Speeches

Address by Ms Mary Harney, T.D., Minister for Health and Children to the Annual Conference of the Irish Medical Organisation

Thank you for the invitation to speak at your annual conference again this year.

The Irish Medical Organisation is, of course, the largest organisation of medical practitioners in the country, with members from medical students to GPs to senior hospital doctors and consultants.

Common purpose in diversity

This underlines the great diversity among medical practitioners – diversity across specialties, across health care settings, across cities and counties and across the organisation of the service you give.

This underlines the great diversity among medical practitioners – diversity across specialties, across health care settings, across cities and counties and across the organisation of the service you give.

It is the challenge of your organisation to work with this diversity, and a challenge also for health care policy and management.

Faced with diversity, a natural human reaction is to find and build on sources of unity, what people have common.

In your gathering at this annual conference you understandably focus on what you share in common with each other across all the range of experience and specialisations.

And it is not just understandable, but imperative, that Government, health care management and doctors’ organisations, should also build on a common ground of purpose and commitment.

The common ground for us all has to be about patients’ interests, and more widely, the public interest, which we all share in.

We naturally pursue this common ground from different perspectives. Our dialogue and engagement together will, however, be much more productive if we bring things back more frequently, and more simply, to these questions: how does this advance patients’ interests, how does it advance the public interest?

Focus on results for patients: outputs, not inputs

In all the debate and discussion on health at the present, I would like to suggest that far too much attention is spent on inputs to the health system, and far too little on outputs for health patients.

By inputs, I mean staffing, funding, pay, buildings, beds, hours, drugs and contracts.

The system needs all these things for sure. But patients want and need something else: results from the system.

They want to enjoy better health; to get medical advice faster; to be communicated with better; to get medical intervention when its needed; to be assured they will be safe; and to be assured of the best results possible from medical interventions.

To achieve these results for patients requires many inputs. It also requires us all to use these inputs in new and different ways. That’s a challenge. It requires new thinking and change.

It can be much easier to focus solely on the inputs, without the trouble of making a connection with results for patients.

It is easier to call for more inputs, and easier to promise them. Ironically, with our strong economy, it is much easier to promise more public spending than to deliver better results with existing spending or new results from new spending.

It is easier to offer things for free with taxpayers’ money than to demonstrate the actual health benefits of that spending and why it should take priority over other service improvements.

It is much easier to focus attention on more resources for big institutions like hospitals, rather than targeted initiatives and resources for a myriad of highly effective community services.

The temptation is to say that more beds will solve the problems. And if not, well then, a lot more beds will solve the problems. Or more nurses, or more doctors.

To call for, or promise, more hospital beds is no longer enough as a health policy. That’s the past. The future agenda for health is about standards of care and better results for patients from existing, scarce and precious taxpayers’ money.

New investment is being carried out clearly within that context of reform.

The Government and the HSE are indeed implementing plans to increase the number of public acute hospital beds. Not to scale up the old system, but in a changed system. There are 1,600 more acute hospital beds now than ten years ago. That’s the fastest expansion ever in acute hospital capacity. We have specific plans to add about more 1,500 public beds through a combination of public and private investment.

The co-location initiative has one purpose: to free up approximately 1,000 beds in public hospitals for public patients. It will improve services for those patients. It will make sure that all patients will be admitted to all the beds in that public hospital, and are admitted in order of medical need. It will also mean that the private facility will be available for use by the public sector at discounted prices based on service level agreements.

In regard to staffing, we are doubling the number of medical school places. We will hire about 1,500 new consultants on a new contract. This is to re-balance the ratio between consultants and non-consultant hospital doctors, not as an end in itself, but because public patients will get a better service by having care provided by the most senior clinicians.

We are doing all this in the context of change driven by better outcomes for patients.

For example, to achieve better results for cancer patients in each region, we are going to re-organise cancer care around multi-disciplinary teams, each with sufficiently large numbers of patients to remain skilled in specialised cancer care.

More clinical staff will be recruited, into this new system, rather than into the old organisation of cancer services, where one general surgeon alone carried out dangerously low numbers of breast surgeries, for example.

To achieve better primary care, we are not simply adding to the single GP practices of old, but growing the number of primary care teams, 200 more by the end of this year.

To achieve better health for people with chronic diseases, we are moving services out of hospitals and into the community.

To provide better long term care for older people, we are building up home-based clinical care teams in what are called home care packages – five times more this year than only two years ago. We are also providing more public nursing home places for high dependency patients. This is within the context of much more home-based support, and a clear policy that no more than about 4½% of people over 65 should need nursing home care.

As I mention nursing homes, one of the areas where the biggest change is taking place in the context of new investment is in regard to standards being set and enforced. This is the agenda of the future.

Standards and safety for patients

I see very wide common ground between doctors’ fundamental commitment to patient welfare and the new legislation we have introduced to set, monitor and enforce standards for patients in all health care settings.

The new organisation, the Health Information and Quality Authority, will set and monitor standards in all healthcare settings. Within HIQA, the Chief Inspector of Social Services will enforce standards of care in residential settings, in particular, in nursing homes, with the power to register and de-register nursing homes if necessary.

This is the start of an agenda to move to licensing of all health care settings and, ultimately, licensing of hospitals.

I have established a Patient Safety Commission to work with HIQA to move this agenda for licensing forward as well as to demonstrate ways to improve patient safety systematically across all health care settings.

And, finally, an important part of the new Medical Practitioners’ Bill – which I hope will be enacted in the next few weeks – will be to support in law for the first time a system of continuous professional development and competence assurance for doctors by the Medical Council.

The IMO made a useful contribution to the debate on the Bill. Specific concerns about competence assurance have been addressed, through the inclusion of an explicit exemption from release of documents under FOI and other confidentiality provisions.

Fitness to Practise provisions now include a number of routes for the resolution of complaints, including referral to mediation, competence assurance and the statutory HSE complaints system, where appropriate.

These developments put in place the building blocks for the future agenda in health – better results and guaranteed standards for patients.

And they most definitely complement, rather than contradict, the professional commitment and standards of doctors in their clinical work with patients.

In no way do they threaten doctors.

In no way do they undermine clinical decisions.

In no way do they damage the doctor-patient relationship.

Advocacy and change

The most powerful cases for investment and change in health are made when the focus is on better results for patients.

As they say in management, ‘start with the end in mind’.

I have no difficulty at all with doctors individually or collectively advocating improvements for patients. I don’t believe that this is a matter for consultants alone, nor that they should be treated differently to other doctors and GPs, or other clinical care professionals.

I would invite you to consider how advocacy will best be carried out in a clinical team environment, which will be the environment of the future. I don’t want to enter into detailed contractual issues, but I do believe that advocacy can be carried out consistent with the normal obligations of a senior employee to team colleagues, to a clinical director and to an employer.

As a practical matter, I don’t ever see doctors being prevented from advocating for patients.

I also recognise that we need protection for whistle-blowing in our health services, and I have provided for this in the Health Bill that was recently considered by the Oireachtas. So I am strongly in favour of courageous advocacy and actions that are focused on the welfare of patients.

Could I invite you to consider a broader point? As we have learned from political developments in Northern Ireland over many years, the strength of advocacy, and the authority of leadership, is often related to how much one is prepared to challenge one’s own comfort zone and support base.

There can be no doubt but that the IMO has achieved a lot for its members over the last ten years. For example, the fourfold increase in health spending has seen a corresponding increase in the amount paid to doctors under the GMS, for example.

Over the next ten, I believe that the more that doctors themselves embrace change and reform where patients’ interests clearly demand it, the stronger will be their advocacy for the whole health services.

The more you advocate solutions that involve the better use of public resources, rather than just more public resources, the more taxpayers will listen to your voice.

The broader your agenda, the better for all. The more change, the better. The more re-thinking, the more solutions.

I am a supporter and an advocate for the idea of a health forum in social partnership to achieve real change, just as we achieved real change in the economy through the social partnership process.

Partnership has the potential to do a lot on health. But like the best social partnership processes, it can’t start out with a specific and difficult industrial relations claim as the first item on the agenda, requiring agreement before all else. That would not be fair to all participants, nor to patients and the public.

Consultants’ contracts

Finally, I would put in the context of change, reform and better outcomes for patients the current discussions on a new contract for medical consultants. I know that many of you are not consultants and are concerned with other contracts, so I would ask for your understanding that time does not permit me to discuss each of these.

The people of our country, including the taxpayers, rightfully have an expectation that the fruits of our economic success will be used for improved health services. They have an expectation that new public contract holders, whose salaries they pay, will be highly dedicated to delivering top quality patient care in public hospitals and in community settings.

The Government have undertaken to the public to hire new consultants on a new contract to improve patient care. We did not undertake that yesterday, but years ago, at least as far back as the 2001 Health Strategy. The public rightly expect to see movement on new consultant appointments on new terms.

When I came into this job, I was told by consultant organisations there was one big issue holding up talks – clinical indemnity and the MDU. I was told that a three month timeframe for talks could follow. I brought a solution to my Government colleagues and they endorsed it. That was two full years ago.

I think people are now entitled to see Government policy on new consultants begin to be implemented.

I would much rather that this could happen in the optimal scenario – in agreement with consultants’ organisations. And I will continue to encourage agreement. But I do feel obliged to ask, what is the over-riding public interest here? Is it to begin to hire new consultants where there is a pressing need for improved public services and where waiting times for public patients, particularly for outpatient appointments, have been unacceptably long? Don’t we need the new people in place in psychiatry, respiratory medicine, rheumatology, neurology, geriatric care and so on? My colleagues and I in Government can give only one answer to this question. It is to deliver what patients need.

How could we conclude anything else? I cannot see how anyone could conclude that patients’ interests demand a further delay in advertising for new posts. I cannot see how advocacy for patients could suggest postponing the recruitment of badly-needed new consultants. I certainly don’t see how patient advocacy entails boycotting of new consultants by existing consultants, and I hope it never comes to that.

I want to emphasise again that we do not seek to disadvantage any existing contract holder with a new contract. That would be against the thrust of public sector employment policy. I am realistic enough to know that no existing contract holder would sign up for a contract that was worse. I have encouraged flexibility as well as focus in these talks, and that is why a range of contracts has been on offer.

I believe we can work with a diversity of contracts. I don’t think anyone really believes that one-size-must-fit-all – across the diversity of specialties, locations, public and private work, academic posts, existing and new contract holders. There is already a diversity among contract holders, in terms of rights, obligations and, indeed, earnings, public and private. I do not see that changing fundamentally. We will have to continue to manage with diversity around certain core commitments. That is a challenge, but it is also an opportunity for flexibility.

So we will advertise new consultant posts next week. I will also seek to encourage agreement by existing contract holders to new terms and conditions. The two are not incompatible.

But we must move on. Patients can’t wait. They and their families pay all our salaries and they are entitled to see movement, now, for improved services.

Conclusion

I have often said that I am optimistic for health in Ireland. We have a tremendously strong economy, to deliver resources to match reform. We have achieved substantial improvements in health services in a wide variety of areas– a fact. The reform process is not easy, but it is worthwhile and will deliver improved services for patients in their communities and in better hospitals.

And finally, I reiterate, that we have the advantage of great professionals working in health in Ireland, and in particular, the vast majority of doctors who deliver a top class service to their patients, day in, day out.

The high levels of patient satisfaction in actual encounters with the health services is testament to that.

As Minister for Health, I value greatly your professional commitment and I want to work with you to foster it for generations of new doctors, in the best traditions of their predecessors and in the best interests of patients.   ENDS