Speech by Micheál Martin TD Minister for Health and Children at the IMO Annual Conference 6th April 2002
Firstly let me thank you for the invitation to address your conference. It is one of the most important occasions in the health service providers´ calendar and I´m delighted to be here.
Some of you may recall that when I addressed your conference in 2000 I remarked on the regular and emphatic use of the term “challenging” when I was being given the Health portfolio. I think it is fair to say that I now understand every possible meaning of the word. The service we provide is unique in that not only does it hold the highest profile in Government expenditure but the provision of health care also touches the poorest and most vulnerable in our society. It can be so disheartening to see and hear reports of people having to wait, for long periods in some cases, for the treatment they or their family need. The onus on us to provide timely professional care is a responsibility that at times can be almost unbearable. But if we can’t respond to this need why are we here. Our health service has been improving and modernising over the last number of years but we now need to speed up this process to meet the demands of the 21st century.
This Government´s commitment to improving the health service has been clearly demonstrated by the substantial increase in funding since 1997. In fact this year’s health allocation – more than j8 billion – represents an overall increase of 125% on the funding provided in 1997. In addition to this revenue funding there is over €2.5 billion in capital funding being provided under the National Development Plan for the years 2000 – 2006. Such levels of funding and commitment to our health services are unprecedented and will be vital in progressing the development of the health services.
New Health Strategy
It was in the context of the need to provide a more modern people-centred health service that my Department published the new health strategy “Quality and Fairness – A Health System for You”. The strategy sets out a clear direction for the health system for the next 10 years. The strategy draws up the framework to get us from the good health service we now have into the great health service we want – a health service based on equity, accountability, fairness and people-centredness. It provides an ambitious agenda with a number of strands including plans for the growth and development of key services as well as a major programme of modernisation and reform.
As you will be aware, the Health Strategy sets out four national goals that will drive reforms in the health service and also sets out a series of actions so that these national goals can be achieved. These four goals are:
- Better health for everyone
- Fair access
- Responsive and appropriate care delivery, and finally,
- High performance.
I am sure we all recognise that our current health system needs to be reformed and developed so that these goals can be achieved. As I see it, the necessary frameworks for change can be categorised under six headings:
- Strengthening primary care by developing a properly integrated system, capable of delivering the full range of health and personal social services appropriate to this setting. I will expand on this topic a little later.
- Secondly, reform of the acute hospital system. This essentially will mean improved access for public patients and the establishment of a National Hospitals Agency.
- Thirdly, funding aimed at improving access and responsiveness in the system by increasing capacity and improving performance through evidence-based funding methods such as case-mix budgeting, improved accountability and stronger incentives for efficiency.
- The fourth aspect of the framework for change is the development of human resources aimed at harnessing fully the vital contribution made by all staff working in the health system. I will go on to speak about this in more detail shortly.
- The fifth aspect is organisational reform aimed at providing a responsive, adaptable health system that meets the needs of the population effectively and at an affordable cost. This is the particular framework for change that I wish to concentrate on this evening.
- Finally, there is information. The framework for information is aimed at improving performance by supporting quality, planning and evidence-based decision-making in the health system.
Implementation of some of the actions outlined in the Health Strategy has already commenced.
- The Travellers Health Strategy was launched on 26 February.
- The Crisis Pregnancy Agency has been established and held its inaugural meeting in December 2001.
- I have just established the Primary Care Task Force and it will be having its first meeting next week.
- An independent review on the Department of Health and Children is taking place and will be completed by June 2002 with any new structure in place by December 2002.
- An independent audit of functions and structures in the health system will be carried out. A request for tenders has been advertised in the Official Journal of the EU and in the national dailies.
- The National Health Information Strategy should be published by the end of this month.
- The National Treatment Purchase Team has been established to spearhead the purchase of procedures for public patients from private hospitals in Ireland, and from international providers. It may also make use of any capacity within public hospitals to arrange treatment for patients. The Government has provided €30 million in the current year for this initiative. This considerable investment is in addition to existing waiting list initiatives, and is over and above existing capacity in public hospitals.
Additional Acute Hospital Beds
You will no doubt be aware of this Government´s commitment in the Health Strategy to provide a total of 3,000 additional acute beds for public patients over the next ten years. In order to do this a comprehensive review of acute hospital bed capacity needs has been conducted by my Department in conjunction with the Department of Finance, and in consultation with the Social Partners. The Review was published in January.
This initiative represents the largest ever concentrated expansion of acute hospital capacity in Ireland. The first phase will see the commissioning of an extra 709 acute hospital beds within the next 12 months at a cost of €65m. I am pleased to announce that 100 of these beds have already come onstream.
The increase in bed capacity will allow the hospital system to significantly increase activity levels for public patients in the current year. It is estimated that the increase in bed capacity will enable over 30,000 additional public patients to be treated in the full year. The additional beds represent further tangible evidence of the commitment of this Government to investment in the development of additional facilities for the treatment of public patients, and to the reduction of waiting lists and waiting times.
National Task Force on Medical Staffing
We are all very much aware of the need to radically improve Workforce Planning in the health service. What is now needed is a coherent, strategic approach to Workforce Planning. That means improving and enlarging the education and training possibilities for professionals.
In this context, I recently established the National Task Force on Medical Staffing. The Task Force has broad representation from all of the major stakeholders in the health service, including substantial representation from your own organisation. It goes without saying that the doctors and consultants represented by the IMO are central to any future development in medical staffing structures.
The Task Force will produce an implementation plan that will be critical to the success of the health strategy. It will map out a restructured acute healthcare service based on
- hospital work patterns that match patient needs,
- delivery of care by appropriately trained doctors,
- reduced working hours for doctors in training,
- increased consultant numbers,
- an updated medical education and training framework,
- more medical places at postgraduate and undergraduate level,
- structured training posts for all non-consultant hospital doctors, whose numbers will be linked to future workforce requirements.
The Task Force on Medical Staffing will place patients at the centre of planning our care delivery. It will aim to ensure that each patient has timely access to fully trained doctors in a restructured hospital system. It will help ensure that we have the right number of trained doctors to match patient needs as closely as possible, with the appropriate care being delivered in the appropriate setting.
It will underpin its planning and decision-making with an evidence-based approach. I have asked Mr David Hanly, the independent Chairman of the Task Force to keep me briefed on developments, with a view to achieving significant progress by the end of this year.
Development of Human Resources
The old style approach to the management of people has been a problem in the health service. I believe that it is time for a new approach, and I am glad to say that we are already well on the way to establishing that new approach. A partnership approach that will change the health service from being just an employer to being the preferred employer.
The core element in the development of the human resources function in the health service will be the preparation of a People Management Action Plan. The Health Strategy clearly recognises that a central tenet of human resource management must be to explicitly value our staff in the health service. While the Health Strategy spells out the high level of objectives for the human resource function, it does not go into detail. The detail will be contained in the People Management Action Plan, which is currently in preparation and will be completed and published by the Autumn.
This Action Plan will focus on ensuring that the health service has the right people, with the right competencies, in the right numbers, organised and managed in the right way, to deliver the goals and objectives of the Health Strategy.
The objectives for the People Management Action Plan are very demanding, as is the timeframe, I also recognise that additional investment of resources may be required to ensure that the plan can be implemented. I particularly welcome the fact that the plan will be developed using the existing partnership structures for the purposes of ensuring that the process is as comprehensive and inclusive as possible, and that issues around the implementation of the plan can be addressed. I await the outcome of this process with particular interest. On that note, I wish to thank Mr. Fintan Hourihan for his significant contribution to, and his able and effective leadership at, the National Partnership Forum.
Now from the general to the particular, I would like to turn my thoughts to the subject of primary care. Primary care and general practice are at the frontline of our health services. It is essential that they be at the forefront of development if we are to achieve the challenging goals we have set ourselves for the Irish healthcare system over the next few years.
For that reason, the Primary Care Strategy has major implications for all those involved in primary care in Ireland. Together with the Health Strategy, it represents a blueprint for future development by which we will all be judged. However, it has to be acknowledged, at the outset, that progress on the Primary Care Strategy is only possible if there is real commitment from all the stakeholders to its philosophy and goals.
It is not just a question of money and resources. These are critical for success but experience clearly shows that merely providing the resources and funding for issues or problems in healthcare doesn´t guarantee success. Most frequently, it simply buys a temporary reprieve and postpones facing the reality until a future date when the problems have compounded from past neglect.
A radical vision for the future of primary care means change and significant change, at that. It won´t be achieved or even achievable if consensus on the need for change cannot be agreed upon. It is no good hoping that the goals of the Primary Care Strategy will just happen. They won´t. Nor it is any good to simply cherry pick those parts of the Strategy that are most appealing and ignore those that involve some degree of discomfort. The Strategy hangs together as a whole or, quite simply, it falls apart.
In order to implement the Primary Care Strategy effectively, I have established an interdisciplinary Task Force of personnel from my department and from the health boards. This has already commenced work and in particular it will focus on;
- driving the implementation of the team-based primary care model as outlined in the strategy
- identifying representative locations for the implementation projects which will enable different options for service delivery to be evaluated
- planning human resources, information and communications technology and capital requirements for primary care on a national basis
- putting in place a framework for the extension of GP co-operatives on a national basis with specific reference to payment methods and operational processes.
The Task Force will report to a wider steering group. This will provide overall guidance to the Task Force in its work and will include representatives from primary care professional groups, unions, the community and voluntary sector and other relevant stakeholders. The IMO will, I am sure, play a constructive role in the important work of the Steering Group.
No one discipline holds the solution to delivering effective primary care. While general practitioners will undoubtedly continue to play a very important part, a wide range of other health and social care professionals must also be involved, such as nurses and midwives, dieticians, psychologists, occupational therapists, physiotherapists, psychologists, social workers, chiropodists, counsellors, speech and language therapists and community pharmacists, all who have particular roles and skills. Our aim will be to bring this wide range of service providers together in primary care teams, so as to deliver integrated services in the community in the most appropriate and accessible way.
The Government is fully committed to the implementation of the Primary Care Strategy in line with the timetable set out in the Strategy. This will require co-operation and support from the many interests involved. It will involve new approaches to service delivery, and innovation as regards how the services as a whole interface with their clients.
The process of change in primary care will require leadership, commitment and consensus. It involves not only new ways of doing things but a fresh perspective on professional and management relationships. I look forward to working with the Irish Medical Organisation, the Irish College of General Practitioners and all the other bodies representative of those involved in the primary care field.
Turning now to a concrete and positive example of change in primary care. As Minister, I am delighted to be associated with the continuing development of General Practice Out of Hours Co-ops. After their successful pilot phase in the North Eastern and South Eastern Health Boards, I was able to announce a significant increase in funding for 2002 which will see the Out of Hours Co-op model take off in most parts of the country throughout this year. The Co-ops are an important part of the primary care change process because as the Primary Care Strategy makes clear they offer a real opportunity to develop into something much greater that they currently are. They can become focal points not just for general practice services but for a diverse range of primary and community healthcare services.
There is, of course, always the industrial relations aspect to consider and reflect upon. The previous 12 months since your last Conference has been a period of activity on the general practice IR front and I will address this issue in a moment.
I recognise that it is in the nature of things that industrial relations issues will always be with us but they should only be a part of the process rather than a fundamental block to progress. In that regard, I want to emphasise that responsibility for industrial relations matters involving general practitioners and the other medical grades represented by your organisation lies with the Health Services Employers´ Agency and not with my Department. That division of responsibilities is an important and deliberate one intended to allow the Department to concentrate on its policy role. It may be a division that we both need to be reminded about on a more regular basis.
I would now like to turn to some of the issues raised at this conference in relation to the implementation of the agreement entered into between the IMO and the HSEA on a range of matters relating to General Practice. This agreement was set out in a letter dated 8 June 2001 from the HSEA to the IMO.
It is my intention to honour in full the various elements of this agreement in line with my Department´s commitment to honour all such agreements.
I accept that some disputes have arisen over the interpretation of the agreement and some unexpected problems have arisen in relation to identifying the particular patients to which payments applied.
I´m informed that agreement was reached on all of the outstanding issues relating to the agreement set out in the letter of June 2001. These referred, in the main, to payments for discretionary medical card holders, asylum seekers and various practice grants relating to nurses, secretaries and managers.
The total cost of the package is in the region of €l30m covering arrears for 2001 and the full year costs of 2002. I understand that some elements have already been paid.
I would like to assure you that arrangements are being put in place to effect all these payments as soon as possible.
Clinical Negligence Scheme
Now I would like to turn to the matter of medical insurance. In December 1999 the Government gave approval in principle to the introduction of enterprise liability as the basis for providing indemnity cover for doctors and dentists employed by the public health system. This will replace the existing fragmentary arrangements whereby hospitals, consultants and Non Consultant Hospital Doctors have separate insurance/indemnity cover to meet the cost of claims arising from alleged clinical negligence. The existing arrangements have been found to be inefficient, poor value for money and potentially unstable.
In mid-December 2001 the St Paul Insurance Company announced a worldwide withdrawal from the medical malpractice market. St Paul Ireland insures all of the major Dublin acute hospitals as well as several hospitals outside Dublin. It also insures NCHDs and other salaried doctors in the Medical Indemnity Scheme. The policy covering this scheme expires on 30th June next and will not be renewed.
Substantial progress has been made in planning for the introduction of the new scheme and the Clinical Negligence Scheme will come into effect on 1st July 2002. The fundamental principle underlying the scheme is that “the enterprise” will assume liability for the acts and omissions of all its employees in handling claims for personal injury arising from clinical negligence or malpractice. The most significant change that will result from the introduction of enterprise liability is that doctors and dentists will be incorporated into the liability borne by each agency.
I recognise that there are issues to be resolved. However, I´m confident that the scheme can be implemented by the required deadline.
Public Health Review
You are all only too aware of the ongoing review of Public Health Departments in the Health Boards. This review has been underway for a considerable period of time. However, I understand that it is finally nearing completion. The role, responsibilities and reporting relationships of the public health doctor is one of a number of areas which are being looked at during the course of this review. Management consultants were appointed to carry out comprehensive information gathering and interviewing within the health boards.
The report should identify strengths, weaknesses and opportunities in the overall public health function. I will await submission of the report of the independent Chairman and its recommendations before committing to any changes in this important area of public health medicine.
I am aware of the ongoing issue in relation to the on-call requirement for Public Health Doctors in the event of a Bio Terrorism attack. I hope that a solution to the present impasse can be found as soon as possible.
In my earlier comments I referred to the work to be undertaken by the National Task Force on Medical Staffing. This will entail the restructuring of services to ensure that they are consultant-delivered as opposed to consultant-led. This obviously will require significantly more consultants and fewer doctors in training. Building these consultant posts into the existing structures is not an option. A number of factors affect consultants´ ability to be present on site outside of normal working hours or at the weekends. Patients may in turn only have limited access to appropriate levels of senior clinical decision-making. This has resultant implications for safety of diagnosis and treatment on one hand and efficiency and cost effectiveness on the other.
Public health systems, demographics, lifestyles, technology and expectations are all exhibiting an international pattern of unprecedented challenge and change which urgently demand new methods and approaches. We must introduce more flexibility in the cover provided, better team-working, a pro-active involvement in management functions, a review of professional boundaries, evidence-based practices, a commitment to quality and efficiency and especially putting the patient at the centre and not at the periphery.
I recognize that there is a necessity to negotiate on these and other key issues and this will be done within the context of the contract negotiations, which are currently at an early stage.
Non Consultant Hospital Doctors
In the course of my many visits to acute hospitals around the country I frequently meet with groups of non-consultant hospital doctors. In our discussions, these doctors still refer to the long hours that they are currently required to work – however, as you know this situation will improve significantly within the next three years under the terms of the EU Directive on Working Hours.
What I find very satisfying to hear form these same doctors, and from their partners or family members, is the very significant improvement in their terms and conditions of employment that has resulted from the Agreement reached in 2000. Substantial increases in overtime rates have been implemented, generous training grants have been introduced, a programme of refurbishment of medical residences is well advanced. These and other elements of the deal will cost in excess of h100 million in the current year.
The next stage is to ensure that all of our doctors in training have appropriate access to education, training and research requirements. This key objective is also being examined by the National Task Force on Medical Staffing.
I would like to mention one group of our NCHDs in particular – that is the complement of approximately 1,500 doctors who come from outside the European Union. These doctors have, for many years, provided essential services in our hospitals and in some regions they constitute well over 60% of the NCHD cohort. I wish to publicly acknowledge the quality and quantity of their contribution to the Irish public health system.
Recent amendments to the Medical Practitioners Act, 1978.
I am happy to inform your conference that within the last week the Oireachtas has passed the Medical Practitioners (Amendment) Bill 2002. The main proposals contained in this Bill relate to:
- taking account of relevant professional experience in the assessment of an application for permanent registration;
- reducing the period of temporary registration required before application for permanent registration can be made from four to two years;
- provision for intern registration and temporary registration to apply in a number of health care settings; and
- provision for any EU citizen who has obtained their primary degree within the EU to obtain internship registration in this country.
This Bill, when enacted, will ensure that doctors, who may otherwise have had to leave the country when their seven-year period of temporary registration expired, can now remain here and apply for permanent registration.
With regard to the amendment of the overall Medical Practitioners Act, a thorough review of the current Act has been undertaken in consultations with all key stakeholders. My Department has used the information contained in these submissions to prepare a structure for the development of the Draft Heads for a new Medical Practitioners Bill. It is my intention to publish the new Bill in the autumn.
Working Visa and Work Authorisation Scheme
In addition to the steps already outlined the Department of Health and Children has been working closely with the Department of Enterprise, Trade and Employment, the Department of Justice, Equality and Law Reform and the Department of Foreign Affairs. The purpose of these contacts is to explore ways in which the processing of visas and work permits can be streamlined in order to assist health service employers with their recruiting drives.
In this regard the possibility of extending the working visa/work authorisation scheme, which already applies to nurses, to other health service staff is being examined by the Departmental group. The scheme would provide a more flexible mechanism for regulating the entry of non-EU and non-EEA citizens into Ireland for the purpose of working in the health service. It is hoped to progress this initiative in the very short term.
You are all only too well aware of the demands which the practice of medicine in your chosen specialties places upon you. These demands may change, but are unlikely to diminish in the future. These demands have implications for everyone working in the health sector. I readily acknowledge the significant and ongoing contribution by made by your members to the provision and development of our public hospital system. In turn, both the Government and I, are committed to making the necessary changes to, and investment in, our health care system in order to ensure the removal of inequalities and the provision of the highest standards of patient care. Many important issues are currently being addressed but further significant and co-ordinated action is needed to improve health status and to develop, reform and modernise our health and personal social services. This action will be implemented through the Health Strategy over the next number of years. With your continued support we can achieve these aims and look to the future with confidence. Our combined efforts will help to ensure that the Irish health care system becomes a hallmark internationally for all that is best in health care provision.
Finally I hope you have had an enjoyable conference and that you get some time to enjoy the delights of Killarney.