Speech by Minister Varadkar to the IHCA Annual Conference
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President, Secretary General, office-holders, members of the Irish Hospital Consultants Association, colleagues, distinguished guests.
First of all, I want to thank you for inviting me to be here at your Annual General Meeting. I want to apologise for not having made it last year. This was due to a personal commitment. I know that my Secretary General addressed you in my place. I hope you found his contribution to be worthwhile.
I understand this is the first time that the Minister for Health has addressed your conference since 2012. It is my first time to do so and I hope it won’t be the last.
This morning, I want to divide my remarks into two parts:
- Some general thoughts on medicine and the health service
- And some specific words on consultants and the crucial and enduring role you play in our health service and society.
Our health service, as you know, has been through a very difficult period. We had three years of spending cuts under the last Government and a three year spending freeze under this one. That occurred against a backdrop of rising demand from a growing and ageing population and the development of expensive new treatments and interventions.
On a positive note, in 2015 we secured the first Budget increase in seven years, which has allowed us to take on or regularise 4,000 more staff and fund new treatment programmes. Nonetheless, we are still operating with about 10,000 fewer staff and a budget that is still more than €1.5 billion lower than it was at peak.
That is, of course, reflected in things like excessive waiting times and ED overcrowding. Needless to say, this makes it a real challenge to deliver the kind of health service we aspire to and that’s true from the frontline to the back office, in Dr Steevens and Hawkins House. It’s a challenge that I welcome and I’m determined to meet it head-on.
And so I support your call in your pre-Budget submission for a substantial further increase in the health budget in 2016, and you can be assured that that is what I am working towards in my negotiations in the run-up to the Budget in two weeks’ time. Having said that, I am conscious of the limitations on the public purse, and the need to ensure that we do not repeat the mistakes of the past by growing public spending too quickly.
I am also very aware that it isn’t all about money. As you point out eloquently in your own Budget submission, the number of patients treated in 2012 was a quarter of a million more than in 2008, despite a significant cut in the health budget during that period. This came about as a result of our health service becoming more efficient, but also reminds us of the need to continue to become ever more efficient, so that we can demonstrate to taxpayers that their money has been well spent and has delivered real improvements for patients.
Because of the enormous sacrifices that the Irish people have made and the decisions by government, all of which were tough on people, the country is now back on track. The economy is recovering and we can see it all around us:
- 120,000 more people back at work.
- Unemployment at a six year low.
- More cars and trucks on the road.
- The public finances back in order – the budget deficit below 3% and the national debt falling as a percentage of GDP.
- The first reductions in Fianna Fáil’s USC and income tax in our pay slips last January, and more to come next January, alongside the first reductions in the public sector pension levy.
The recovery is strong but it is also fragile. The challenge now is to protect the recovery from those who would wreck it. We must sustain the recovery as without a strong economy we will not have the resources we need to invest in our health service, in education, childcare, housing, infrastructure, and all of the other areas that need attention.
If the first phase of the recovery was about repairing our economy, the second should be about restoring our society. That is our ambition and our vision.
I can, of course, understand why people sometimes feel overwhelmed by the scale of the challenge facing our health service. While there is much still to address, we should allow some space to recognise some of the real improvements that have occurred in recent years.
Having returned to Health after a period away, I am frustrated that so many long-standing problems remain, but I am also impressed and enthused by many of the positive developments that have occurred.
Compared to four years ago, we have more consultants and NCHDs employed in our public health service than ever before. We have 5,500 NCHDs, a thousand more than when this Government came to office, and 2,700 consultant posts, 320 more than when this Government came to office, and 700 appointed in the last decade.
If it has been possible to do that during a period of retrenchment, surely it’s possible to do better again during a period of growth? I believe we should now set ourselves the objective of reaching the Hanley target of 3,600 within the next five to seven years.
We have a much better ambulance service. Rather than a mere transport service, paramedics now deliver care on the scene and in transit. We have dedicated paediatric and neo-natal retrieval. Earlier this year I opened the new National Control Centre in Tallaght, which now serves the entire country. And we now have a permanent air ambulance.
We have the National Clinical Programmes making real improvements to pathways of care in areas like stroke, heart attack and COPD to name just three.
And we also have remarkably successful new programmes such as bilateral cochlear implants for children, one of whom I met only yesterday on Arranmore Island, as well as taking the lead in providing curative direct acting anti-viral medicines for patients with Hep C.
We have a major expansion in prevention and screening including the extension of Breastcheck to women aged 65-69, Cervicalcheck, Bowelscreen, screening for Cystic Fibrosis and deafness at birth, and diabetic retinopathy in later life.
We have improving cancer survival rates and rising life expectancy, more people surviving stroke and heart attack, falling medicine prices, and falling MRSA infection rates.
We have HIQA setting, raising and monitoring standards in hospitals, nursing homes and now care homes.
All of us have been shocked at the content of some of HIQA’s reports, particularly when it comes to hygiene in hospitals, quality of care in some hospitals, and the treatment of elderly residents and those with intellectual disabilities in some care homes. But truth be told, these problems cannot be new, they must have been going on for decades. The difference now is that they are made public and we can deal with them and deal with them we shall.
The health service is an enormous contributor to the economy, employing 100,000 people in the public health service, and 100,000 more in private healthcare, the pharmaceutical industry, medical devices and life sciences, and keeping millions of workers healthy.
I have never pretended that all is well. I know that’s not the case. But there is a lot to be positive about in Irish healthcare, and which we should be proud of, and you should be proud of, as you are the ones that are making it happen.
And so I ask you not to be critics of the Irish public health service, but rather to be advocates for it. Tell people about the good work you are doing, and how we could do more, and do even better.
Doctors, I believe, have a responsibility to advocate on behalf of patients and must continue to do so. There should be and will be no gagging clauses as long as I am Minister. But I know what patient advocacy is, and I also know what it is not, and I think you do too. Patient advocacy should never compromise patient confidentiality, and should never be a tool to be used in industrial relations or inter-personal disputes. And I know most of you will agree.
Hospital beds are not used as efficiently as they should and average length of stay, day of surgery admission and day case rates vary inexplicably from place to place. According to the OECD, which has no axe to grind, and is extensively quoted in your own pre-Budget submission, Irish doctors see fewer patients on average than their peers. There might be good reasons for all of this but it is still not as it should be and we need to change it.
Now that we are in a time of rising budgets again, I believe that it should be a basic principle that no additional resources should be provided to any service that cannot demonstrate that it is using its existing resources to maximum effect, whether that’s staff, beds or cash. The taxpayer deserves no less.
At the start of the year, Minister Lynch and I set out our work programme for 2015. It contained 25 actions. The good news is that I am not going to go through them one by one but I do want to outline the five major themes.
First and foremost is always Healthy Ireland. We need to improve our health as individuals and as a nation. This is the best way to ensure we live long and healthy lives and the most effective way to keep health costs under control in the long term.
The Healthy Ireland survey is now complete and will be published next week. It is the first measure of Ireland’s health since 2007 and will be repeated annually to monitor progress.
The legislation on plain-packaging of tobacco has now been signed into law, and subject to court challenge will be in force next year. Later this month I will publish the Public Health Alcohol Bill. Earlier this summer we further restricted sunbed use and published the new National Strategy on Suicide. We will also update our policies and strategies on obesity, sexual health and physical activity.
The second theme is patient outcomes and patient safety. As you know, I have taken a personal interest in Emergency Department overcrowding and have secured almost €100 million in additional funding this year to alleviate the problem. This has allowed us to reduce the waiting time for the Fair Deal Nursing Home Support Scheme from 15 weeks to four, which in turn has reduced delayed discharges for hospitals from 850 to under 600 now, freeing up 250 acute beds every day. It has also allowed us to open another 150 community beds, including Dublin’s first community hospital at Mount Carmel. More community beds will be opened before the end of the year. It’s also allowed us to increase investment in health services and keep patients out of hospital altogether, or allow them to get home earlier, thanks to community intervention teams, day hospitals, and acute medical admission units. This will continue.
While we have seen an improvement in patient experience times in our emergency departments, and a fall in numbers of people waiting on a trolley for more than nine hours, overall morning peak overcrowding has not improved and is worse than the same point last year.
The next steps are to open about 300 additional hospital beds across the country in November and December, and the Director General and his team are visiting the worst affected hospitals to see what can be done to address other blockages such as diagnostics and rapid access to outpatients. It’s also clear that we need more weekend discharges, and more evening ward rounds to reduce length of stay, and also senior decision makers reviewing patients shortly after or before admission, in order to reduce unnecessary admissions and length of stay.
I understand the distress and hardship that all of this is causing to patients and their families.
I know that you are at the front line of their distress and are often abused for the shortcomings of the system. I really want to appeal to your members and to everyone who works in the health service to work together to implement the Emergency Department Task Force Plan. Patients deserve no less and should be unforgiving if implementation becomes a source of conflict, rather than co-operation.
Treatment delayed can be treatment denied and I share the Association’s concerns about long waiting times around patient appointments and procedures. An additional €50 million has been provided to the HSE this year to focus on reducing substantially or eliminating where possible the number of people waiting 15 months by the end of the year. My preference is that these additional resources should be used in-house, but outsourcing to private hospitals is an option.
I intend to publish a package of patient safety measures in the coming months which will include measures to establish an enhanced patient safety function within my own Department, the creation of a Patient Advocacy Service, the development of monitoring of the National Clinical Effectiveness Guidelines, a Health Information and Patient Safety Bill to extend the role of HIQA to private hospitals and homecare and to protect Open Disclosure, and also progress legislation to bring in a licensing system for healthcare providers.
The third theme is Universal Health. This year we successfully implemented the first two phases of Universal Healthcare by extending GP care without fees to the youngest and oldest in our society, those under 6 and over 70. Some 300,000 of the youngest and oldest people in our society no longer have to pay to visit their GP. Last week I launched the new Diabetes Cycle of Care, enabling Type 2 Diabetes patients to be managed by their GP. More than 31,000 patients have been signed up. In the next two years I would like to extend GP care without fees to all children, and expand the role of general practice to cover the management of other chronic diseases.
In the last year we have introduced a number of measures to increase the number of people with health insurance, including discounts for young adults, lifetime community rating, and a reduction in stamp duty and Health Insurance Authority levies. As a result, 100,000 more people have health insurance today than a year ago. I will be proposing further measures to make health insurance affordable in the future.
I am a strong believer in universal healthcare, by which I mean access to affordable healthcare for everyone in a timely manner. But the foundations have to be put in place first. These include addressing some of the significant capacity constraints that exist in our health service, the full implementation of Activity Based Funding, the establishment of the Healthcare Pricing Office on a statutory basis, a new fairer Drug Reimbursement Scheme, and the further development of the Hospital Groups and Community Healthcare Organisations. I don’t think it’s something to be rushed, but I do think we can do something every year to significantly improve access to healthcare. Universal Healthcare in steps.
The fourth theme is reform. I am very much behind the Hospital Groups. The CEOs and their senior teams are now in place, and I hope to appoint the remaining boards as soon as possible. Legislation is being prepared to establish the Children’s Hospital Group Trust on a statutory basis, and legislation to establish the other hospital groups can be done within two years.
Nine Community Healthcare Organisations have also been established. Together these reforms will enable the creation of a purchaser/provider split, the establishment of a Commissioning Body, and for the HSE to be dismantled during the term of the next Government.
One of my priorities is to ensure that Activity Based Funding is embedded across the health service. The HSE Healthcare Pricing Office has published an implementation plan which sets out objectives up to 2017. With your co-operation, this is a great opportunity to use ABF to improve the quality and efficiency of inpatient and daycase treatment, and expand ABF into other services like outpatients.
The fifth theme is investment in modern infrastructure and facilities including ICT. Earlier this week the Government approved a capital envelope of more than €3 billion over six years for health, and public private partnerships to the value of €150 million. This will allow works to begin on the four major national hospital projects next year, subject to planning permission. These are:
- The new National Children’s Hospital on the campus of St James’s and the satellite centres in Blanchardstown and Tallaght;
- The new National Maternity Hospital to be co-located with St Vincent’s;
- The new National Rehabilitation Hospital in Dun Laoghaire;
- And the new National Forensic Mental Health Hospital in Portrane.
It will also allow significant progress to be made on five major national programmes:
- The National Radiation Oncology Programme;
- A major €300 million programme to refurbish or replace community nursing units and residential facilities for people with disabilities;
- To continue to provide ten new primary care centres every year;
- Relocating the three remaining stand-alone maternity hospitals;
- A major investment in new ICT.
Staying on that subject of ICT, we have clearly lagged significantly behind our peers. But good work is now underway and we are finally starting to catch up.
Obviously ICT is really important for communications, and earlier this year the new Healthmail e-mail service was launched. This allows clinicians in primary and secondary care to communicate with each other over a secure network.
Healthmail is connected to all HSE hospitals and health centres, and to over 20 voluntary hospitals and agencies. It allows clinicians to access clinical information immediately at the point of care, and GPs to send queries to hospital clinicians. In many cases it removes the need for an outpatient referral. It also has the potential to speed up discharges by enabling direct contact between GPs and hospital personnel.
Another initiative that I am enthusiastic about is the National Electronic General GP Referral Project. This has been successfully implemented in all hospitals in the former Cork and Kerry Hospital Group and in the paediatric specialty area in Tallaght Hospital. This project is now under the remit of the HSE’s Chief Information Officer. A further five sites have been identified and are preparing to implement the service.
The five sites are:
• St Vincent’s Hospital, Dublin;
• St Michael’s Hospital, Dun Laoghaire;
• The Mater Hospital, Dublin;
• University Hospital Galway; and
• Letterkenny General Hospital.
Other major projects include the electronic patient record, a new financial system for the health service, and the individual health identifiers.
Other national developments
We have started work on a national policy for trauma services. There is international evidence that there are many benefits to organising trauma on a national basis. We have set up a Steering Group to develop a Trauma Network for Ireland, which met for the second time last month, and will report by the middle of next year.
Work is also underway on a new National Cancer Strategy for the period 2016-2025, which we expect to be ready by the end of the year or early next year.
The Department is currently developing a National Maternity Strategy which will be completed this year. At the same time, a National Women and Infants Health Programme is being established to reform and standardise care across all maternity units. The leadership post for the programme will be advertised in the near future. The two initiatives will be closely integrated.
Confidence in our maternity services has been badly damaged in recent years. But on any objective analysis maternity services in Ireland are good. This is evident from the fact that maternal and perinatal mortality rates in Ireland are lower than in the UK or US, for example. Far from being neglected, maternity services have been strengthened in recent years. We have more midwives than ever before and are recruiting more.
We have more consultants, obstetricians and gynaecologists than ever before, and we are recruiting more. Nine additional posts were approved in the last year alone. Morale at the moment is very low, and that is due to pay cuts, staff being overstretched, and relentless and often negative publicity. In the interests of patients and mothers, particularly those on their first pregnancy who have enough to worry about, I think we all need to be careful not to do anything to fuel that.
The challenge we have in recruiting consultants and nurses is well known and very real. What’s less well known is the very real progress we are making. We have 500 more nurses on the payroll than we had this time last year, and more midwives, advanced nurse practitioners and clinical nurse specialists than ever before. Early indications suggest that the vast majority of the graduating class of nurses in 2015 are staying in Ireland. The spend on agency staff is €11 million lower.
So far this year the number of doctors and dentists employed in the public health service has increased by 150. The number of consultants employed in the year to August 31st has increased by 72 net. That’s an increase from 2,623 at the end of August last year to 2,695 at the end of August this year. At the current rate, we could see as many as 130 additional consultants appointed this year.
While it remains the case that it is hard to fill vacancies in some specialties and hospitals, overall the picture is improving. The new pay scales agreed with the Irish Medical Organisation at the Labour Relations Commission mean that post-CST experience and relevant higher qualifications are now recognised for incremental credit.
This means most new entrant consultants will come in on a salary of €150,000-€155,000 for a Type A post, rising to €175,000 at the top of the incremental scale.
Pay for consultants will continue to improve over the next number of years. On January 1st a change in the pension levy will give €733 back to doctors in 2016, and €1,000 in subsequent years. There will also be reductions in income tax and USC to boost take-home pay.
Consultants who have accepted the Haddington Road and Lansdowne Road agreements will have pay restored in three phases: April 2017, April 2018 and April 2019. This represents pay restoration of about €12,000 to €13,000 per person. For example, this will bring the salary of a Type A consultant at the sixth point on the scale appointed prior to September 2012 back up to €192,000 in April 2019. I think this is going to make us much more competitive with other English-speaking countries when it comes to salaries than we are at present.
I know that there is considerable dissatisfaction across the public service about the disparity of pay between new entrants and established employees. I am sure this is something that can and should be addressed in the next public sector pay round. It is my deep regret that the IHCA has not signed up to these agreements. I would ask you that you reconsider.
Last year the Secretary General of the Department of Health spoke at your conference and asked how you can fully influence change if you are not fully involved in the State’s public service processes. I would again ask you to consider your position. Surely it’s better if we work together to address the issues and create solutions?
It is simply not possible to have some sort of special arrangement or bespoke process to negotiate consultant pay. Consultants are public servants and the same system of collective bargaining that applies to all other public servants should also apply.
I also want to give some thoughts on the different types of consultant contract. It is my own view that the system of Type A, B and C contracts isn’t working any more. It creates an inequality among consultants in what’s a very unequal health service. I would prefer to move to a single contract, perhaps similar to that of consultants in the NHS with a basic salary and a system of bonuses and excellence awards.
Being a hospital consultant in a public hospital is a really busy, full time job. And consultants shouldn’t really have time for private practice outside of the hospital during normal working hours. Those who want to do private practice, should perhaps have part time or session contracts instead. And those who wish to do private practice in their own time should be allowed to do so, provided they honour the terms of their public contract, and provided we have a means of verifying that they have. But these should all be matters for future negotiation.
I know that for many consultant colleagues, the issue of litigation and the high cost of indemnity is a real concern. It is of concern to me too. I am working with Minister Frances Fitzgerald on this matter. Legislation is in train to introduce pre-action protocols so that litigation can be avoided more often and expedited where necessary.
Legislation is also in train for periodic payment orders. As I mentioned earlier, legislation is being advanced to protect Open Disclosure of patient safety incidents. It is intended that this legislation will provide legal protection for disclosure to patients and their families for adverse events which may occur in the treatment of a patient. However, legislation or no legislation, open disclosure has been national policy since November 2013, and I ask all staff to familiarise themselves with that policy and adhere to it.
More and more, the state claims agency, in defending claims on behalf of hospitals, advocates mediation as the preferable alternative to the adversarial courts system. The agency settled 13 cases in this way in 2014, and offered mediation in many others. I know the issue of caps under the clinical indemnity scheme has been raised with me by the Association on a number of occasions. On foot of this, the State Claims Agency has been asked by the Department to conduct two evaluations.
The first study is being conducted by PWC and is examining the high and medium risk specialties where premiums have increased significantly. This report is expected soon.
Separately, Lane Clark & Peacock are undertaking an actuarial study of the financial impact on the State, if it were to indemnify consultants on a ground up basis. That is – the abolition of caps and the collection of subscriptions from consultants in full time private practice. I should point out that any change in policy would require Government approval and would have to conform with competition law, which could be a major barrier. I think it’s also worth recalling that no other professional group in full time private practice is indemnified by the State.
The role of medics
Everything that I have discussed today is predicated on having the consultants and staff to implement these changes and reforms. That’s why I have committed to implementing the recommendations of the Strategic Review of Medical Training and Career Structure, the McCraith Report, which was completed in 2014.
I want a public health service that values the contribution and commitment of all trainee doctors. There have been a number of positive developments arising from the recommendations of the Group. I believe these will have a positive impact on the quality of the training experience, and the working lives of trainee doctors.
For example, many trainees now have pre-defined rotations at the start of their training schemes.
I also regard the implementation of the Lead NCHD Initiative at national level as a very important step. This initiative was piloted by the HSE in five acute hospitals in 2014. It has now been expanded, and this year a total of 31 hospitals are involved.
The Group made recommendations on a number of issues which will interest you as consultants. These include:
• a more differentiated consultant career structure;
• developing flexibility within your work commitments;
• family-friendly flexible working;
• improved supports for newly-appointed consultants;
• and more clarity around the availability of consultant posts by speciality and location.
We need to achieve full compliance with the provisions of the European Working Time Directive. We have also made progress in reducing the numbers of NCHDs working over 48 hours per week to 25% of the cohort.
But we have to do a lot more to enable the remaining 25% to comply with this provision of the Directive.
We have to get there. While the Court of Justice judgment in July did not support the Commission’s referral of Ireland for breaches of the Directive, the Commission can still choose to refer Ireland back to the Court if it is not satisfied with our further efforts.
In some areas, compliance can only be achieved through service reform and reconfiguration. I will support the required measures. In some cases there needs to be a change in mind-set, as I did. Some of you here today may have worked well in excess of 48 hours and may believe that this is critical to achieving a high standard of training and education. But we now need to adapt our training and work practices.
We need your support if we’re going to do this. As medical professionals who are training staff, it is imperative that you support and encourage NCHDs to work within their rostered hours.
While we’re still on the subject of trainees, the most recent survey indicates that a majority of trainees see their future in Ireland, and less than a quarter say they are definite or likely to leave. This is really encouraging. However, when you drill into the numbers, those who plan to leave are much more likely to have had a bad experience during their training years. We all agree that bullying of any shape or form should not be tolerated. And the Medical Council report shows a significant and moderate association between trainees’ general health ratings and their reported experience of bullying.
I would also like to take this opportunity to draw your attention to the MacCraith recommendation on mentoring. I support this for trainees as it can help to integrate them into their role in a supportive manner. I recognise that many of the training institutions have voluntary and informal arrangements in place. It is my intention that the mentoring role will be formally introduced and that this will provide additional support for our trainees.
Young doctors and doctors in training are among our brightest and best. We have invested in their education and we want them to want to stay. From the Government’s point of view we can do this by improving pay and working conditions over the next couple of years. But others need to play their part too. This includes the training bodies who need to ensure that rotations and training posts are attractive, and also you as consultants and trainers in finding the time to mentor trainees, teach them, and encourage them and be empathetic and supportive towards them.
I’m delighted to be at this year’s AGM in person because it’s my first real opportunity to speak to you, and to acknowledge the vital role that consultants play in the health service.
No hospital could function without you. Many of you have demanding or stressful roles, or work in difficult environments. But I know that you do the very best that you can for your patients. And I want to recognise that today.
I also would like you to take a message of hope away from this meeting. Yes, we still face very many difficulties, but I hope I have explained why I think there is every reason to be optimistic about the Irish health service. There is a lot of work to be done, but things are getting better in many sectors.
We will never have a perfect health service. No country can, or does. But we can all strive to make it the very best health service that Ireland has to offer. And I know that you try to do that on a daily basis.
And that is why I want to ask you again to play your part as advocates for the health service. Tell people about the great work you are doing, and about the good things which do happen in the health service.
So thank you and keep up the good work. I look forward to the rest of the conference.