Speeches

Address at the University of Limerick by the Minister for Health and Children, Mary Harney T.D.

Thank you for the invitation to address you at the University of Limerick.
Both the setting tonight and the theme invite a very broad sweep in the discussion.
The setting: we are in a University, the place where our society takes time and invests resources to do fundamental thinking and research, with you, people with open minds to question, imagine and shape the future.
Looking forward to the future is the task you have given me this evening, in addressing the theme ‘The Role of the State in Health the 21st Century Ireland’.
I would like first, to set the scene and make general remarks about health developments at a broad level and what it has taken to achieve high health status we now have in Ireland.
And then I would like to focus on some of the building blocks and the cornerstones for better health we are now putting in place for this century. In particular, I want to highlight the era of patient safety that we have now commenced in Ireland and the sustainable use of resources.
We will seek to align both standards and resources to achieve our fundamental goal better health outcomes for people, that is, better quality of life, lower rates of death, fewer complications and longer life.

Introduction

Let me invite you to picture this: millions of people have just died from an epidemic. Millions more have died in wars. The world economy is in turmoil. A small, newly independent country is struggling. It has no currency of its own. It has few natural resources and little industry. Its population has fallen. Life expectancy is low relative to many other countries. Thousands live in urban slums and rural poverty. There’s been local guerrilla war and civil war.
But in the middle of this grim picture the leaders turn to you and say: before this century is out, we want our people to have the health status of the top 10 per cent in the world. We want to add 25 years to the life expectancy of our people, to bring that close to the highest in the world. We don’t want people dying early from infectious diseases any more. We want top quality health care.
How do you do it? Do you try at all? Do you tell them they are mad?
Where do you start and what are the most important things to put in place?
Do you say, such a level of change can only come about if we have a dictatorship – a benign dictatorship – not a messy democracy?
Do you appoint a Minister for Health immediately with sweeping powers over everyone else, including the Minister for Finance? Will Health need a blank cheque?
Who do you call in to help first? Doctors? Lawyers? Nurses? Economists? Engineers?
Do you build hospitals all over the country? Do you buy in the best surgeons and physicians from the rest of the world?
Of course you know that this scenario was Ireland 90 years ago. The Great War had ended, the Western world was in the grip of a devastating flu epidemic, the War of Independence was getting underway. Urban and rural poverty were endemic, leading to infectious diseases.
Very similar scenarios, of war, of disease, bad infrastructure and poor governance, still unfortunately face certain countries of the world today.
But we have achieved the result I spoke of: the population of Ireland now enjoys a health status well into the top 10 per cent of the world – better than more than 5 billion people, is one way of looking at it.
Let me repeat that if I may. On our small island with our population of just a handful of millions, we nonetheless enjoy a quality of life (in terms of our health) that is superior to that enjoyed by over five billion people.
According to the latest WHO data (July 2008), our life expectancy at birth is now just under 80 years. It was about 55 in 1920. And we’ve added three years in the last decade alone, which is unusual, indeed, unique in the European Union. Life expectancy is now one year over the EU average.
Children born in Ireland today have a life expectancy higher than children born in other European countries such as the United Kingdom and Finland, and we are at the same level as Germany.
Ireland is also now one of the safest places in the world to have a child. Infant mortality is down by a third in the last ten years alone. It has been halved since 1990, and is now at the low level of 4 per 1,000 live births – as Unicef reports, lower than in the UK, the USA and Canada, and the same as in France, Germany, Denmark and the Netherlands.
And while we have achieved this, it has to be acknowledged that there was no plan in 1919 on how to do it. It would have been a very challenging, impossible-sounding goal; beyond comprehension.
Could the same be true for our wishes for this century? Are we to add another 25 years to life expectancy in the next ninety years? Or will we achieve the next major advances in quality of life more than length of life?
Having made the big steps in the 20th century, and as we reach the top of the league, the incremental change from further reform, investment and scientific advances may seem harder to identify and achieve. So I am not going to suggest an impossible sounding goal or dream, a result that no-one can imagine.
But I do want to put forward my conviction about the critical building blocks we are now putting in place for health improvements in the 21st century and to advance further, even beyond what we can presently imagine.
These building blocks will be as important for health in the 21st century as were the keystones of the 20th century.

Need for well-functioning, democratic State and society

When it comes to discussing the State, let’s recall that there was a time, centuries ago, when there was no centralised, modern administrative State, as we know it. There was also a time, not so long ago, when there was no independent State of Ireland. And there are presently places in the world today where there is no State – or very little evidence of it, in any case.
What’s for sure is that there always was, and always will be, a state of human health, in Ireland and elsewhere. Even in the most stateless parts of the world today, there is human health status. Usually, in those parts, it’s very bad human health.
So we won’t get too many credits for concluding that the arrival of, and functioning of, the modern political State has been good for human health. What type of State, in a political sense, is also critically important, in my view.
Will any political State do? Communist, totalitarian, democratic?
I also believe the evidence clearly shows that modern democratic States do better for the health and well-being of their populations than totalitarian States.
Totalitarian States of the right and left have often, to put it mildly, shortened the life expectancy of their people and others by the pursuit of wars and the imposition of ideology, internally and externally. The 20th century is unfortunately too full of examples.
The totalitarian States tended to put the State itself first, and the population of a given time as the servant of that State. In democracies, we like to put things the other way round. People see Government and the State as their servant – as it should be.
The relationship of the individual and the community to the State in our democracy poses particular questions for health.
What do we expect the State to do – and not to do? What accountability and limits should there be on State power? How are personal autonomy and responsibility expressed and respected? How is trust established and sustained between individuals, organisations and clinicians? How are conflict and failures dealt with?
So how does a State go about building better health?

Starting points show interdependencies

Where we have come from in the 20th century is instructive.
Think of this. If you read the Irish Times from Saturday the 1st of March 1919, you’ll find an article titled…. “A Ministry of Health – the Case for Ireland”. A paper was presented by the Rt. Hon. M.F. Cox at the Statistical and Social Enquiry Society at Stephen’s Green in Dublin arguing that while England, Scotland and Wales were to get a Health Ministry, Ireland was being excluded.
For some people that may come as a great surprise. Ireland had no Ministry for Health in 1919. But it begs the question, if you are trying to improve the health status of a nation, is your starting point the establishment of a Minister and Department of Health?
Of course, our people left behind the argument as to whether the House of Commons in London should decide if Ireland would have a Ministry for Health or not.
As it was, under our independent Oireachtas, which met as the first Dáil less than two months before the Irish Times report, we waited until 1947 to appoint a Minister for Health with a dedicated Department.
This may suggest that the leaders of the new State, in setting ambitions for our country for the 20th century, missed out by not first appointing a Minister for Health.
But that’s not where you start with health necessarily.
I asked earlier, who do you call in first, and where do you start with health? Assuming you’ve got some economic activity going and some resources to invest, the answer is probably the engineers.
You start with water. You provide clean drinking water and you separate it from waste water.
The investment in water treatment plants and sewage works is a fundamental health investment. An uncontaminated, reliable food chain would come very high on the list.
Sanitary, warm housing for the whole population is also an important health issue – and was a big issue for Ireland in combating diseases like TB.
You want to have enough money to buy the commonplace drugs and new technologies that tackle the major diseases, and the ability to get distribute and prescribe them safely to people.
The State is clearly best positioned to ensure this basic public health infrastructure is in place for all the population. Indeed, I would add, that in sharing our sovereignty in the European Union, we now recognise, that in areas like pandemic planning, the role of the State is best carried out with our partners in the European Union.
And if we then asked what is the most important health service to start with, it would probably be a combination of maternity and perinatal care and the basic mass immunisation programmes.
Dr Noel Browne’s historic drive to eradicate TB by building sanitoria was essentially complemented by improved sanitation, housing and nutrition, and the wider availability of primary care.
What I want to suggest is that, looking at the fundamental drivers of health status quickly shows how health policy is part of an interdependent, organic whole which relies at is core on two things: a well-functioning, well-governed State and society and an economy that delivers increases income per person over many decades.
Sustained increases over the medium and long term in wealth and income per person remain absolutely necessary for developing healthcare.
The dependency on economic growth and performance for resources for health is surely clear to all by now.
The engine of economic growth will continue, in my view, to be enterprise, risk-taking, competitiveness and innovation, winning new business overseas and attracting new investment into our country.
But I also want to emphasise interdependencies in relation to health, the economy and the role of the State and society.
For example, home care services for older people will depend on how much we can invest, but the need for such services will also depend upon the level of support provided by the family and local community.
Similarly, on cancer, diabetes, cardiovascular care: it is not only a question of generating wealth to pay for services. Prevention and early intervention are not as expensive as the curative services but require lifestyle and behavioural changes among ourselves, the population.
Poor mental health affects a large number of people, but again, it is influenced by building good family and community support, not simply interventions from health services that are dependent for funding on economic growth.
There are complex, interdependencies therefore affecting health policy.
So while you might start with basic infrastructure, as your country develops, you certainly need to move into specific health policy matters; and it’s the job of the Minister for Health to drive that agenda at Government.
It is very much in that context that we take policy decisions and choose new building blocks and our cornerstones for this century.

Standards cornerstone: the era of Patient Safety

The first such cornerstone I want to focus on is Patient Safety.
We have begun a new era in Irish healthcare: an era of patient safety.
As fundamental as clean water and sanitation were for us in the 20th century, is the patient safety agenda for the 21st century.
Among building blocks, this is the ‘standards’ cornerstone.
We have started out on a path from which there is no return: the path of setting and implementing objective standards of care and allowing evidence lead decisions.
This is to ensure that the most ancient promise of doctors to patients is adhered to – the Hippocratic Oath’s promise by doctors, ‘first, do no harm’.
Patient safety, quality assurance and explicit standards involve a myriad of issues across the already complex, vast area of health services and interventions.
Patient safety, as a guiding principle for change, is not aimed at saving money. It is aimed at achieving the best outcomes for patients. It is a powerful guiding principle for how resources should be applied. It brings along the requirement for evidence as the basis for decisions.
I believe it is a principle guiding change that the public can and will support – particularly if doctors, nurses and other professionals provide leadership around this agenda and explain the issues.
The evidence is compelling in many areas that doctors and hospitals practicing higher volumes of procedures leads to better outcomes for patients – simply put, lower rates of death, fewer complications and longer life.
In the medical literature, over two-thirds of studies conducted across a range of specialties show improved health outcomes with increased volume. This evidence is particularly strong in the fields of cancer surgery (breast surgery, pancreatic resection, oesophagectomy, gastrectomy), and also vascular surgery (particularly abdominal aortic aneurysm), and paediatric surgery (heart surgery, and cleft-lip and palate).
One significant American study has shown that the extent to which death rates were lower at high volume centres compared to low volume centres were the following:

  • For Coronory artery bypass graft 17% lower
  • Coronory angioplasty 30% lower
  • Cerebral aneurysm surgery 36% lower
  • Pancreatic cancer surgery 58% lower
  • Oesophageal cancer surgery 59% lower

In Ireland, many cancer specialists have contributed to our understanding and policy on this question of volumes and quality.
Experts such as Professor Niall O’Higgins and others who informed the National Cancer Forum, and subsequently our National Cancer Control Strategy, have based their policy recommendations on many, many international sources.
Professor O’Higgins’ first report on “The Development of Services for Symptomatic Breast Disease” cites over 90 scientific references for various aspects of breast cancer services, many of which relate to specialist centres.
The National Library of Medicine in the US is the primary source of evidence from scientific studies in health care. It can be accessed through the PUBMED gateway. A search using the key words ‘breast cancer survival surgical volume’ identifies close to 200 papers. Professor O’Higgins has cited many other publications not included in this source, such as consensus guidelines from bodies including the British Association of Surgical Oncologists and the National Institute for Health and Clinical Excellence in the UK.
Better outcomes for various cancer surgeries arising from high volume surgical practice are beyond doubt. This appears to be particularly true for high surgical volume for individual surgeons as distinct from surgical units.
Here, we know that there have been regional variations in breast cancer survival rates in our own country. We conclude this has been the result of not enough volume, specialization and indeed sub-specialisation.
If we take the Mid West as an example, the data from 1994-2001 showed that a woman who resided in the Mid West had a 5 year survival that was 28% worse than a woman who resided in the former Eastern Regional Health Authority region.
As Health Minister, I believe we are simply compelled as a country to act on this evidence, organise ourselves on this evidence, work on this evidence, for the safety and the lives of the population.
That is the fundamental reason for the re-organisation of cancer services to eight specialist centres. This has been challenging for some doctors, staff, hospitals, local representatives and local populations. But it is compelling and it is right.
We seek to offer the same outcomes, the best outcomes, to patients from every regional and county in the country. We simply cannot deliver on that promise of best outcomes and equal outcomes by fragmenting services that should be brought together for better outcomes for patients.
For this reason, in 2007, at my recommendation, the Government endorsed new standards for the treatment of symptomatic breast disease. By September of that year, the HSE directed 13 hospitals, some with very low case or no volume, to cease breast cancer services immediately.
That November Prof Tom Keane became Interim Director of the National Cancer Control Programme and has spearheaded the programme since with a team of clinical leaders.
By the end of 2008 breast cancer services had ceased in 21 hospitals, including Ennis and Nenagh.
Services will transfer from 4 more hospitals (Drogheda, Sligo, Tallaght and South Infirmary) in the first half of this year. By mid-2009 symptomatic breast services will be centralised in the eight specialist centres (Mater, Beaumont, St James’s, St Vincent’s, Cork University, Limerick, Waterford and Galway) with an outreach service in Letterkenny linked to Galway.
My point is, we can, and will, make the changes necessary to deliver best outcomes for patients.
The reorganisation of hospital services in the Mid-Western Region is another case in point.
I fully support the work of the HSE on this and the project led by Mr Paul Burke, Consultant Surgeon. I pay tribute to his commitment and that of his clinical colleagues, and I look forward to hearing his presentation this evening.
The HSE has shown that the Mid-West has enough consultant surgeons and anaesthethists to deliver emergency general surgery in line with international standards of practice. But they can’t do that dispersed across four hospitals, Ennis, Nenagh, St. John’s and the Regional.
The fact us that just 7.6 patients attend Nenagh and 9 at Ennis between 8pm and 8am on average. Most of these are self-referrals; most could be treated by a GP.
Over a six month period last year, Ennis had 28 surgical cases out of hours and St. John’s had 21. In one month in Nenagh, of 105 emergency cases requiring treatment, only 12 involved a general anaesthetic.
We know that practicing low volume caseload in higher volume specialties is detrimental to the maintenance of skill and continuous learning on the part of specialised clinical staff. Smaller hospitals simply cannot be staffed by teams of specialists for low volume cases that may present.
To offer treatment by staff or doctors with fewer specialised skills to patients in some parts of the country is not to offer the safest care and best outcomes to patients. It is simply not fair to those patients.
What is fair to patients is to organize hospitals into networks and teams of specialists where the best care for each condition is provided in the right location. And second, that hospital care and primary care are much more integrated, so that as much care as possible is provided as close as possible to the patient.
But let me emphasise this: every teaching hospital, every primary care centre, every nursing home can be a centre of excellence for the care they can provide.
Nenagh, St. John’s and Ennis can be, and shall be, I believe, centres of excellence in a network with the Mid Western Regional in Limerick. I know that staff are already providing excellent care. We must get away from the idea that the big hospital – the Mid-Western Regional in this case – is somehow anointed with the status of ‘centre of excellence’ which is denied to others.
Any distinction like this makes absolutely no sense when hospitals co-operate in networks and integrate with primary care. Every part of the system, starting with the GP surgery or primary care centre and moving to local, regional and national hospital will have a role to play in delivering excellent, safe care for patients.
We are surely all compelled to put outcomes and safety for patients before institutions and traditions. Let us move on now on that basis.

Statutory provisions on patient safety

At the level of Government, we are implementing the patient safety agenda through new law, organisation and regulations.
We have set up the Health Information and Quality Authority as an independent body to help set and enforce standards. It is early days yet for HIQA, but it is already making a strong contribution in nursing home standards, hospital hygiene, and advised where mistakes have happened, how to avoid the same problems recurring.
Of course, patient safety is not just the agenda of one organisation – it is for every organisation and every person in health.
Accordingly, we have radically updated the law regulating the medical profession through the Medical Council. For the first time, the norm will be for fitness to practice hearings to be heard in public.
No longer will the medical profession regulate its own members on its own, with the public feeling they are left outside the door. This is not the model of regulation and governance for a 21st century democracy.
We have also modernised regulation in the same way for pharmacists and other health and social care professionals. We will move on to the nursing profession now.
This new regulation is guided by the principle that regulation should be open, transparent to the public and with a lay majority on the governing boards of regulatory bodies. Also for patient safety and public confidence reasons, the Government has built in statutory support for continuous professional education.
An example of the new approach is the one we are putting in place for nursing homes: there will be one set of explicit, enforceable standards for all nursing homes, both public and private, and fully transparent to patients and their families.
In addition, we are moving towards accreditation and licensing of all health care providers. This is the recommendation of the Commission on Patient Safety that I established.
I will bring forward new legislation to implement the Commission’s recommendations.
Among the steps we have already taken was to introduce last summer the World Health Organisations’ Surgical Safety Checklist together with the Royal College of Surgeons and HIQA.
There will be many challenges ahead in implementing this whole agenda. It is, however, the clear and decisive direction our health services will take for decades to come.

Translating insight from research

Research is an important way to provide the evidence-base for policy and practice in health.
In this century, I am confident Ireland will play its part in the generation of new knowledge through research that pushes back the boundaries of understanding of disease, its causation and its treatment.
This is part of our vision for a smart economy based on research, knowledge and innovation.
One of the most significant issues for health systems internationally relates to the translation of new knowledge and insight into clinical practice. For many years we have known the role of aspirin in reducing mortality from heart attacks, the role of warfarin in preventing certain types of stroke, how to prevent the diabetes and its complications, how to prevent lung cancer, colon cancer etc.
But together, Government, academia and clinicians, we must ask ourselves critically do we apply this knowledge as well and consistently as we should?
The public who fund research can legitimately ask, what use is research if it is not used as soon as practically possible? We must improve our methods of applying the knowledge we have already gained through research to achieve full value from our investments in research and health service delivery. This is a key responsibility for all researchers, all practitioners and all managers.

Financial cornerstone: sustainable use of resources

Just as patient safety is a standards cornerstone, the sustainable use of resources is a financial cornerstone.
It is very clear that, as countries increase their national income, the proportion they allocate to health also increases. Some have calculated that the amount of growth in health spending is 2 percentage points typically higher than growth in national income. Clearly, this growth would have to reach a limit somewhere.
We have not had a policy goal of investing X or Y percentage of GNP in health. However, clearly, we keep an eye on health spending as a proportion of national income, and particularly, the direction of any increase.
We currently allocate about 9% of Gross National Product to health specifically (excluding, of course, those critical things like water, waste water, housing and other infrastructure).
Cross country comparisons are interesting, but complex; but for a country with the youngest population in Europe, we are investing a reasonable proportion of national income. Our health spending per capita is higher than the OECD average.
The big question for the future is how do we invest sustainably? What if we put in place measures now that we can’t fund in the future, except at the expense of education or welfare? How to we achieve continued improved in health status and outcomes for people without an inordinate growth in cost?
For this reason, the critical focus of this year is also one for many years ahead, in good times and bad: how do we get better outcomes for a given and limited level of resources?
It’s about how the money is spent; how costs are controlled; how incentives work in the system; how we pay for ever-more sophisticated, ever-more brilliant, but ever-more expensive drugs and therapies.
The money has to come from the population, and the State has to raise most of it.
The mechanics of how that money is collected – through insurance or general taxation – is not as critical as addressing the question of how limits are set on funding. Because there will always be limits – to both funding and benefits – and there will always be arguments about those limits.
There is no system of healthcare funding that has unlimited budgets for unlimited procedures, treatments, drug therapies or consultations. This is not something that people tend to focus in on the political debate, but it is a reality.
There will always be choices to be made by Government and State organisations about how limited resources are allocated. To govern is to choose. There will be argument and resistance to such decisions. Health will continue to be controversial. It is the nature of it.

Funding outcomes

From now on, I believe we will focus more on identifying health outcomes for the resources we invest.
Traditionally, we funded inputs – staff, drugs, equipment and so on. We gave the money at the start of the year and hoped for particular results. It was only much later we could see if we got the health outcomes we wished for or not. And if we didn’t, it has been very hard to adjust.
For the future, we will have to link funding to health outcomes, as closely and as best we can. v Clearly the goal is simply not health care activity. It is health itself – the health status of people individually and as a whole society.
An intermediate step is to identifying and funding outputs – numbers of treatments, long term care places, respite days, etc – for given resource inputs. It means identifying better exactly what we are paying for, at what cost. This year’s Service Plan from the HSE has made a lot of progress in this regard.
There are more initiatives we can develop here and I will be bringing forward the work on it.
Among health payment systems, public or private, tax-based or insurance -based, it has proven very difficult so far to achieve a clearly effective system of funding for outcomes. I believe, however, the direction of this work is the way to go.
It does involve a greater integration of services – primary, acute hospital, tertiary and long term care. The creation of the HSE as a single organisation provides this opportunity.
For us in Ireland, this will probably mean adjustment in payment methods for hospitals, health care providers, doctors and others. This need not be a threat to anyone. It will mean change, however. But I believe it is compelling that we move to the most transparent way of linking resources to desired outcomes.
Focusing on health outcomes should also lead to more integration between the HSE and other public service organisations and better co-ordination with the private sector.
The HSE as a single health organisation is a real building block for better health care management.

Balancing interests of stakeholders – patients first

The allocation of resources also requires Government to strike a fair balance among all those with an economic interest in providing services – from medical professionals and staff, to hospitals, to drugs companies. The interests of the number one stakeholders – patients, the population – has to come first.
The reality is that any health system carries the risk of ‘capture’ by providers. We could end up paying people and providers too much. We could increase the proportion of GNP spent on health by increasing staff salaries or drugs payments excessively – with no benefit to patients or the public.
I am highly conscious that another critical success factor for health is how to invest in, design and sustain the education of the full range of clinicians that we will need for decades ahead. We have to teach the right things, in the right way, at the right time – and that means continuously. I am a strong supporter of continuous professional education.
We have to strike the right balance across medical specialties and staff in general – so that we have enough surgeons, and also enough psychiatrists; the right number of consultants, but also enough GPs for expanding primary care; the right balance between nurse managers, nurses and nursing assistants; and between clinical and management/administration staff.
We have had approximately 4,000 non-consultant hospital doctors and 2,000, a ratio of 2:1. That is not the best for teamwork and achieving best outcomes for patients. Now we are beginning the process of reversing that ratio, with the aim of having two consultants for every one non-consultant doctor – and doctors working in teams. The new consultant contract we have agreed will enable this change – and it will be funded in a cost neutral way by reducing the reliance on excessive working hours of non-consultant hospital doctors.
The balanced allocation of resources between staff, providers and drugs costs is a major success factor for sustainable progress in health.

Clinical leadership – local leadership

The greatest asset of our system is the knowledge and capacity of the people who work within it. We need to encourage, support and indeed require clinicians – doctors, nurses and other professionals – managers and other health care workers to deliver the best possible services to their patients.
We want to empower local decision making within a coherent national policy framework and governance structures.
I have been a strong supporter of the involvement of clinicians in leading change, in being part of management, in the organisation of services and the best use of resources.
Clinical involvement in management, reform and innovation is one of the most powerful forces for improvement.
I have seen brilliant and dedicated clinical leadership throughout the health services – often not recognised. There’s an old cliché about not cursing the darkness but lighting a candle – truly, though, the satisfaction and the progress made when candles are lit by clinicians with management and staff together is worth all the effort.
I am very pleased to have made this a central feature of the new consultants’ contract. It is of strategic value to the health services. It is the new way; it is the future.
A strong example of clinical leadership in action is our Cancer Control Stategy that I mentioned earlier. It’s a realistic and ambitious strategy, rooted in medical evidence and conscious of resources, drawn up by clinicians, and now implemented by a team of clinicians, managers and other staff.

Information

There will also be a pressing need for better information in the health sector and investment of time and money in information.
Information must be at the centre of what we do. Information must be accurate; it must be collected at the right time, in the right place and in the right way.
In general, better information can tell us the likely success rate if a surgeon or surgical team perform a certain number of specialist procedures; and therefore how we should organise doctors working together for best outcomes.
Information tells us if one hospital can service the needs of 50,000 patients with fewer staff or resources than another, allowing us to allocate resources better.
Information can tell us which patients among the hundreds in each hospital need visits from doctors when. Information can help older people be treated better at home to stabilise conditions and avoid ending up unnecessarily in hospital or the A&E department.
Up-to-date electronic patient records are at the heart of the best use of information.
Critically, information has to be made available to those who need it – especially clinicians – in the right form and under the appropriate conditions, so that decisions, both clinical and management, are based on good knowledge. Good information is essential to drive improvements in safety, efficiency, quality, effectiveness and sustainability.
We have brought forward new proposed legislation on information in health specifically and have carried out a wide public consultation on it.
Just as vital is public trust that personal information is totally protected. The Bill strengthens patients’ rights and establishes clear rules for the use of information.
Investment in information and IT cannot be something we do only after all demand for services and new drugs is met. Sometimes we will need to invest in information even while there are limits for funding for services. But to denigrate either new IT systems or management information – as occasionally we hear from within the health sector – is a deep disservice. Top quality information is integral to better health outcomes.

Fair access

Another key role for the State is to ensure fairness across the whole population in access to health services.
Access to health services based on medical need has to be the guiding principle for publicly-funded health services, now and permanently. We are making progress on this agenda through specific features of the new consultants’ contract, for example, providing a ‘one for all’ access to outpatient diagnostic services for all patients based solely on medical need.
The contract includes much tighter management of the public-private mix.
And over 300 consultants have signed up for a public-only contract.
I do not believe in hidden subsidies for private care within the publicly-funded health facilities. That is why we have taken decisive steps towards charging the full economic costing of private beds in public hospitals.
Fairness and equality of access need not mean, in my view, that everyone should pay the same, or nothing, for a service.
To use an analogy from transport, everyone uses the same train or bus, but some benefit from free transport, some people have subsidised costs and some pay the standard amount. It’s the same bus or train but the cost of its use is tailored to the ability of people to pay.
This is the model we are using for nursing homes under the Fair Deal: one range of regulated nursing homes, public and private, available to all, but people contributing to the cost based on their means. We will ensure, of course, that the health or social status of the person, or the amount of their contribution, does not influence the quality of service provided to them.

Primary care teams

The work to re-balance care more towards primary care and community settings and away from acute hospitals is also a key task we have now embarked on.
Between 80 and 90 per cent of most people’s health care will be provided at local, primary care level.
This is where better healthcare for patients is also more efficient healthcare. Most patients prefer not to have to go to hospital; most want to get out of hospital as fast as possible; and for most people, local settings are more convenient than an acute hospital.
Simply put, primary care teams bring health professionals together to provide better care locally. Members of the Primary Care team include GPs, nurses / midwives, home helps, physiotherapists, occupational therapists and administrative personnel.
A wider health and social care network of other primary care professionals, such as speech and language therapists, social workers, community pharmacists, dieticians, community welfare officers, mental health services, disability services, dentists, chiropodists and psychologists, also provide services for the population of each PCT.
While providing new centres and facilities is important, this is fundamentally about people working together as clinical teams.
There are now 328 GPs attending or being represented at primary care clinical team meetings around the country.
The HSE’s National Service Plan that I approved aims at having 210 primary care teams running by the end of this year, up from 97 now; for the Southern region, there will be 63 teams, up from the 29 at present.
The HSE has also approved, in principle, leases for primary care centres at 48 locations. It has also entered into direct construction contracts for Primary Care centres at small rural towns and disadvantaged areas.
The development of primary care is not only the way forward for most clinical care. It is also facilitating teams of staff putting in place their initiatives at local level to provide better care for their populations.

Conclusion: Technology, hope and trust

The canvass of health status, health policy and health provision is large indeed. And it is constantly developing.
Technology in medicine is advancing at a tremendous rate. I believe Irish people will be part of those scientific developments as users of the advances and inventions they bring, and also in developing many of these new technologies.
Screening and genetic profiling and targeted therapies will develop rapidly. New issues of cost and resource allocation will come up. New ethical issues, some of which were never anticipated before, will continue to arise.
Some people may see these as threats – but we should see them as reasons for hope.
We can, in Ireland, in the developed world and in the developing world, have great hopes for health in this century.
Ultimately, of course, the role of the State in health, in a democracy, is to earn and sustain the trust of the public. The State – the Government and public service – has taken on and will continue to discharge onerous roles in regard to health. I believe it is best if the State is indeed ‘entrusted’ with these roles by a public that has confidence in the role of the State. This means clarity on behalf of the State of what its role is – and the limits of its role in respecting personal autonomy.
The achievement of public trust is why, for example, patient safety, the setting of standards and quality control, is a compelling guiding principle.
It’s the reason why the regulation of professions and the licensing of health organisations are very explicitly being done in the public interest, with a new openness and transparency.
It is why leadership is vital from all involved in providing health services, particularly from clinicians to whom we give great personal trust.
It’s why working to allocate funding based clearly on best health outcomes for patients is both most sustainable and best placed to command public support.
Trust is built on respect, and respect is built on telling it as it is. Evidence based medicine means evidence-based health policy and evidence-based communications with the public we serve.
Trust is earned, not owed, and not once, but continually.
The relationship between State and individual, between State and communities, will be ever more built on trust and respect in this century – to a degree that would have been unimaginable 100 years ago.
This is the very foundation stone of success for a modern, democratic, prosperous Ireland. We all have a role and a stake in it.