National Healthcare Conference – Opening Address by the Minister for Health, James Reilly TD: “Reforming the Health System”
The theme of today’s conference could not be more timely. As the new Minister for Health, my primary goal is to radically reform the health system so as to guarantee equal access to healthcare for everybody in our country. It is my firm view that this can only be achieved through a single-tier system. One that gives access based on need – not on ability to pay. Hence, commitment to introduce Universal Health Insurance for the whole population of Ireland.
The introduction of Universal Health Insurance will be the most profound reform of our health system since the foundation of the State. And as with any real and worthwhile reform, it’s not going to be easy. We’ll have to chart our course carefully with the needs of the patient as our constant priority and guiding star. That is the critical point. Right now, the needs of the patient don’t come first. You’ve only to look at the funding arrangements for hospital care to see that. Public hospitals are funded using block grant historical budgets and, in the case of private patients, on the basis of per diem charges. Thus, each private patient is a source of additional income for healthcare providers, while each public patient is effectively a cost to the system. Moreover, neither funding mechanism encourages optimum efficiency. Global budgets ‘lock in’ historical inefficiencies and provide no incentive to increase service delivery. On the other hand, per diem charges may encourage increased service delivery but can also encourage longer lengths of stay.
Waiting times and waiting lists. They’re the constant measures of what’s wrong within our hospital system. Waiting times within Emergency Departments. Waiting lists for many elective procedures. Both unacceptable. And both with roots in our underdeveloped primary care sector.
But, of course, access to GP care is also organised along the lines of a dual system of support. This was noted by the Expert Group on Resource Allocation and Financing. It commented that the mechanisms in Ireland to finance healthcare are inequitable, placing particular burdens on people just above Medical Card threshold who require regular contact with primary care. This burden could deter people from getting care at the appropriate time and in the appropriate setting, resulting in missed opportunities for early, cost-effective intervention.
I share the views of the Expert Group; I believe the system is inefficient and inequitable. A truly, integrated and cost-effective healthcare system must involve moving away from the old hospital-centred model, where healthcare was episodic, reactive and fragmented, to more care in the community. That means reallocation of resources so we deliver more services in the less costly primary and community care sector.
Reform is also required if we are to deal with future cost pressures on the health system. I don’t believe much of the the investment to date has delivered enough improvements for patients. A number of key issues are likely to drive the future cost of healthcare. Firstly, demographics. Ireland has achieved a rapid and unprecedented improvement in life expectancy and improved living conditions.
But demographic changes will undoubtedly place pressures on the health system. In 2006, 11% of the total population was aged over 65 years; the CSO forecasts this to increase to over 22% by 2041. Moreover, the number of people aged over 85 years will quadruple over the same period.
Older people have more complex chronic illnesses, visit GPs more often and attend outpatient departments more frequently. We must plan for that. Secondly, the issue of technology. Investment in new medical technology has the potential to deliver better patient outcomes and greater efficiency. It also costs a lot of moneym On top of this, increased consumer expectations can mean that people are reluctant to have access restricted to new medical technologies or treatments, regardless of evidence of their effectiveness. The use of health technology assessments is particularly important in this regard to ensure the most effective use of valuable health resources.
Thirdly, the health sector is, by its nature, labour intensive. Medical inflation and employment costs are, therefore, very significant issues within the health environment. To this end, our commitment to renegotiating contracts with GPs and consultants and to achieving better utilisation of healthcare resources through the Croke Park Agreement will be key to delivering better value for money.
Now to the steps required to achieve our vision of an equitable and efficient single–tier health system.
The first step in this journey is the provision of universal primary care.
In our Programme for Government we have committed to introducing free GP care at the point of use to the whole population within our first term. We will achieve this on a phased basis supporting the sector to prepare for this major initiative, and allowing time to deal with issues such as GP workforce levels and registration.
2,600 GPs are currently in active practice. We must ensure there are enough GPs in place to respond to the likely increased demand for services arising from the implementation of free GP care for all. Workforce requirements will also be addressed through the recruitment of practice nurses to undertake work with GPs in primary care.
In order to achieve universal primary care provision, Primary Care Teams and Primary Care Centres must also be addressed. To date, the Primary Care Strategy ‘A New Direction’ has been the blueprint for the development of primary care services in Ireland and a key aim of that strategy was the development of Primary Care Teams. I acknowledge that some groundwork has been undertaken by the HSE to get Primary Care Teams up and running. I still want to see greater progress in this area and it is something that I will seek significant action on in my time in office as Minister for Health.
Primary Care Teams are one of the central components for the creation of a modern, integrated health service. In turn, one of the central components for the creation of successful Primary Care Teams is the development of primary care centres, a topic which, I understand, you will be discussing here today.
International research shows that shared premises are a key enabler for successful team working in the primary care setting. Shared premises encourage and facilitate interaction across all health care professionals and that is why we are committed to developing a network of new primary care centres. I appreciate that the HSE has advanced the development of these centres but, again, I want greater progress on this issue.
In Ireland, chronic diseases account for 86% of mortality and 77% of overall disease burden; they tie up 70% of health resources and account for 2/3rds of emergency admissions to hospitals. Approximately 80% of GP consultations and 60% of hospital bed days are related to chronic disease.
These statistics highlight the importance of managing chronic disease. Best practice promotes the use of multi-disciplinary teams to deliver responsive, community-based care. However, the incentives within the current health system don’t support this. We must do better. That’s why we have stated in the Programme for Government that we’ill negotiate a new GP contract requiring GPs to work in an integrated way with Primary Care Teams and to care more intensively for patients with chronic illness. GPs and Primary Care Teams will be supported in the provision of chronic disease management by a number of complementary initiatives including . the development of clinical care pathways and the development of electronic patient information systems.
Briefly, on ICT, one of my priorities will be to progress the Health Information Bill. This Bill will provide an enabling legal framework (i) for the introduction of a unique health identifier for patients, healthcare professionals and healthcare organisations and (ii) to facilitate greater linkages between electronic health record systems.
Another key priority area where integration across the whole health system is crucial is that of mental health. It is a well known statistic that ‘one in four Irish people will experience a mental health problem at some point in their lives’. Now more than ever, we need a mental health system that works.
That is why we are committed to enhancing mental health services and pursuing the recommendations of ‘A Vision for Change’. In particular, we continue to support the movement of patients out of psychiatric institutions to more appropriate community based facilities. This again highlights the need for an integrated joined-up approach.
Patients must be able to access a comprehensive range of mental health services in the primary care setting, and we will seek to strengthen GP education and training in mental health.
Having an effective, modern mental health service embedded in the primary care sector will help in reducing the stigma of mental illness, will avoid isolation by treating mental health similarly to other health needs, and will contribute to building a healthy and productive society.
The developments I have outlined demonstrate our commitment to enhance the capacity of the primary care sector to encourage integration and a more efficient use of resources. That, however, is only the first step of the reform process.
The second step in the reform process involves the acute hospital sector. In parallel to developing the capacity of the primary care sector, there will also be a strong focus on reforming the acute hospital sector and this will begin with waiting lists.
This Government has agreed a plan of action to deal with waiting lists. The central plank of this plan will be the creation of a Special Delivery Unit (SDU). Modelled on the Northern Ireland experience, the SDU will be established in my Department, with strong representation from the HSE and also input from individuals from both Northern Ireland and the United Kingdom who were instrumental in its set up. It will have as its core focus the elimination of waiting lists. Rigorous performance management processes will be put in place and waiting list times will be monitored on a daily basis. As Minister for Health, I will directly oversee the results of the unit.
I believe the Northern Irish model will work well here. The establishment of this unit will focus minds on achieving maximum efficiency in the delivery of quality care, thereby reducing waiting lists and times and, ultimately, benefiting patients.
I will also be driving a more fundamental financial reform of the acute hospital sector. Under ‘Money Follows the Patient’, hospitals will be paid per patient seen. This is a more efficient financing mechanism which incentivises acute hospitals to treat more patients; an incentive absent from the current block grant funding allocations.
That said, I am acutely aware that, in designing any new payment system, it will be necessary to build in safeguards for ‘quality’ and to ensure that the payment system does not encourage ‘cherry picking’ of straightforward cases. “Money follows the patient” will be an important stepping stone to Universal Health Insurance.
Under the new Universal Health Insurance system everyone will have health insurance from their choice of insurance company. This insurance will guarantee every citizen equal access to a comprehensive range of hospital and medical services. Moreover, it will offer greater transparency for people by directly linking their payments on health insurance to an associated level of benefits or service entitlements.
The core purpose of universal health insurance is to achieve equity of access to healthcare. Similarly, the concept of equity will inform the internal design of the insurance system which will be based on community rating and a robust risk equalisation scheme, governed by a new Regulator – the Hospital Insurance Fund.
I’ve outlined here today why the health system is in need of reform and how that reform might look. Universal Health Insurance is the ultimate destination of this Government’s reform programme. That end objective of all the reforms I’ve touched on is to deliver a healthcare system that:
- keeps people healthy,
- provides equitable access to services based on need,
- is of the highest quality and
- represents value for money.
In other words, the journey of reform is toward a health service that all have access to and feel safe in and that those who work in are proud of. It’s not going to be a short journey. Not going to be an easy journey. But it is a pivotal journey. It is at the heart of our duty of care to every citizen. And it is an urgent journey. Let’s start with the confidence that we’re doing what is desperately needed. For now. And for generations ahead of us.
Can I finish by saying a few words about my first two weeks as Minister for Health I have had many meetings with the Department of Health and a number with the HSE. I have been truly impressed by many of the people I’ve met, by their knowledge and grasp of the problems but even more so by their energy and enthusiasm for change.
I’m looking forward to working with them all and all other healthcare professionals to deliver the excellence in healthcare that I know we are capable of and that our citizens so richly deserve.