Speech by Minister Harris at the MacGill Summer School 2016
**check against delivery**
I want to start by thanking the organisers for the invitation to speak at this, the 36th Annual MacGill Summer School and to Dr Donal de Buitleir for moderating this session.
That’s the nice bit.
Here’s the not-so-nice bit.
The word “dysfunctional.”
Now, I’m not having that. Most of the service given by dedicated, highly skilled, highly motivated staff is excellent. The main problem is the way we subject patients to a unique kind of hazing process before we get them to that excellent care.
I’ll come back to that.
First, though, the reactions I experienced when I was lucky enough to be appointed Minister for Health. (Yes, lucky enough.)
The reactions were a curious mixture of congratulations and sympathy. A curious mixture based on the assumption that I’d be shaking in my shoes and properly fearful about entering what still gets called “Angola.”
That’s not the case.
Of course, I’m in no doubt about the scale of the task. But I’ve never bought the Angola analogy and – more to the point – I don’t think any of us should.
Where’s the gain in standing in a defensive crouch, ready to reach to excuses? Where’s the gain in talking about reform – talking about tinkering with the works – when we could be talking about vision, about direction, about setting out to be the best in the world?
I believe in a vision where we stop worshipping the system, the process and the problems. Where we turn everything to face the patient. Where we start with the rights of the citizen: to a healthy life, to an equal chance at a healthy life, to civilised care in the face of illness.
That’s not a problem.
That’s a massive challenge.
A massive positive challenge.
It demands energy and vision and hope and determination and – yes – optimism.
And – before you go “Ah, isn’t he very naive, God love him,” let me lay it on the line.
Without great objectives, no great achievements happen.
We must be realistic, but we must drive for the best. Nothing less.
The fact is that every great advance in health (not just healthcare, but advances in survival and also in health promotion) came out of times of great challenge.
Just one example. Back in the Crimean War, the mortality rate was horrific among British soldiers (many of them Irish actually). We all kind of vaguely remember that Florence Nightingale was involved – walking the wards of the wounded with a lantern: the Lady with the Lamp.
Yeah, Nightingale was kind to the patients.
But that’s not why she’s important in healthcare.
She’s important because of the advances she made.
She worked out that lads weren’t dying of their wounds. They were dying of preventable infection in those wounds. So she drove new systems of hygiene and sanitation.
She figured out that the hospitals she was running needed to be re-configured. That meant more money from the Government – and she was thousands of miles away. So how was she going to explain to the powers that be what was going on at ground level? Nightingale worked out that visuals make data understandable. She essentially invented the bar and pie charts that pop up today in every second PowerPoint presentation. They worked.
Out of that tragedy came better practice. And – over time – that better practice became basic. Essential. Unquestioned.
But – here’s the thing – neither her advances nor any of the other breakthroughs like antibiotics bring the health service anywhere into a state of perfect balance. They don’t ever create a health service that’s all set. Grand. Fixed. Perfect.
Every advance creates new needs, and sometimes new crises. Since 2004, life expectancy in Ireland has increased by two and a half years and is above the EU average.
That’s an advance.
Between 2005 and 2014 mortality rates a range of diseases fell, including
- circulatory system diseases by 31.5%;
- cancer by 7.9%; and
- respiratory system diseases by 20%.
Every one of those advances creates a knock-on need. A century and a half ago, the health system didn’t have to think about, never mind care for, people in their seventies, eighties and nineties, because those people were “outliers.”
Well, they’re not outliers any more, thank God.
We have learned to prevent many of the diseases that felled previous generations and felled them early.
We have learned to cure many of the diseases that way lay us today.
We have other diseases to cure now that are systemic, rather than a patient disease.
But it can be done. We’ve cured other systemic ailments.
We can make major changes, when we put our minds to it. We can modernise and improve the way we deliver health services, when we have strong policies and determined and sustained delivery.
The health service we have today grew up as a patchwork of individual initiatives and institutions. Those institutions tended to develop themselves and the services they provide in response to local needs. What they have never done, is function fully and coherently as part of a national system.
We haven’t yet combined excellent people and excellent institutions into an excellent system.
We’ve tried. In two different ways, we’ve tried.
One of the ways we’ve tried is by re-jigging structures. That started with the development of the health boards, followed by the creation of the HSE and now focused on the development of Hospital Groups and Community Health Organisations.
And the other way we’ve tried to combine excellent people and excellent institutions has been through concentrating on the finances: trying to ensure that resources flow to where they are needed.
This second approach started long before my time – in the 80s – with the Commission on Health Funding which reported in the late 1980s.
It continued with the last Governments work on Universal Health Insurance. That work established that we couldn’t afford the model of UHI set out in the White Paper.
Both of those approaches – the structural and the financial – make sense. And yet…and yet neither has got us to where any of us would want healthcare to be.
Now we have a new model for funding public hospital care called Activity Based Funding. It involves moving away from inefficient block grant budgets to paying hospitals for the volume and quality of care they provide. It’s complex, takes time, but will be a powerful driver of reforming the way we deliver health services.
So, we are moving ahead with those reforms, and changing the way that the system is financed.
But, if you think about it, they’re reforms that are good for the system. We tend to assume that when we have a reform that’s good for the health system, it’ll be good for the patient.
That’s where I believe we have to have a constant learned reflex that causes us to say “Really? REALLY?”
Let’s say one of us here gets a sudden onset of painful disabling symptoms and we pitch up at an ED to get those symptoms addressed and a diagnosis made and treatment commenced. You know something? I seriously doubt we’ll be thinking about Activity Based Funding.
We’ve been triaged. We’re sitting among crowds of people who are sick or injured in different ways. We feel wretched. Hours are passing and we have no clue when we’ll be seen. Activity Based Funding, I can assure you, is going to be way down our list of priorities.
Elizabeth Kubler Ross defined a series of stages people go through when they’re given a diagnosis that tells them they’re going to die.
They go through shock, bargaining….- several emotional reactions before they reach resignation or serenity.
If we took a Kubler Ross approach to the entry point to most acute care, I suspect the patient first experiences fear; the terror of having some pain or other symptom they can’t explain. Next comes relief, they feel, at least I’m in the hospital. Then comes worry: why are those people being seen before me? Then anger: why is nobody telling me anything?
And then all too often, comes the hospital trolley. And that’s bad enough, but it’s when they’re left there, in the bright apparent chaos of an emergency room, that another feeling takes over. The feeling of being disregarded. Disrespected. Of not mattering. Of being a cog in a system. A system that’s meant to serve. Not meant to process.
A system that knows how to count trolleys, but where the people on them feel like they don’t count. A system where trolleys seem to evoke acceptance instead of intolerance.
We have to move forward structurally and in our financial systems, and in two other areas I’ll come to in a minute, but we have to build in, every single step of the way, the question “Is this good for the patient? Really?”
What I want to do is take all the good work done down through the decades, all the passionate and committed health & social care professionals, all the investments we will make, and point them, not just at clinical excellence, however important that is. But at making every interface with the patient Respectful, Responsive and Reassuring. Every time an Irish patient comes in contact with healthcare, whether that patient is three years of age or three score and twenty years of age, it should be a positive experience.
The patient should feel that they matter. The patient does matter.
That healthcare people want to see them quickly and solve their problem quickly.
That they’re not an irritating factor gumming up an otherwise perfect system.
That they’re not a statistic.
That’s about communication – but it’s about every other tiny aspect of healthcare too. The patient matters. The patient comes first. And that means two further missing links need to be joined up – Prevention and Primary Care.
Right now, patients in each and every one of our hospitals are suffering illness and death because of failure to prevent their illnesses thirty years ago. The cost to them and to their families is unspeakable. The cost to the state is incalculable.
And that’s because of one product – the only commercial product that kills one out of every two of its users. The cigarette.
The death march of the cigarette teaches us so much about prevention of ill health. Tough lessons – but positive lessons, too. We now know that many of the dire illnesses, whether cancer or heart disease, that a couple of generations ago were regarded as visitations from an evil God, could, in fact, have been prevented if patients had never become addicted to smoking. So we say “Had we but known…”
Yeah, well, we now do know that if we want Irish people to live longer, healthier lives, prevention has to start early and with every individual. Every one of us needs to be put in charge of our health from very early on, and not just in relation to tobacco. To understand that how we live now will determine how we live later. To have the data to inform habits around food, around exercise, around stress, around sleep.
We have a national framework in the Healthy Ireland Programme. What we have to recognise is that prevention is not an optional extra or a ‘nice-to-have’ – it’s a vital part of any coherent healthcare strategy.
How have we allowed it to be that one out of three children under three are either overweight or clinically obese? How have we allowed this to happen?
Tightly linking into prevention is primary care. And a new vision of primary care.
Primary care is key to the future. Yes, we must have acute care that matches the best in the world. But we need primary care that matches or exceeds the best in the world in order to keep people from needing acute care.
It must focus on keeping patients well, actively manage patients’ needs and reduce as far as possible, the number of patients admitted to hospitals in the first place. I think of it as ‘better care, close to home’. A primary care system, which is not just about bricks and mortar, but about the services inside.
GPs are central. So are nurses, social workers, physiotherapists and a range of other professionals whose work requires co-ordination and integration. Co-ordination. Integration. And challenging existing lines of demarcation. Because we have to keep asking “Is this good for the patient? Really?”
We are also seeing a growth in the numbers of people living with chronic disease – cancer, heart disease and diabetes.
If you’re over fifty, you’ve a good chance of having a chronic disease. That’s the simple reality. Over fifty, one in ten has more than one. Chronic disease accounts for 80% of all GP visits, 40% of hospital admissions, and 75% of hospital bed days. As the number of older people increases, this burden of chronic disease will also increase.
But the rising burden of chronic disease also requires us to re-think the way we provide and deliver health services. Chronic disease is ongoing and continuous, so care models also need to be continuous. We need systems that are reliable and capable of addressing and responding to the many and sometimes complex needs of patients. For that to work, we have to place a far great focus on primary care.
We’ve made a good start in this area. The first two phases of universal GP care are in place. This covers all children under 6 and all persons over 70 years.
800,000 people are now automatically covered for GP care without fees, and without the need for a means-test. The service for under-6s includes health checks and also a new cycle of asthma care. 20,000 children have been signed up for that. More than 62,000 adults with type 2 diabetes have been registered by their GPs for a new programme that sets out to manage it better and keep them healthier.
The kind of reforms that we need won’t happen overnight, but they can happen in a way which, step by step, improves services for patients. Provided that, as a country, we stick at it.
That’s why we need to build consensus around a ten-year vision for our future health care. As you may know, the Dail recently established a Special All-Party Committee on Future Healthcare to achieve this.
When I meet front line staff , in the health service, they don’t tell me that they are fed up with reform, but what they are rightly fed up with is piecemeal reform. Minister for Health X arrives in the Department, and tinkers around the edge of the system, and then is often shortly followed by another new Minister for Health, who tinkers with another bit of the system. We need to stop running the health service based on election cycles and individual Ministerial ideology, and instead put in place once and for all, a ten year strategy with cross-party political and societal buy-in to build, develop, reform and modernise healthcare services for the future.
The theme for the MacGill School this year is about ‘moving on from the past to build the future’. For a while back there, building the future wasn’t a possibility, never mind a priority. For the health service or any other service. Because we had to get the economy out of intensive care before we could do anything else.
We did it. As a people we did it. And let’s reflect on that. Why did we work so hard to get to this point? Why did we fight so hard for economic survival? I mentioned earlier the rights of the citizen to an equal chance at a healthy life. Well, I believe that’s why we did it. To rebuild opportunity. To recreate the future that seemed our fate in the bleakest moments. Because we have a national instinct that people should have an equal chance. And a national allergy to the notion that it’s okay for some people to have no chance. I heard that loud and clear not so long ago on the doorsteps and in the ballot boxes.
Now is the time to change the focus and concentrate on creating a better, fairer society for our people. A compassionate society and one which looks after its people from the time we come into this world to the time we leave it. Central to that is building, not a better health service, but a health service that is the best in the world, and that starts every initiative from that simple but very important question “But is this good for the patient? Really?”
Ladies and Gentlemen, that is the single biggest challenge facing all of us – because it will take all of us to get it right. The single biggest and most positive challenge for the next ten years. One that requires energy and vision, hope and determination and – yes – optimism.
It’s time we moved beyond “Angola” and “dysfunctional” as terms for keeping the people of Ireland healthy and giving them great care when they fall ill. It’s time we stopped looking at the obstacles and concentrated on the direction. And maybe stopped assuming that to be realistic, you have to be negative.
It’s not naive to aim high. In fact, it’s the only way to achieve anything worth achieving – and a world class health service is so worth achieving.