy access to medical professionals who can treat and provide them with the health outcomes they desperately need. Access to the delivery of these services is the key difficulty that many patients face. The committee has prioritised this issue in its work schedule, which I welcome. We recognise that the current model of high volume hospital-based treatment is unsustainable and costly. This is not the future of health care for Ireland. It is internationally recognised that access to safe, timely care as close as possible to a patient's home is the most effective treatment plan for patients. Accessing appropriate treatment should cause the least disruption as possible to the individual's daily life and the lives of his or her family. This is particularly important for vulnerable persons such as those with mental health issues or the elderly and ageing population. While addressing patients' needs in the community has a myriad of advantages for the patient, it also aims to reduce the cost of delivering care in the longer term. Driving this initiative to have a positive impact must be a priority.

I am pleased that the committee is consulting widely with national experts and interested parties from within and outside the health care system. What we are discussing is its interim report. It has yet to meet a huge volume of experts and interested parties. I am also pleased that it is reaching out to experts from other countries to ensure a comprehensive search for the best solution for health care in Ireland. Like many colleagues, I too, listened to Professor Allyson Pollock from the University of London who spoke to the committee about her experiences. She rightly stated no one model was perfect. I am sure we all agree with her. We need to build a model that has a real fit with what Ireland needs for universal health care and be prepared to review and amend it when we have not made changes for the better. That is why a ten year term for the model is so important for the future. It is important to note that the Minister for Health, Deputy Simon Harris, has postponed putting the hospital groups on a legislative footing until such time as the committee has completed its work. The Minister has done this out of respect for it as obviously none of these changes can happen until they have been discussed in committee.

While the work of the committee is progressing, it is important that the Government make improvements to services where it can. The Minister has already outlined a range of initiatives which we have been able to advance since the new Government took office. These are aimed at delivering immediate improvements for patients and implementing various actions included in the programme for Government. In my area additional funding of €40 million has been provided this year for home care services. I agree with Deputies that that level of investment is not enough, but as the economy improves, so too will our ability to improve on that figure. I hope that following the work of the committee, we will see great progress in that regard. I have established a national task force on youth mental health to improve the mental health and wellbeing of children and young people. These are two important steps in the right direction.

The work of the Committee on the Future of Healthcare has the potential to create an historic new consensus and long-term vision for health care and health policy. I look forward to the conclusion of the committee's work and urge all Members of the House to engage in a constructive and positive manner. I wish the committee well in its work. I also wish Deputy Róisín Shortall well in her work as Chairman of the committee.

Deputy Róisín Shortall

I welcome the contributions of all speakers to the debate. It is refreshing and encouraging to have a health debate which is focused not on health problems but solutions. That is a real step forward and it is the general approach that has underpinned the committee's work.

We talked about a number of common themes. One of the most surprising things we have learned through the work of the committee is that there is common ground not only among members of the committee but also among all groups, individuals, researchers and so on. That is the basis on which we hope to build the consensus we are all seeking.

One of the most common themes is the integration of services. In other words, there is a need to integrate primary and community care services with acute hospital services to ensure a shift of focus and activity away from acute hospitals where it is most expensive to the community. That, in the main, is what patients want. They want to receive services locally. We know that approximately 80% of health needs can be met in the community within primary care services. That is where patients are happiest and we get the best health outcomes. It is also where we get best value for money; therefore, it makes sense on many fronts.

The fact that we have a two-tier health system greatly militates against the critical integration required. The concern is that this or a future Government might move to pursue a policy of developing hospital groups into trusts as this would further disintegrate the health service. We would be foolish not to learn from the experience in the United Kingdom and other jurisdictions where elements of the health service have been hived off on the grounds that greater efficiencies and value for money will be achieved in privatised models or independent trusts. We know that where this has been tried it has not been the experience and that taking this approach has generally worked out to be more expensive. We would be foolish not to heed that experience.

Another issue about which I am concerned in what is being proposed is the organisational structures of the HSE and current hospital groups. Leaving aside the issue of whether hospital groups should develop into trusts, that we have six hospital groups and nine community health organisations that are not aligned does not seem to make any organisational sense. It militates against the objective of having good integration of services.

How can we measure activity and outcomes in geographic areas if we cannot define the area and state this is how much is being spent on the hospital sector and this is what we need to transfer to the community and primary care sector? Let us measure this transfer of resources and better value and outcomes. It is very hard to do this if the hospital and community health organisations are not aligned. Nobody wants to engage in further churn in the health services, because constant change is what has done a lot of damage and caused such huge uncertainty and lack of morale in recent years but, at the same time, we must pose the difficult question on whether it makes sense to go ahead with the type of very disjointed, disconnected and disintegrated organisational structure that is being put in place at present. This certainly needs to be addressed if we are to move to a situation where we can profile areas and their level of need, and match resources and services to this need and ensure we get best value for money by having strict data collection and measurement of outcomes. It is hard to see how this can be done in the existing proposals.

A point we have picked up in recent days in particular is the importance of legislation to underpin eligibility. This has been the problem with the health service. The Department for Social Protection has clear legal eligibility criteria for various payments, but in health we do not have clarity on eligibility. We must legislate for this. The point has been made to us very clearly that if we start with the legislation and establish people's eligibility, identifying the exact services for which they are eligible, by and large the rest will follow. If there is a legal entitlement to eligibility for certain services those services must be put in place. This cannot be done overnight of course, much and all as we would like to see it being done very quickly, because it is a very big ship which needs to be turned around. This is why we speak about a ten year perspective. This cannot be an excuse for delaying reform. We need to put in place the building blocks and make the reform happen as quickly as possible. This is our responsibility to the people we represent, and we would be failing in our duty not to avail of this historic opportunity we all have.

Question put and agreed to.

The Dáil adjourned at 5.45 p.m. until 2 p.m. on Tuesday, 4 October 2016.