Address by Mr. Micheal Martin TD Minister for Health and Children to the Health Strategy National Consultative Forum
I am very pleased to welcome you to the first plenary session of the Consultative Forum today. Thank you for accepting my invitation to participate in the Consultative Forum, one of a number of levels of consultation, which will support the development of a new Health Strategy. I hope, through this and other strands of consultation, to capture the ideas aspirations and changing health and social needs of modern Ireland.
My purpose today is two-fold: to listen to what you have to say, and to give you my view of how we might best map the way forward. I want to emphasise that the new strategy is not just about health services. It is also concerned with improving the health status of the Irish population. This is a much broader issue and brings a cross-sectoral focus to the work of preparing a new Health Strategy.
Why a New Health Strategy?
The first thing I think we need to set out is why we need a new health strategy. Later on this morning Miriam Wiley from the Economic and Social Research Institute will talk to us about the 1994 Health Strategy – “Shaping a Healthier Future”. The E.S.R.I. critique provides a useful input to developing the new strategy, but we already know that the current system of providing health and personal social services needs reform.
The 1994 Strategy set about reshaping our health services in order to ensure that improving people’s health and quality of life became the primary focus of the work of health policy makers and providers. There is no doubt that it has helped to focus the minds of service planners, providers and recipients in terms of their role with, and what they should expect from, their health service. However, it is my view that there are fresh challenges for all of us involved in provided health and personal social services.
These challenges have been created by the economic and social evolution of life in modern Ireland. They have increased our expectation of what a good system of health care should provide. They have increased our demand for transparency, equity and accountability in the way services are delivered, and finally, they have provided us with the knowledge and technology to develop new techniques for improving our health status.
I believe that it is clear that we need to take a fresh look and develop a strategy which is framed in the context of contemporary life in Ireland and which gives us a direction for the future – a plan to lead, guide and support us in meeting these new challenges.
Michael Kelly, Secretary General of the Department of Health and Children and Chairperson of the Steering Group will talk to you shortly about the structures and processes governing your work and the overall preparation of the Strategy. However, I wanted to speak to you briefly about the consultative process of the Strategy.
In setting about the task of developing a new Strategy, I believe we must be open to new ideas. We need to ensure that we fully understand and take account of the challenges facing us. It is for this reason that I have embarked on a wide consultation process. I am particularly conscious of the Economic and Social Research Institute’s findings in their review of the 1994 Strategy that the formulation stage of the Strategy was weakened by its failure to include a wider and deeper process of consultation. We hope to rectify that on this occasion.
My hope is that this level of research and consultation will ensure that the Strategy which evolves is :
- firstly, one which is informed by a wide variety of perspectives, as well as by “expert” views;
- secondly, that there is support for the choices we make in devising the Strategy; and
- thirdly, that the public, the providers, the services users and the staff have ownership of the plan for the future.
Vision and Principles
As the Steering Group and Project Team works through this stage of the process, I have asked them to begin thinking about what the characteristics of a future health service might be. While we await the input of the consultation processes to this, a number of central ideas are already being to emerge.
- We’re trying to build a health system which helps people be healthier. This means looking beyond the traditional view of the health and personal social services to the full range of intersectoral issues which affect our health.
- The health system needs to be focused on the individual and treat the individual with respect. It needs to provide, not just treatment, but also information, so that individuals can contribute to and share decisions relating to their own health.
- On top of all that, the system needs to be accessible, well-organised and well monitored to ensure that standards of best practice are constantly being striven for and achieved. These kinds of ideas are not contentious. However, in order to achieve that vision, we need to consider what are the principles which will guide us through the incremental steps needed to get us there. The 1994 Health Strategy adopted the principles of equity, quality of services and accountability. I would like to talk about the relevance of these to the new Strategy and to you as stakeholders in the health system.
When we talk about equity we mean two things,
- a service that is delivered on the basis of an individual’s needs – in other words accessible to the individual, and
- A service that targets the inequalities in health status which continue to exist in the Irish service.
We have all seen the influence that geographic location and ability to pay has had on the kind of the health care service some individuals trying to access the system have experienced. At a broader level, the Report of the Chief Medical Officer (1999) highlighted the issue of health inequalities in Ireland.
Quality may be defined as a health system based on excellence and where standards are set in partnership with the stakeholders. These standards are best built on evidence-based practice which can be measured by external validated performance indicators. In health care quality is multi-dimensional and will require an integrated approach to the delivery of health services. Setting quality as a principle means giving a commitment to best systems with high standards. Achieving high quality is a concern for everyone – the providers, the individual caregiver and the patient/client.
When we talk about accountability, we mean transparency about who decision-makers are, and what decisions they are being asked to make. To have greater accountability we must have clear objectives and targets for decision-makers and we must put in place mechanisms to monitor and evaluate progress towards objectives in an open and transparent way.
I am sure that you will agree that accountability and measurement standards for quality in the health system should be on a par with the levels of accountability that are, quite appropriately, now required for budgetary control. Strengthening and clarifying these mechanisms will require action on a number of fronts in a system as complex as the health sector. There is a high level of public concern about the perceived quality of our health system and, in particular, the hospital sector. It is important to address these concerns so that healthcare operates to higher standards into the future.
Undoubtedly, these are principles which we will be staying with in any new Strategy. However, I believe we also have to make a further re-orientation to meet the challenges which I referred to earlier. I believe that we need to seek explicitly to develop a system which is “people-centred”. This means have a service that is planned and delivered on the basis of the best interests and the needs of the individual. This may mean changing the way we deliver services at present. It also means giving clear information to the public about their entitlement and, for professionals, a greater openness in their dealings generally, with patients or clients. I am also keen that there should be a greater involvement by the consumer in the planning and delivery of services.
Within the Department a number of working groups have been established to examine key themes for the strategy, some of which I have already referred to. The sub-groups of the National Consultative Forum which you are involved in are mirroring these groups. The themes being considered are “eligibility”, “funding”, “service delivery/HR”, “e-health”, “quality”, “health promotion/population health”, “futures”, and the “voluntary/statutory interface”. Now I would like to outline some of the main questions being examined under these key themes. The answers to these questions, many of which are interlinked, will form the backbone of the new strategy.
Eligibility for health services in Ireland is primarily based on residence and means. A person who is ordinarily resident in this country has either “full” or “limited” eligibility depending on their level of income. One of the strengths of this system is the fact that around one third of the population is eligible to a wide range of health services free of charge. However, there are also weaknesses in the current system.
- Eligibility is not the same as entitlement. This means that although a person may be “eligible” for a service, it does not mean that they will actually receive the service.
- The statutory basis for eligibility is mainly limited to hospital and GP services. There is a lot of confusion about people’s eligibility for many community services and a lack of consistency between health boards in how people are treated. The current system of eligibility has developed in a piecemeal way
- Many people with “limited eligibility” have chosen to take out private health insurance. This trend has accelerated in recent years with some 40% of the population now covered by insurance. This has contributed to what some people see as a “two-tier” health service where people take out private health insurance to have faster access to treatment. This applies primarily to acute hospital services.
So what changes would I like to see and how can we provide a better service for all? The underlying principle should be fair access for all based on medical need. Keeping this in mind I would like to pose the following questions:
- Should we move to a rights-based approach to access to health care? Should we move away from the concept of eligibility to that of entitlement?
- How can we achieve fair access for all based on medical need? Would this mean a radical restructuring or could it be achieved by increasing capacity and targeting certain problem areas?
- How should we use eligibility (or entitlements) to incentivise people to use certain services? – For example, primary care rather than hospital services.
- How can we develop a system of eligibility that is simple, clear and comprehensive in that it covers all aspects of health and personal social services?
- In view of changing demographics, the long-term care of the elderly is a major concern. This has also been a cause of considerable controversy in recent times. What rules or entitlements should we plan for in this area? How should the considerable costs involved be met?
Funding is obviously an issue of concern to all of us. There has been major investment in the health services in the past few years. We have doubled health funding from £2.5 billion in 1997 to £5 billion this year. However, in addition to the level of funding for future health services we need to consider the method of funding. In the context of the strategy, these are some of the questions we need to address:
- What are the pros and cons of moving away from the current tax based system of funding health care?
- What other funding methods might be considered?
- How do we compare with other developed countries in terms of the level of expenditure devoted to health care? What level of funding is needed to achieve a more people-centred, equitable and high quality health service?
- Within the health system, how can we use funding as an incentive for great efficiency and to drive strategic change?
- What impact does the public/private mix have on the effective use of resources? What changes should be made to achieve greater efficiency and fairness?
Delivery Systems/Human Resources
Delivery systems have a very clear impact on the responsiveness of our health care system. We need to be in a position to make more appropriate and sensitive responses to the changing needs of individuals and the rapid pace of new technology. We need to develop delivery systems that are more efficient and facilitate change, innovation and flexibility.
Discussion on this theme is going to raise questions about our organisational structures; and questions about the recruitment, retention and training of health personnel who plan and deliver services. This discussion will inevitably look at the changed environment since the establishment of the health board structure and at the great many changes in human resource theory and practice since then. Clearly, there will also be implications for the way in which the Department of Health and Children is organised.
We all know that the staffing shortages in the health system are probably the single biggest potential obstacle to addressing the current service deficiencies. Developing the “people” resource in the system will promote better quality services; give existing health personnel greater motivation and job satisfaction; and make the public service a more attractive place to work.
Whatever the answers to these questions, they must be framed in the context of the requirements of patients/clients who receive services. Major improvements have been made in this area of serving patients and clients better, but further action is needed. I believe that in the future, systems and structures must be designed from the patient/client perspective.
The Government is already committed to the development of an e-government strategy by each Department. There is no doubt that e-health services have the potential to play a major part in delivering health and personal social services. This is a new and rapidly evolving area and will be the subject of constant review as the National Health Information Strategy, information and communications technology and service priorities progress.
Again, this is an area where the health service has already established a number of initiatives. A balance needs to be achieved between fostering local innovation, capitalising on technological development and ensuring that there are, at the same time, system-wide standards. By having a group that is focused on this theme we can ensure that the cross-cutting importance of e-health to many of the other themes is not lost sight of and that the strategy framework ensures appropriate co-ordination, integration and prioritisation of e-health technologies.
I have already outlined what we mean by quality as a principle. Quality is also one of the themes being considered by a working group and a sub-group of the Forum.
The reform of medical indemnity, development of a hospital accreditation system, the development of risk management programmes in hospitals will influence the quality agenda in the secondary care system. The preparation of a National Health Information Strategy will influence the quality of service delivery and planning in the primary and tertiary sectors. We also need initiatives in a variety of other health and personal social services which set national standards of performance across a range of safety and quality issues.
These should include quality assurance in professional practice; human resource management and development; the management of information for the purposes of audit, performance measurement, quality assurance, epidemiological research and service planning; and in relation to the incorporation of a patient focus to health information and service delivery. Even more importantly, this discussion should provide an overall strategic framework which integrates these initiatives for improving healthcare quality.
Health Promotion / Population Health
This topic is concerned with tackling the nation’s health status. You will all be aware of existing work and initiatives in this area – the national health promotion strategy, the national cancer strategy and the national cardiovascular health strategy are three key policy documents mapping out programmes to impact on the health of the nation as a whole. However, there is a need to give this issue greater prominence and a new momentum in terms of its key role in tackling a persistent health status problem including inequalities between population sub-groups in Ireland.
Key questions include :
- How do we develop the cross-sectoral support to tackle the full range of issues which affect health ?
- How do we advance this agenda at a regional/local level ?
- How can we maximise the use of existing resources and structures aimed at tackling the persistent link between poverty and health status ?
- I know that a genuine commitment at the highest level will be part of what is required to ensure that health status becomes part of the social/economic agenda, but what are the practical actions to achieve the change necessary ?
These are the kinds of questions which I hope the working group and its parallel sub-group may be able to answer.
This working group is undertaking an analysis of the issues which might impact on health and healthcare over the next 10 years or so. We’ve already discussed the impact that a variety of areas have on health. In particular, this group are being asked to think about what the future might hold in terms of :-
- the physical environment;
- patterns of demography and disease;
- developments in science and technology;
- social trends;
- changes in the workplace;
- change in public expectations and the issue of ethics;
This is a particularly challenging topic as it requires us to think very creatively, while at the same time requires us to forecast likely scenarios which we can use to anticipate and plan for our health needs further down the road. I see this as being a very relevant theme for the strategy as a whole and one which will have an important impact on the deliberations in relation to many of other key themes.
The Voluntary / Statutory Interface
The Government has already signalled its support for the role of voluntary sector activity in a wide range of areas. The White Paper on Supporting Voluntary Activity was published in September of last year. It sets out to
- recognise the contribution of the Community and Voluntary Sector;
- give a commitment to supporting that sector with additional resourcing;
- provide a framework of good practice standards for both the voluntary and statutory sectors.
I think it is worth noting that the “interface” in the Health Sector is considered very advanced in some service areas. In fact, the White Paper comments “the trend of partnership and accountability is now well established in the health sector”. In particular, our achievements in the area of intellectual disability are most impressive. I am hoping that in considering this theme, the task of extending these well-developed mechanisms to other service areas will be considered. In addition, I believe that discussion on this theme should go beyond an examination of service delivery aspects of the partnership between Statutory and Voluntary organisations, to developing principles in the other areas of activity relevant to the health service, for example, resource co-ordination, self-help and mutual aid, advocacy and policy development.
I have already described the eight key themes as forming the backbone of the new strategy. Building up from this we will be setting out an action plan for each of the main services and professional development areas. A lot of important policy work has already been completed in specific service areas.
There is no question of recreating the wheel and where clear policies are available and accepted, we will incorporate these in the new strategy. The ideas and plans already developed in relation to specific services will inform the development of a new strategic direction. It is with this aim that the Steering Group and Project Team are also working closely with developments in relation to the National Anti-Poverty Strategy.
However, there are also gaps and areas where policies need to be developed and these will be identified. I am also conscious of the multiplicity of initiatives underway in different service and professional development areas and I see the strategy as an opportunity to pull these together. Having said that, the strategy will not provide fine detail, it should instead give a strong direction for moving forward.
It is essential that there is an integrated approach to both policy formulation and implementation. This has implications for everyone working in the health services. We will need improved communication, openness to new ways of doing things and a willingness to embrace change. The driving force behind this approach brings us back to the vision and principles I outlined earlier, in particular the idea of a “people-centred” health service.
Concluding Remarks / The Task Ahead
The Government is fully committed to the development of a new Health strategy. It accepts and supports the need to establish an agenda of reform for the Health system. I should emphasise that the Government also accepts that an examination of funding methods and levels will be an intrinsic element in development of an agenda for the future.
Personally, I am committed to making progress towards finalising a new Strategy as soon as possible. I have indicated to the Government that a new Strategy will be produced mid-year. This is an ambitious target but one which I believe we can achieve with your help. I attach the greatest priority to making the necessary changes to our health care system to further improve people’s health and quality of life.
With this backdrop, and your support, I believe that we can achieve this target and, together, make plans for :
- 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 in the health status of all the people of Ireland.