Opening Statement by Minister Harris at the Joint Committee on Health
**Check Against Delivery**
I am delighted to come before the Committee today. I am joined by Jim Breslin, Secretary General of the Department.I am very grateful to have the opportunity today to discuss the Sláintecare report with the Committee. I will set out the process that we are engaged in to act on the report and will outline some of the steps already taken to advance recommendations in the report.
At the outset, it is important that I reiterate some general messages. These are things that I have said since the idea of the All-Party Committee was first mooted. And they are things that I believe even more so now that the Committee has completed its work. The establishment of the Committee provided a unique opportunity and space for all parties to put aside political ideologies and policy differences and to work together in the best interests of the people they serve. The Committee members did not side-step that task and lived up to their mandate. I will take this opportunity to again acknowledge and thank the Committee members and all those who engaged in consultation with them throughout the process.
This is the first time in our history that we have achieved consensus at a political level on the future direction of our health system. These opportunities don’t come around too often and I am determined to harness this political consensus and to work with colleagues across the political spectrum and with all stakeholders to move forward on a programme of health reform that will ultimately benefit the health of our citizens and our society.
The process of reform will only succeed through the commitment and buy in of all stakeholders to a shared vision. We have started on a solid foundation of unprecedented political consensus and must now seek to build consensus across the system, including clinical consensus and buy-in, to the necessary reforms.
We are all aware of the challenges of implementing change in our health system. Healthcare delivery is a complex endeavour and we in Ireland are not unique in encountering a variety of challenges. We now have an opportunity to learn from our own past experience as well as international experience, and to design a programme of reform and the necessary supports to engage stakeholders across the system and sustain momentum over the coming decade. Moving towards a universal health system for all citizens is a transformational change in the Irish context and it will take on-going commitment. Our continuing motivation will be our shared and agreed ambition to better serve the people of Ireland and to help shape a healthier future.
The Case for Change
It is important to set out the context for the Sláintecare report. The Committee on the Future of Healthcare was established in recognition of the fact that our current health system, despite notable achievements, is not well placed to meet the demands of future generations. We need to design a system today to meet the many challenges coming in future years.
These challenges are well cited – our population is rising and the increase in those in older age groups is particularly relevant; there is a growing prevalence of chronic disease; health inequalities and unmet need are increasing; and there is an on-going challenge to attract and retain the right workforce in terms of skills mix and numbers.
Committee members will have seen the report published by the ESRI last month entitled Projections of Demand for Healthcare in Ireland, 2015-2030. The picture painted in this report is stark and highlights the challenges that face our system in the next decade and reinforces the case for change.
The main findings of this report are that over the years 2015 to 2030:
· The population of Ireland is projected to grow by between 14 and 23 per cent adding between 640,000 and 1.1 million people to the population
· The share of population aged 65 and over is projected to increase from one in eight to one in five
· Numbers of people aged 85 and over are projected to almost double
Because of these changes in demographics, demand for health and social care is projected to increase across all sectors, with the greatest increases for services for older people:
· Demand for home help care and for residential and intermediate care places in nursing homes and other settings is projected to increase by up to 60 per cent
· Demand for public hospital services is projected to increase by up to 37 per cent for inpatient bed days and up to 30 per cent for inpatient cases.
· Demand for GP visits is projected to increase by up to 27 per cent
We also know that the nature of the illnesses faced by the Irish population is changing. Now approximately 60% of Irish people over the age of 50 have one chronic disease and around 25% have two or more chronic diseases. Chronic disease requires a different type of care – care that is preventative, ongoing and managed close to home.
Ireland is not unique in the challenges that face our system. It is clear that the world around us is also changing rapidly and similar demographic and disease challenges face countries worldwide and particularly in Western Europe. Rapid changes in mobility and technology present new challenges such as the spread of infectious diseases and the risk posed by antimicrobial resistance. The development of knowledge and technology also presents opportunities to fight diseases that were previously debilitating and to access the best new therapies and medicines. The world will continue to change in ways we can’t yet imagine, so we must have the flexibility, ability and leadership to respond. We must be innovative in thinking about how to best serve the Irish population into the future. The work of the Future of Healthcare committee has provided us with the collective space to reconsider our direction and start to plan for a healthier future.
I will now turn to the report itself. The recommendations in the Sláintecare report are grounded in eight overarching principles that I fully endorse. These support a re-orientation of the health service towards a high quality integrated system providing care on the basis of need and not ability to pay; a universal system providing the right care in the right place at the right time, provided by the right people.
The principles describe a system that is modern, responsive and integrated, comparable to other European countries, one that inspires long-term public and political confidence. In order to achieve this system the report highlights the need to place the patient at the centre of a system which delivers care that is timely, provided free at the point of delivery, and provided at the most appropriate, cost effective service level with emphasis on prevention and public health. The report also points to the need to create an enabling environment for reform. This is an environment where the workforce is appropriate, accountable, flexible, well-resourced, supported and valued, with accountability, value for money and good governance at the heart of the system. I believe that this describes a health care system that will command the support of the people of Ireland and will meet their needs.
It is also important to highlight that a number of the recommendations in the report are supportive of current policy developed by successive Governments and initiatives that are already in train. In particular, the report strongly supports a real shift in our model of care, moving away from a hospital centric approach to one which is focused on prevention, early intervention and providing the majority of care in the community.
A range of other ongoing initiatives are given strong endorsement in the report including: the Healthy Ireland strategy, eHealth, integrated workforce planning – and I was delighted to launch our new National Strategic Framework for Health and Social Care Workforce Planning last week, a robust clinical governance framework, enhanced community nursing, integrated care programmes, and current strategies in the areas of maternity care and mental health. The support for these initiatives is helpful and can add greater impetus to their successful delivery. Sláintecare also gives us a means to pull together these various initiatives into a coherent framework for the future.
Progress to Date
I would now like to outline decisions already taken and work that is underway to develop a programme of reform to take forward the proposals in Sláintecare.
When I spoke in the Dáil chamber in June during the debate on the Sláintecare report, I was clear in my conviction that the publication of the report will come to mark a critical milestone in the history of our health service. I was also clear that we needed to allow time to reflect and deliberate on the findings of the Committee and consider how best the vision and spirit of the report can be realised. This process of consideration is well-advanced.
In July, the government agreed to move forward with the establishment of a dedicated programme office and specifically the recruitment of a Lead Executive for that Office. This marks a critical first step in gearing up for a significant programme of reform and demonstrates the Government’s commitment to this process. €1 million has been allocated to this Office in 2018 in line with the report’s recommendation.
The recruitment process for the Head of this Office is underway and is being managed by the Public Appointments Service. It is essential that we are positioned to attract candidates of calibre for what will be a considerable reform programme. An extensive national and international executive search is being undertaken as a first step in this recruitment process, with the aim of attracting very senior candidates with a strong track record in implementing large scale programmes of reform.
In parallel to this process, I have also been tasked with developing a response to the report and a draft implementation plan for consideration by Government by the end of this year. This process is seeking to translate the Sláintecare report into a programme of action for the next ten years and will consider issues that arise in designing such a programme including key actions, deliverables, costings, timelines, and interdependencies. It was acknowledged in the Sláintecare report that more detailed consideration of these issues would be required and this is the work that is currently underway.
This process is being led at the most senior levels in the Department and the HSE and also involves close engagement with the Departments of the Taoiseach and Finance, Public Expenditure and Reform.
The involvement of these Departments was a key recommendation in the report, as was the need for strong cross Government political leadership. This view is shared by Government. In recognition of this, the Cabinet held a special Government meeting in Cork last month focused specifically on healthcare reform and the Sláintecare report. Later this week, there will be further discussion at the Cabinet Committee on Health, which is chaired by the Taoiseach, of the development of the implementation plan which is underway.
At the meeting in Cork, I was tasked with continuing the process of developing a response to the report for Government’s consideration, and given approval to move ahead with a number of actions recommended in the report.
These are as follows:
1. The initiation of an impact study on the removal of Private Practice in Public Hospitals.
One of the transformational recommendations of the Sláintecare report is that we would move towards a universal system of healthcare which would address the current inherent unfairness in our system when it comes to accessing care. The report rightly points to the issue of private practice in public hospitals in this regard. The Committee acknowledges that it will take time to change this system, that careful consideration will need to be given to the impact of such a change, and that there will be a very considerable price tag attached. But we can’t shy away from the core issue – that when the public system is under severe strain, when EDs are full and waiting lists grow, it is hard to defend an arrangement whereby private practice continues unquestioned in public facilities.
As Committee members will be aware, Dr Donal de Buitléir has been appointed to chair an independent expert review group to examine this issue. The review group will be a strong and balanced group, bringing extensive experience and expertise in healthcare including in hospital management, and also in governance, finance, human resources and employment law. Membership of the group is being finalised and I hope to be in a position to make an announcement in the coming days.
The Group will specifically examine potential benefits and potential adverse consequences which may arise in the separation of private practice from public settings. I will be asking the group to pay particular attention to the following elements:
· the existing nature, level and role of private practice in public hospitals;
· the negative and positive aspects of private practice in public hospitals, including as regards access to healthcare, equity and the operation of public hospitals;
· what practical approaches might be taken to the removal of private practice from public hospitals, including timeframe and phasing;
· possible impacts, both direct and indirect, immediate and over time, of removing private practice from public hospitals, including but not limited to impacts on access; hospital activity (including specialist services); funding; recruitment and retention of personnel;
· and any legal or legislative issues that might arise.
The Group will conclude its work within 9 months of commencing – by the end of next summer.
2. A Public Consultation on the future alignment of hospitals groups and community health organisations
The Sláintecare report endorses the need to achieve greater alignment between hospital groups and CHOs. We all know that different health service management structures have been put in place over the years. And we all know that finding the ideal structure will not suddenly solve all our problems. But having the wrong structures will certainly undermine our chances of successfully developing a coherent efficient and integrated system.I welcome the emphasis on integrated care that is embedded in the report and believe that aligning our delivery systems will ultimately help the system to move towards a population based approach to service delivery that will provide a more integrated service for the citizens of this country and help those in the system to better understand and manage health outcomes. Having Hospital Groups and CHOs operating on this basis will facilitate collective performance and accountability arrangements based upon pre-agreed and shared goals, budgets and incentives.
I am conscious that structural reforms can be disruptive and that there can be unintended consequences. For this reason, I have agreed to undertake a consultation process before any firm decisions are made on this issue. The Department of Health will commence this process shortly.
3. Plans to establish a Governing Board to oversee HSE performance.
I have also committed to establish a board to strengthen the oversight and performance of the HSE. This will require legislation and I hope to have a board, with very strong competencies across key areas, established in 2018.
Taken together with the consultation on alignment of hospital groups and CHOs, these are significant foundation steps in moving towards an evolution in our health structures. I am very aware of the need to bring decision making closer to the point of care delivery and provide a counter-weight to unnecessary over-centralisation which impedes service responsiveness. But I am equally aware of the need to maintain a national-level focus in certain areas. These matters are under consideration as part of overall reform proposals.
Finally, it is important to mention that funding for new initiatives in Budget 2018 were closely aligned with proposals in Sláintecare. This allocation of funding shows the commitment of the Government to supporting key actions necessary for reform. This included:
· A new Primary Care fund of €25 million. Minister Minister Donoghue was clear in his budget day speech that this investment represents the start of a period of multi-annual investment in primary care.
· Additional funding of €25 million for home care and transition beds
· Reductions in medicine and prescription charges costing over €17 million
· Targeted funding for waiting list reductions of €75 million
· As already mentioned, €1 million for the Sláintecare Programme Office
The agreement of capital expenditure allocations over the next four years has also allowed me to significantly increase the financial investment in ICT from €60 million next year, to €85 million in 2019, €100 million in 2020 and €120 million in 2021. Thus, the budget for eHealth will more than double over its current level allowing for a very significant expansion in digital health and ICT systems.
I also recently announced that in 2018 I will undertake a process of engagement with representative bodies of contracted health professionals, aimed at putting in place a new multi-annual approach to fees, commencing in 2019, in return for service improvement and contractual reform and in line with Government priorities for the health service. This will support the development of a new, modern contract with GPs and other primary care providers, and is in line with emphasis on this area in Sláintecare and issues raised at this Committee over recent meetings.
I have heard some Deputies express frustration with the pace of the response to the Sláintecare report. We can all agree that sometimes the pace of policy making and decision making isn’t what it should be. But in this case I don’t believe that the criticism is fair, or realistic. I am firmly of the view that a careful and proper process of consideration is vital. The proposals in Sláintecare represent one of the largest programmes of reform not just in the health sector, but in our public service more generally. They reach into the very operation of our health care system, and in our systems of entitlement and access. The change that is required to deliver on these proposals should not be under-estimated, nor the challenges that will be encountered in making them a reality.
We need to properly consider these challenges and seek to learn from past reform attempts within our system and internationally. Our success will very much depend on the formulation of an effective implementation path. Implementation requires planning and identification of strategic decisions to be made as well as a consideration of the current status of the system and how we can best move towards the future system we all want.
This is the process that I am engaged in at present with Government colleagues, my Department and with the HSE. And I can personally attest to the commitment of all those involved in this work. In recent days, there have been challenges to the bone fides of this commitment and I would like to refute this in the strongest terms here today.
Government has charged me with developing a draft implementation plan by the end of the year. I am extremely serious in this task and, as you would expect, I am receiving the whole hearted and enthusiastic commitment of the civil servants in the Department of Health in the detailed implementation planning which is underway.
To conclude, I look forward to returning to government with a detailed response and to continuing to put in place the necessary supports to work towards the vision outlined in the Sláintecare report.
I am also committed to continuing engagement with this Committee and with all colleagues across both Houses and I am very appreciative of the opportunity provided today. I also look forward to continuing to work with stakeholders across the system to deliver an ambitious and realistic programme that builds on our current system and implements the necessary reforms.
This concludes my opening statement and I look forward to your questions.