Address by Micheál Martin, Minister for Health and Children, to the Health Strategy National Consultative Forum
I am very pleased to welcome you to the second plenary session of the Health Strategy Consultative Forum today. Thank you once again for taking the time to attend this two-day session. A lot of progress has been made since April on the new strategy and we are now entering the final phase in its preparation.
To be meaningful, a health strategy has to be both focused and comprehensive at the same time. While there is no difficulty getting people to agree that there are problems to be addressed, there is and never will be one general opinion on what should be done. My overriding hope for the consultation process has been for it to help to distil attitudes and options. I think the consultations to date have been very effective in achieving these objectives.
The purpose of the sessions today and tomorrow is: firstly, to give you feedback on the views from the consultation process, and secondly, to discuss the key issues emerging.
Allowing for the pressures of other Government business, I intend spending as much time as possible with you and listening carefully to your views.
As has been identified already, one of the key weaknesses identified in the 1994 strategy was the lack of consultation undertaken during its preparation. I have been very keen that the new strategy would involve a fully inclusive and extensive consultation. I am pleased to say that we had an excellent response from the public with over 1500 submissions received. Feedback from these submissions has already been fed into the Steering Group´s work. You will be hearing from Ann Colgan later this morning.
As expected, we also had an enthusiastic response from the many organisations involved in the health area and from organisations in other sectors that impact on health. Some 360 submissions were received from organisations. Anne Colgan will also be outlining the key findings from this element of the consultation process.
The views of the public have confirmed a number of impressions I had formed. I was not at all surprised to find that community services and in particular services for specific care groups such as older people and people with disabilities were top of the list for change. The next two biggest priorities for change were acute hospital services and health promotion. I was very pleased that health promotion and illness prevention was the fourth biggest issue identified as in need of development. This is a positive sign and perhaps indicates that health promotion efforts since the last strategy are starting to pay.
You will also be hearing this morning about the outcome of the consultation process under the National Anti-Poverty Strategy. This has important implications for the new health strategy in view of the strong focus on equity. Another major strand of consultation relates to the views of the 80,000 people running the health services. It goes without saying that the support and involvement of health personnel will be crucial to achieving the vision of a health system proposed in the new strategy. A comprehensive report on the findings of the various elements of the consultation process will be published at the end of this month.
Sub-Group/Working Group Reports
Since we last met both the sub-groups of the Forum and the parallel working groups in my Department have reported. You will recall that the themes involved were “eligibility”, “funding”, “service delivery and human resources”, “e-health”, “quality”, “population health”, “futures” and the “voluntary/statutory interface”. The sub-groups reported in mid-May and their views were then taken into consideration by the working groups which finalised their reports in early June. Both sets of reports have been fed into the Steering Group´s work.
I would like to thank all of you for the effort and commitment which went into preparing the sub-group reports. The standard of the reports was very high and they provide an invaluable resource. I very much appreciate the fact that you gave up your time to prepare these reports within a very tight timescale. The objective of the sub-groups was to get informed, independent views on some of the major issues facing the health services. I have asked for all of the sub-group reports to be posted on the strategy website. This will help to inform the debate on many of the complex decisions facing us. In addition, it will not be possible to capture all of the detail of the reports in the strategy document itself so I am keen that they should have as wide an audience as possible.
With so many people and organisations giving their views across such a wide range of issues, the challenge of reflecting these within a meaningful framework is quite difficult. What we have decided to do is to set a series of overarching national goals which flow naturally from the consultation process and provide a general framework within which to build the strategy.
The recommendations from the various groups and the initial feedback from consultation have been distilled into four major goals for our future health system. In addition, these inputs are being used to identify the strengths and weaknesses of our current health system and to set out a programme for development and reform. The four national goals are:
- Healthy people;
- Fairer access;
- More responsive and appropriate system of care;
- High performing health system.
You will see that these goals also reflect the vision for the future and the guiding principles I outlined at our meeting last April.
Goal: Healthier People
The first goal, Healthier People, is concerned with improving the overall health of Irish people. As we know, while our health status has improved, our mortality and morbidity rates still lag behind the EU average. We have achieved a lot, but there is more to be done. In addition, there are inequalities between different population sub-groups so that, for example, travellers and those on low incomes have a lower than average health status. Many of the factors influencing peoples´ health are determined outside of the health arena and include areas such as education, employment, housing, work environment, food production, water and sanitation. This means that public health considerations need to be taken into account in devising policies across a range of sectors.
The groups examining the theme of “population health” have come up with some useful and practical recommendations to ensure that this happens. In addition, an inter-Departmental working group chaired by the by the Secretary General has been examining joint working to achieve improved health status for Irish people. By adopting a population health approach, and implementing it across both the formal policies of government and the more informal actions of many of your organisations, I believe we can make a significant move forward in public health outcomes.
The focus on the health of the population also involves a more intensive approach to preventive medicine. We need to look at how we can improve the uptake of immunisation and preventative screening programmes. The focus on population health has implications for many other aspects of our health system.
It suggests a broader role for health professionals, as clinical leaders, taking on responsibility for population health and not just the health of those individual patients whom they see. It also underlies the vision of a strengthened primary care system which can pursue preventative strategies at a local level in an integrated way.
Goal: Fairer Access
In relation to the second goal, at our April meeting I explained how equity would again be a guiding principle in planning our future health system. There is no doubt that achieving fairer access to services is one of major concern of the public. This has come through very clearly from the consultation, particularly through complaints about waiting lists. There is no “magic bullet” in terms of achieving fairer access to health services. The underlying issues are complex and embedded in our organisational and eligibility structures, professional practice and contractual arrangements. Achieving change will take time, greater transparency and a willingness to accept new ways of doing things.
I am not underestimating the challenge this presents. Based on the work done by the eligibility and funding subgroups, we found it necessary to convene an additional working group to examine the whole area of public/private mix with a particular focus on short-term measures to achieve fairer access to services. This group is still working and its findings together with the reports from the groups examining “eligibility” should provide a basis for short and longer term change to give effect to a fairer more equitable system.
One of the main recommendations of the eligibility groups was that the system for determining eligibility for health services should be simplified and standardised. Their review of existing arrangements points to the need to define clearly the core range of services for which a person is eligible. As I have pointed out previously, eligibility is not the same as entitlement and although a person may be “eligible” for a service, this does not mean that they will actually receive the service. Our objective should be to improve the capacity of services so that in time we can reach a stage where people have a clear entitlement to a service within a particular timescale.
A related issue which has received strong support in the consultation process concerns greater transparency in decision making. There have been many calls for published information about entitlements such as the income guidelines for medical cards. In addition, the adoption of evidence-based decision making by clinicians is seen as crucial. This is linked to the principles of quality and accountability. I think it also reflects changing public attitudes and the fact that through the internet, many people now have access to extensive information about various medical problems.
Goal: More Responsive and Appropriate Care
The third goal, ´more responsive and appropriate care´ flows from the principle of a “people-centred” health service. Many people who participated in the consultation process complained about very simple things: they felt they were not treated with respect, they wanted to be listened to and to have things explained to them. This goal has important implications for how services are organised. People should be able to access the services they need easily and as far as possible there should be effective links between GP services, community supports, hospital services and so on. The ideal of the “seamless” service has been advocated for many years, however, it is still not a reality and is something on which we need to see concrete progress under the strategy.
Another objective under this goal will be to achieve greater participation by the public in the planning of their local health services. While we have democratic structures at health board level, it is clear that there is a widespread belief that the system is often closed to the inputs of ordinary people. It is a natural part of any professional system that it can tend to turn inwards, but it is clear that we have to renew our efforts to make our work responsive and accountable. Based on models in other countries there is considerable scope for greater involvement of the public both in airing their views and where appropriate in joint decision making.
I see this as a major component in modernising our health service structures. This type of change will take time but I am convinced of its value in achieving the ambitious vision proposed in the strategy.
Goal: A High Performing Health System
The 4th goal, “A High Performing Health System”, fundamentally relates to ensuring that a culture of quality dominates what we do. This will include an emphasis on patient safety and appropriate risk management practices. This programme will need to be strongly driven and supported and the sub-group on quality have recommended that we put new structures in place to do this. There is certainly an urgent need to develop and implement national standards of care and quality. This is closely linked to the adoption of evidence-based decision making which I referred to earlier. It is also linked to the concerns of staff, many of whom expressed the wish for more regular training and peer review.
As you all know, funding for health services has over doubled since 1997. This funding is leading to a situation where we are making great strides forward in the level and nature of resources available within the system. There has been very strong public support for this step-change in funding. What all of us in the health system have to realise is that to maintain this public support we have to operate in such a way as to give assurance that we will concentrate on key priorities and deliver to the public in line with their legitimate expectations. We will not be able to ask for increased levels of resources if we also insist on maintaining practices which may owe more to historical circumstances than the needs of a modern public health system.
We must set ourselves definite targets and we must be accountable to the public. It is essential that we optimise the impact of public investment and that we have a culture which actively seeks ways to improve. We need to strive at all times to maximise the impact of investment and we have to be able to measure the results achieved. In order to do this, we need accurate and meaningful information at all points of the decision making process.
Good information is vital for users, service providers, policy makers and the political system. We do not have accurate and reliable information on many aspects of our current health services at present and this is a major impediment to evaluation, planning and improved service delivery. Again, this need has been highlighted before. It will receive a strong emphasis in the new strategy and will require additional resources over a sustained period. A separate health information strategy is already being worked on by my Department and this will reflect the issues which have been identified during this process.
Quite apart from the generation of reliable, relevant and timely information on service needs and the performance of the system, we also need to shift our mind-set in how we use such information. Evaluation need to be given much stronger emphasis on our management agenda. We need to create the capacity for health services research and policy research as strong drivers for leading change in the system, bringing the most recent international thinking to bear much more quickly on our own ways of doing things. Auditing our performance generally, clinical performance, delivery performance and management performance, will have to come centre stage in the outcome-focussed health system we must strive for.
Action Plan and Investment for Specific Service Areas
There is a general wish to see commitments relating to see specific commitments relating to individual service areas or care groups. A review of services is forming a part of the consideration of what needs to be in an action plan to be part of the strategy. Central to this will have to be a clear prioritisation. A whole range of considerations, most particularly basic capacity, mean that we couldn´t and shouldn´t pretend that we can move on everything at once. We must focus our work in an ordered way on those priority areas which will help us to deliver on the public expectations and key needs of our system.
The next step is to assess the implications for different services or care groups of the four national goals I have outlined. For example, what changes need to be made in services for the elderly to achieve the goal of “more responsive and appropriate care”? The results of this analysis will then be used to set targets for the achievement of the goals over the course of the strategy period.
Programme of Reform
The strategy will provide a framework for growth and development of our health services over the coming years. However, in addition to increasing the capacity of services, the strategy must also outline a significant programme of reform and modernisation. The agenda for modernisation must include organisational structures, human resources practices, governance, planning and service delivery, information systems and arrangements for monitoring and evaluation. This is an ambitious programme but as we all know, many of the shortcomings of our current system are due to a combination of problems. The only practical way forward is through a comprehensive programme of reform. I know that this is what the public want and expect – for example, they want to be more involved in decisions about health services where they live; they also want easy access to information about health services and to be able to access those services at times that suit them and without unreasonable delays.
Equally it is clear from the staff consultation that health personnel also want to see changes. For many organisations, it is something of a cliché to declare that their highly skilled and committed workforce is their main strength. In health care, because it is so obviously about people giving care to other people, human resources are the determining factor between success and failure. However, I know that many people feel stressed and isolated in their jobs. Part of the vision for the future is to make the health services a place where personnel feel valued, have clear career development paths and are facilitated to provide quality services to the public. The recommendations from most of the sub-groups will feed into this aspect of the strategy. In addition, this is another area where the Steering Group is seeking your assistance today.
Other Key Themes
There are a number of other key themes which have come through from the consultation, group reports and other research by the Project Team. These include an enhanced and re-organised primary care system based on a team approach. I believe that this should be the cornerstone of our health services for the future and this would have a very positive impact on other areas such as hospital services. Another area which I have already touched on is the much stronger involvement of communities in planning of services. Michael Kelly will be expanding on these and a number of other issues in his presentation this afternoon.
While we do need to improve our capacity generally, it would be unfair to those working in the health system currently, not to acknowledge the considerable performance we are already achieving. The increased level of investment is delivering increased service provision. There has been a remarkable growth in service development over recent years. While there is undoubted pressure on many aspects of the health system, it is the case that, day-in day-out, many thousands of people receive the services they need and are generally satisfied with the standard of service received. However, this form of good news rarely makes the headlines in media or political terms and can be dispiriting for the professionals and other staff in the front line who we rely on to provide a high quality service, each and every day and night of the year.
Some of the main achievements of the system in recent years include:
- The number of in-patients and day patients treated in public hospitals rose by 10%, or over 80,000 from 1997 to 2000.
- Day work in hospitals has increased by 9% per annum in the same period so that day work now accounts for some 37% of all hospital activity. The capital programme has created more day beds than ever before, and the result is more efficient use of hospital resources.
- Services for people with intellectual disability have been greatly expanded. This includes additional respite, residential and day places.
- We have also improvements in services for the elderly with some;
- 400 additional beds in community nursing units;
- over 1,000 new day places, and
- 880 new staff in place since 1997.
This is a system which has shown dynamism in much of its work and which is expanding significantly in response to public needs. Yes there are many long entrenched issues to be addressed, but I believe that they can be. The key is to have an informed debate with all sides agreeing on priorities and moving forward aggressively to deal with them. There is no quick fix, but there is a real opportunity to make a dramatic move forward in the level, quality and responsiveness of health services and, equally important, in the way we approach health as a nation.
The terms of reference for this Consultative Forum are as there were set out in April:
- To provide advice on the key themes and direction of the strategy and on the process for its preparation.
- To provide for participation by key stakeholders.
- To act as a resource to the Steering Group by providing advice on issues as they arise.
This meeting of the Forum provides a real opportunity for you to contribute further to the shaping of the strategy. The group work is by no means an academic exercise. The topics have been carefully selected by the Steering Group so that you can help to tease out a number of critical questions. The breadth of issues underlines the complexity of this task. It is crucial to have your views at this stage to firm up on specific targets for inclusion in the strategy.
In conclusion, I want to thank you once again for your commitment to this process. The extensive response from the consultation and the need to incorporate all the various inputs has meant that publication will not now be possible until the early autumn. However, a first draft of the strategy will be given to the Steering Group at the end of July and I will be aiming to bring the final report to Government early in September. We have a real responsibility to respond to the public and provide:
- A health system we can trust;
- A system that´s there when we need it;
- A system that makes a real contribution to reducing inequalities and improving the health status of all the people of Ireland.
Your presence here is an indication of the strong commitment you feel to this process and to the development of our health and social services. I invite you to throw everything you can into our work over the next two days and I am committing to listen fully to all that you say. Our combined efforts will ensure that the final outcome should reflect a balanced but inclusive approach to the development of future health and health care in Ireland.