Health Reform Programme – Speech by Minister Martin to Dáil
The sole objective of our health policy is deliver access to all to high quality services. Services have expanded significantly and today there are more people receiving care and support services than ever before. I have addressed this House before in relation to the investments made in the health system and the gains made over the last 5-6 years. Notwithstanding these gains, I have often referred to the need to couple investment with reform.
The purpose of today´s debate is to outline the Government´s plans in relation to a reform programme for the health service. I believe that the programme will be an essential element in achieving the kinds of improvements in health care that we want and that the public deserve.
Origins of the Reform Programme
It is important to recognise that this reform agenda is a central theme in the Health Strategy – it´s not something outside of or separate from our strategic vision for the health system.
At the time we published the Strategy we said that structural reform would have to follow. There were complaints that the system was disjointed and that very often patients and clients were having to respond to the way services were organised, rather than services being organised to respond to their needs. It was acknowledged that, with a new set of goals and objectives, we needed to be certain that the structures in place were fit to meet those objectives.
Under action 114 of the Health Strategy, I commissioned Prospectus Strategy Consultants to complete an Audit of Structures and Functions in the Health System. The central objective of the project was to examine whether the structures in place were the most appropriate and responsive to meet current and future needs in the context of the principles, goals and objectives of the Health Strategy. Also included in the terms of reference was the need to assess the adequacy of governance, integration and responsiveness to identified consumer need.
At the same time, the Minister for Finance had established a Commission on Financial Management and Controls in the Health Service. The Commission, chaired by Professor Niamh Brennan, focused on financial accountability and management issues but also identified the need for structural reform to support improvements.
It is interesting to note that the reports have, independently of each other, reached similar conclusions about the system and have made comparable recommendations.
These two reports provided the background against which the Government made its decisions in relation to the Health Service Reform Programme.
Findings of the Reports
Health board structures are over 30 years old and the wide health system has also seen the addition of a large range of specialist agencies during that period – often to give focus and to protect particular policy developments. The result is that there are now 58 agencies operating in the public health system. It is obvious that this is simply not sustainable. This multiplicity has resulted in a complex and fragmented system which has itself become an obstacle to achieving improvements.
Both reports emphasised the need to introduce rationalisation, standardisation and much improved co-ordination to overcome this fragmentation and to give me, as the Minister a realistic span of control over the agencies for which I am responsible.
Both reports also reiterated the need to clarify roles between the Department and the delivery system. The also draw attention to the tensions between local representation and decision making vis-à-vis national policy objectives. It is obvious, that in a system as complex and as broad in scope, clarity about roles, accountability must be completely clear. The Brennan Report focused in depth in this area and made specific recommendations which have also been endorsed in the Reform Programme.
Other issues raised related to the way things get done in the system. The need to enhance needs assessment and service planning was raised. If we´re serious about putting people at the centre of care, we must begin with an assessment of needs which informs us about how to plan our services. In turn, once we have declared and agreed service plans we must link such plans with funding and measure activity and outcomes.
The Government has taken these reports on board and agrees with their analysis of current problems. There have been improvements in all of these areas in the past. But these have been part solutions. Part solutions by their nature are limited. The Government has recognised that it is time to devise a comprehensive and integrated solution.
The Reform Programme
The principles underlying the reforms are:
- A new national focus on service delivery and executive management of the health services
- A reduction in fragmentation within the system
- Clearer accountability
- Improved budgetary and service planning
- And most importantly, improved patient care.
- There will be a major rationalisation of existing health service agencies to reduce fragmentation – with over 30 agencies to be amalgamated or abolished. This includes the abolition of the existing health board/authority structures.
- A Health Services Executive will be established. This will be the first ever body charged with managing the health service as a single national entity. The Executive to be organised on the basis of 3 core divisions:
- National Hospitals Office
- Primary, Community and Continuing Care Directorate.
- National Shared Services Centre
The Executive will have its own Board and Chief Executive Officer and the Board will report directly to the Minister for Health and Children.
- The Primary, Community and Continuing Care Directorate will be made up of four Regional Health Offices of the Health Service Executive at regional level. At local level, existing Community Care structures will be strengthened to support the maximum local delivery of services and to provide an integrated framework for the development of the Primary Care Model.
- The Department of Health and Children will be restructured to ensure improved policy development and oversight. There will be a clear separation between the executive and non-executive functions of the Department. Key to its role will be holding the Health Service Executive to account for its performance.
- The Health Information and Quality Authority as set out in the Health Strategy will be established as a key agency in the new structure.
- A new governance framework will be developed. The purpose of this governance framework is to ensure that there are common professional parameters across the system designed to deliver accountability, standardisation and value for money. All remaining boards and any new boards established (e.g. the board of the Health Service Executive) will be subject to audit against the new governance standard.
- Supporting processes such as service planning; management reporting etc. will also be modernised to bring them in line with recognised international best practice.
Impact of the Reform Programme
So what will all this deliver ?
These reforms are essential to the advancement of the Strategy as a whole. Without them, the health services will not be able to respond adequately to its strategic objectives.
The new structures will provide a clear national focus on service delivery and executive management. It will achieve this through reduced fragmentation and the creation of clear and unambiguous accountability throughout the system.
In the area of the Primary, Community and Continuing Care, services will continue to be delivered through community care structures but they will be strengthened and will operate within a fundamentally realigned national management structure. This will be a proper framework within which all primary, community and continuing care services can be integrated.
In relation to acute hospital services – the reforms clear the way for a whole reorientation of the hospital sector around national priorities, high quality, best outcomes and better value for money underpinning the commitments made in the Health Strategy. It will provide a unitary approach to the delivery of hospital services and support the even and consistent introduction of consultant delivered services in Ireland.
The Health Information and Quality Authority will ensure that quality of care is promoted throughout the system by developing a framework of quality standards, and promoting the strategic development of information, communications and health technologies within the system. This strengthening of information systems and quality standards will support the evaluation of policy efficacy and system performance.
In relation to accountability, the programme will ensure maximum clarity between roles, clearer lines of accountability and best practice governance.
In relation to efficiency and value for money, it also provides for the development of shared services, where economies of scale can lead to:
- resources being freed up for front-line services;
- improved standardisation and
- a pooling of expertise and best practice.
The delivery of some actions in the Strategy will be linked to investment – this will continue to be true. However, the reform programme will ensure that the system can absorb additional investment effectively, and will help to demonstrate to the taxpayer and my colleagues in Government that any additional money invested will be well spent in delivering an improved service to patients and clients.
The new structures must have a positive impact on the delivery of the Government’s Health Strategy – this is its central premis.
The Democracy Question
The issue of democratic accountability in the new structure has been raised.
As a first step, the most important voice to be heard in planning the delivery of services is the patients, clients and their families. Arising from the Health Strategy, progress has already been made on developing and enhancing the opportunities for such input. Regional Co-ordinating Committees, Consumer Panels and Advocacy Services are all being developed as feedback mechanisms.
In relation to political representation, it was the view of Prospectus, endorsed by the Government, that as we have an Exchequer-funded health service with centrally determined resourcing decisions, Oireachtas members should have a responsibility to ensure that there is a match between funding of services and national priorities.
I acknowledge that it is important that public representatives have an opportunity to articulate their views on issues at regional and local level. I intend to place an obligation on the HSE and its regional offices to appraise and inform local representatives and the public generally in relation to service plans and developments regionally and locally. But it should be noted that the emphasis must be on ensuring that democratic input at regional level is focused on the delivery of national priorities. In addition, the roles of the Joint Oireachtas Committee on Health and Children and the Cabinet Committee on the Health Strategy will be increasingly important in ensuring adequate reflection of the views of public representatives in the ongoing oversight of the health system.
I have agreed to bring more detailed proposals to Government on the representation arrangements over the coming months.
The Hospital Question
I´ve already mentioned the implications for acute hospital service delivery. I want to draw your particular attention to this issue because, as many of you are aware, it is another strand of reform which will be put to Government shortly – the Report of the Taskforce on Medical Staffing (Hanly Report). The principles emerging, are centred on high quality and optimal outcome. International evidence demonstrates again and again that clinical outcomes for patients are improved when they are treated by multi-disciplinary specialist teams operating in units where there are high volumes of activity and access to diagnostic and treatment facilities. But it is neither practicable or realistic to suggest that we can provide this within immediate reach of everyone´s home.
We need to face up to these issues. As a society, we need to achieve consensus about the reality of achieving high quality safe care in a country of this size and population.
Managing the change programme will be challenging. I will not understate the enormity of the task ahead. Change is going to depend on the people working in the system. In that context, I must emphasise that the reports do not criticise the people in the system but the system itself. In fact, they emphasise our human resource as a key strength. The first step in implementing the new structures is an extensive programme of communication and dialogue with key stakeholders. I have already started on that process. The preparations for the consultation phase of the communications process within the health service are well advanced and the first sessions will commence on 9th July.
As an immediate priority, I will set about establishing structures to drive the implementation as soon as possible. This will include a National Steering Committee which will oversee and audit progress and a Project Office to plan and advance the programme. One of their first tasks will be to prepare a detailed project plan setting out a timetable for the various elements of the reform programme including identification of those actions that can be tackled early.
The Government has also agreed to the establishment of an interim Board of the Health Service Executive as well as an interim National Hospitals Office. I intend putting these structures in place in the Autumn to take early action on the advancement of the reorganisation of the hospital sector on the basis of the type of principles that it is understood will be emerging from the Hanly report to be published shortly.
In addition, I hope to make an early start on the internal restructuring of the Department itself.
I am determined to move forward as quickly as possible with implementation. I also believe that the decisions made will reinforce and build on the efforts to date in creating a more innovative and participative working culture in the health services, focused on continuous improvement in service quality. That´s what all of this must be about. This programme is about providing a framework for developing services and maximising the impact of these services on the patient and clients who rely on them.