Speech by the Minister for Health and Children at the Irish Medical Organisation’s annual conference
Ladies and Gentlemen, I thank you all for your invitation to again address your annual conference here in Killarney.
Firstly, I must take the opportunity to acknowledge the very recent death of one of your most dedicated and active members, Dr. Cormac MacNamara. His commitment to his profession, not least in practice as a doctor, but also his membership of Comhairle na nOspidéal, the Post-Graduate Medical and Dental Board and his Presidency of both the Irish College of General Practitioners and the Irish Medical Organisation cannot be underestimated.
Despite his undoubted huge commitment to his profession, Cormac was dedicated to his family and managed to enjoy many other aspects of his life to a great extent, with his love of golf, poetry and his undoubted dedication to and love of the Irish language. Cormac possessed a style and approach that we can all emulate. He made time for everyone, despite his very busy schedule and more recently, his health problems.
I extend my deepest sympathies to his wife, Mary and his children John, Niall, Corrie, Neasa and Mary. I also wish to express my sincere gratitude for all Cormac contributed to the Health Service in so many ways over the years.
Since we were last here twelve months ago we have embarked on a fundamental reform of our entire Health system.
The Health Reform programme is the blueprint which will achieve a balance between old and new in our health services; retaining those aspects that have been most successful, while at the same time introducing new or reconfigured improved practices and approaches where necessary.
The Government is fully committed to meeting the increasingly complex demands of patient care in the 21st century. However, the commitment and support of all key stakeholders are equally essential if we are to achieve the health service to which we all aspire.
Health Reform Programme
Context for Reform
The health services remain a top priority with this Government as has been demonstrated by the record levels of investment made in recent years. Side by side with this investment has been the articulation of the vision of what we want as a nation from our Health Services, as set down in the National Health Strategy. We want a responsive, adaptable health system, which meets the needs of the population effectively.
Last year, the Government outlined the structural changes needed to give life to our vision of a health system that will have the maximum positive impact on the health of the entire nation. These reforms will dramatically improve the scope, quality and accessibility of health services for all who need them. The National Steering Committee, which is charged with overseeing the various strands of the entire Reform Programme, has been appointed and has already begun its work under the chairmanship of Kevin Kelly. The Board of the interim HSE has also been appointed. The Board will design the structure of the new organisation and plan the transition to a single unitary delivery system.
The interim HSE has established a change management team drawing on expertise from people across the health system to support the Board in its task of ensuring an orderly transfer of functions to the full statutory HSE in January 2005.
Four Streams of Work
The reform programme is now moving forward in four separate but inter-related streams:
- Work of the Board of the Interim Health Service Executive.
- The Hanly report – implementation process in the Phase One sites and the development of Phase Two.
- Department of Health and Children ongoing work on the reform programme including restructuring of the Department itself.
- The vital task of all health board staff to ensure continuity in delivery of services, whilst also actively engaging in the change programme.
All of us must work in partnership to ensure the successful implementation and operation of the reformed health service.
Legislation to Underpin Reform
I would also like to take this opportunity to advise you of the publication, today, of the Health (Amendment) Bill 2004. This Bill is an interim piece of legislation, which provides for the abolition of the membership of the seven health boards, the Eastern Regional Health Authority and the three area health boards. It also provides for the abolition of the distinction between reserved and executive functions, with the assignment of those functions currently designated as reserved functions to the chief executive officers of the boards and Authority or the Minister for Health and Children, as appropriate.
The Bill´s publication represents a further phase of the implementation of the Reform Programme for the health services and is a clear demonstration of the Government´s commitment to implementing the proposals in the Reform programme, which include the abolition of the health boards and Authority on the establishment of the Health Service Executive on a statutory basis, scheduled for January 2005. I will be bringing forward primary legislation at a later date, which will provide the main legislative basis for the implementation of the Health Sector Reform Programme. It will establish the new Health Service Executive to replace the Eastern Regional Health Authority and the health boards. It will also provide the legislative basis for other aspects of the Reform Programme such as improved governance and accountability, planning and monitoring and evaluation. The establishment of the Health Information and Quality Authority (HIQA) on a legislative basis will also be provided for.
European Working Time Directive
As you are all aware, Ireland will be legally obliged to implement the European Working Time Directive to doctors in training from 1st August this year. The requirements of the Directive have highlighted the absolute necessity for all workers to enjoy a safe and appropriate balance between work and general life commitments.
The Hanly Report has re-iterated the measures that must be progressed in order to reduce NCHD hours, while providing safe, high quality acute hospital services, 24 hours a day, 7 days a week.
A National Coordinator and support team have been seconded to oversee the implementation process in the health agencies. The Medical Manpower Managers, appointed as part of the NCHD 2000 agreement, are helping to oversee the reduction in NCHD working hours on the ground. They are playing an essential role in the phased implementation of these aspects of the Hanly Report, and helping to ensure compliance with the requirements of the Directive. Latest returns indicate that well in excess of 60% of NCHD’s will be compliant with the actual 58-hour requirement of the Directive by 1st August next. Difficulties arise, however, when the specific details contained in the Directive are applied, i.e. rest breaks and compensatory rest. These issues are being considered and will be progressed on an on-going basis. Time is of the essence in this process. Management representatives have been ready and willing to participate in local working groups, representative of key stakeholders, to implement these measures. These groups would also monitor progress in relation to the reduction in NCHD hours. Management want to make immediate approaches to the other key stakeholders in relation to their participation. Much valuable time has already been lost and I urge your organisation to come on board in order to set this process in motion.
Similarly management has been waiting to establish a National Implementation Group to co-ordinate the work being undertaken at local level, to provide guidance and to monitor progress. These groups should include appropriate hospital managers, consultants, NCHDs, nurses and other relevant healthcare professionals. The need to establish these groups at both national and local level has been discussed with the Irish Medical Organisation at the ongoing meetings in the Labour Relations Commission. I now call on you again for full cooperation in establishing these groups, to help introduce these measures that the IMO has been lobbying for many years to achieve.
The continuing existence of difficulties and the relatively short time frame available in no way alleviates our legal obligations. I am convinced, however, that this also presents a unique opportunity to improve training, services and the working lifestyles of all NCHDs.
I again call on all interested parties to fully engage and cooperate towards the successful achievement of healthier and safer working conditions for doctors and safer provision of services to patients. I am confident that between us, we can overcome any obstacles in the path to the implementation of the Working Time Directive. In fact, we have to.
Hanly Report and Restructuring of Hospital Services
As you are aware much of the frontline medical care and round the clock emergency services in our hospitals are delivered by junior doctors, most of whom work excessively long hours. Patients have limited access to consultant care. This situation is no longer sustainable. The European Working Time Directive requires that from 1st August 2004, junior doctors must work an average of 58 hours per week. The Hanly Report addresses a key question: how to provide safe, high quality acute hospital services, 24 hours a day, 7 days a week and to do so as the working hours of our junior doctors are reduced in line with EU law.
The Hanly Report recommended that we put in place a consultant-provided service, harness the contribution of all our hospitals, and provide a wider range of appropriate services and procedures in Local Hospitals. This will mean a better service for patients.
The Report makes specific recommendations for reorganising hospitals in two regions – the East Coast and Mid West – and sets out a series of principles for the future organisation of hospital services nationally. It also proposes measures to reduce junior doctors’ hours and improve medical education and training.
There are no plans to alter the services provided by other hospitals. Instead, the current and future role of hospitals outside the Mid-West and East Coast will be examined as part of the preparation of a National Hospital Plan.
The Hanly report recommends investment in local Hospitals so that it can provide more services for patients. It points out that capacity, workload and critical volume of patients influence where hospital services can be safely provided, and concludes that hospital services must be organized to maximize the strengths of both large and smaller hospitals.
The Hanly report states that a full range of acute hospital services should be available within each region, so that patients should not have to travel outside the region other than for specialised supra-regional or national-level services. This will, for example, involve the appointment of an additional 195 consultants to the Mid-Western Region. These consultants will be required to work both in Local Hospitals such as Ennis and Nenagh as well as the Mid-Western Regional Hospital, Limerick.
While Hanly notes that high quality accident and emergency services are best provided in larger hospitals with the full range of specialties and trained staff, it also notes that in Local Hospitals services will continue to cater for up to 85% of patients currently attending the Accident and Emergency department. Medical cover will be provided on a 24 hour 7 day basis in local hospitals. This means that a doctor is available to provide a medical assessment or treatment to patients as required. The grade of doctor called on to provide medical cover will be in line with anticipated patient need. There is a number of options for ensuring appropriate overnight medical cover. These could include, for example, consultants, doctors in training, general practitioners, medical officers or a combination of these, depending on the circumstances. As you are aware the Mid-Western Health Board has come up with their own innovative proposal of Emergency Care Physicians providing their medical cover in Nenagh and Ennis Hospitals.
All arrangements for overnight medical cover must be in keeping with the requirements of the European Working Time Directive, under which no doctor may work for longer an average of 58 hours per week by 1 August this year.
Clearly, the implementation of the Hanly Report must be accompanied by further development of ambulance services and a reorganisation and resourcing of primary care. We must train the ambulance staff, ensure our Local Hospitals have the facilities and resources to take on the extra work moving out from the Major Hospitals and make sure that general practitioners, hospital staff and other health professionals are able to work together so that patients, wherever they live, have equitable and rapid access to high quality emergency care.
The Hanly Report addresses the need to improve patient care and is the best means of ensuring that safe, high quality acute hospital care is provided to our citizens in all parts of the country.
To date, neither the local Implementation Groups for the pilot regions nor the Acute Hospitals Review Group has met as a result of continuing industrial action. I must ask that everyone commence participation in these groups immediately to progress the body of work they must tackle as a matter of urgency.
I have noted the widely divergent views expressed by members of the medical profession and by members of your organization on the Hanly recommendations. As you know all relevant stakeholders were represented on the Taskforce; agreement was reached on the recommendations. It is therefore time for the medical community as a whole to come together to further reflect and to develop on the consensus that has already been reached.
Our ongoing and significant consultation with our European partners in Health in relation to the Working Time Directive serves to emphasise the growing importance of health issues on the European political agenda. EU co-operation in health matters – at political, policy-making and expert levels – is now an every-day occurrence and this is an evolution which Ireland supports and which we routinely work to enhance and facilitate.
During the Irish Presidency, perhaps the most immediately visible example of European solidarity in the health care area will be the introduction on the 1st of June of the European Health Insurance Card. This Card will eventually be backed up by electronic administrative systems and will ultimately replace paper-based forms. The card represents a further step towards facilitating ease of movement for citizens within EU Member States.
The establishment of a European Centre for Disease Prevention and Control will help to develop European agreement on best practice for the population and innovative strategies for the prevention of cardiovascular disease. This disease causes 4 million deaths each year in Europe and is the main cause of death in women in all European countries. The Centre is a key element in plans to safeguard the health of EU citizens from the threat of communicable diseases and it will oversee the development of epidemiological surveillance at European level. Ireland´s Presidency Health Programme is very focused and concentrates on regulatory measures in areas such as food, through serious health threats such as tobacco and the orientation of health systems to provide for greater patient mobility. The programme offers a challenging agenda and provides a special opportunity to demonstrate our commitment and determination to advancing public health throughout the Union.
Tobacco control/workplace smoking ban
In that regard, I must acknowledge and thank you all for your support in the implementation of the recent ban on smoking in the workplace. In terms of tobacco control, we can now take pride in being the smoke-free capital of Europe. This initiative has provided a real opportunity for Ireland to lead by example in an area which is one of the most serious threats to the health of all European citizens.
Another pioneering approach, is the establishment of the Strategic Task Force on Alcohol whose remit is to recommend specific evidence based measures to Government aimed at preventing and reducing alcohol related harm. The Task Force published an Interim report in May 2002 and is currently finalising its second report which will contain further recommendations on this issue.
The Health Promotion Unit of my Department has provided funding to the ICGP for an Alcohol Aware Practice Project. The main aim of the project is to assist the G.P. in helping patients with alcohol problems more effectively by involving practitioners in brief intervention and referral, in randomly screening patients for alcohol problems and in categorising patients as low risk or no risk, hazardous and harmful/and dependent.
Further funding has been made available to the ICGP for a second project phase Helping Patients with Alcohol Problems over a three year period which offers education, training and professional development to GP´s and other primary care team members with whom they interact, in the care of patients with alcohol problems and those whose regular alcohol intake is a cause for concern.
In addition to the all of the above, I recently launched a National Taskforce on Obesity chaired by the Chief Executive of the Irish Sports Council, Mr. John Treacy. The Slán Survey, published in 2003, indicates that 47% of the Irish population are overweight or obese in 2002 compared to 42% in 1998, with levels of obesity increasing from 10% to 13% in the same period. The obesity taskforce was established in order to halt and reverse this trend, and members of the taskforce are committed to producing, by the end of the year, a realistic, achievable and measurable strategy. As obesity is directly associated with a number of serious diseases including Diabetes, Heart disease, many forms of Cancer and high blood pressure, the implementation of this strategy should impact positively upon the health of the population.
Obesity in children has been identified as an emerging public health problem, particularly in the Western World. Data from recent surveys indicate that one in five Irish boys and girls are overweight and one in twenty are obese. Worryingly, the age of onset of obesity in children across the world is falling and a child is twice as likely to be an obese adult, if obese in childhood. We need therefore, as a priority, to address the trend and scale of overweight and obesity in Irish children.
To do that we need to look at the eating and activity habits of children and what influences these. In a sentence, we need to make it easier for children to eat healthy foods and be more active.
The health of our population commences at the earliest stage of life and in that regard, the benefits of folic acid supplementation in women planning a pregnancy have been known for many years. Ireland was amongst the first European countries to introduce an official supplementation policy in the early 1990s. Despite all measures taken to date, including health education initiatives, the majority of women are not taking folic acid supplements at the time of conception.
This has led to debate on the issue of fortification of foods with folic acid. In Ireland, the Food Safety Authority Ireland recently completed a detailed risk benefit analysis of fortification of flour in Ireland. Overall, this analysis has indicated that there would be considerable benefits, i.e. reducing the incidence of Neural Tube Defects by 41%, if the policy were implemented.
Implementing a policy of fortification of flour would require intersectoral action and there are a number of issues, e.g. trade, legal, technical, etc, that require further consideration. At this point, the case for fortification of flour is considered sufficiently robust to move to the next stage, namely a consultative process to deal with the technical and other aspects of implementing this policy. My Department, in consultation with the FSAI, is currently preparing plans for this consultative process.
Review of Medical Practitioners Act 1978
In terms of regulatory reform for the medical profession, my Department has undertaken a thorough review of the entire 1978 Medical Practitioners Act in consultation with key stakeholders in the public health service and beyond. These consultations have contributed to the proposals that are contained in the draft Heads of Bill for a significant amendment to the Act. Observations on these draft Heads have now been received from a number of relevant Government Departments and agencies and I expect the Heads of Bill to be presented to Cabinet shortly. The main features of the draft Medical Practitioners Heads of Bill are:-
- that protection of the public will be the Medical Council’s primary concern;
- that the Council will take measures towards increased public transparency and accountability;
- that there will be greater lay representation on the Council;
- that Fitness to Practise procedures will be enhanced and speeded up;
- that an improved complaints mechanisms will be established and,
- that the Council´s Competence Assurance Scheme will have a sound statutory basis;
One of the key changes I intend to introduce is an appeals mechanism for those patients or complainants who feel that the Medical Council has not followed proper procedure in handling their complaint. In that regard I intend, in consultation with the Department of Finance and the Ombudsman, to ensure that the services of the Ombudsman will be available in relation to complaints made to the Medical Council.
In drafting the Heads of Bill, primary regard was given to the recommendations in the Health Strategy, as well as to the various initiatives on regulatory reform, including the Government White Paper “Regulating Better”, and the OECD report on Regulatory Reform in Ireland. These highlighted the requirement that consumers should be placed at the top of the policy agenda. While the encouraging of acceptable competitive activity and promoting accountable self-regulation are prominent, the main priority of this Bill is to ensure quality and safety for the patient and the public.
Negotiations on a New Contract for Consultants
The new Consultant´s Contract will be an essential part of the modernisation programme. The contract will be designed to reflect the requirements identified in the National Health Strategy and the Health Service Reform Programme including the Prospectus, Brennan and Hanly reports. The primary focus of the new contract will be to ensure that patients´ interests are best served. The key principles underpinning this document will be patient-centredness, quality of service, equity and accountability.
The contract will take account of the changing health services, new structures and more particularly, the changing expectations and needs of patients. The contract will seek to support excellence in clinical care. It will enable the Consultant to have a substantial and direct involvement in the diagnosis, care and overall management of patients. Indeed the extension of the Clinicians in Management program will give consultants a greater say in the management of the health service itself.
It is intended that Consultants will work as part of a health system where there are structures that clearly designate individual and organisational responsibility and accountability, protocols for service delivery, mechanisms to compile accurate, comprehensive and comparable data on service provision and regular benchmarking and audit of such services. There will also be provision to take action where standards are not met.
This contract will enshrine accountability for the management and delivery of care to the individual patient, groups of patients and to the population for which the healthcare facility is responsible, having regard to the role and function of all the stakeholders. As one of those stakeholders, each Consultant will have personal and collective accountability for clinical performance and care in the organisation to which he or she is contracted.
We need a framework for establishing more effective and efficient work practices. This includes the provision of a 24/7 health service to be delivered by consultants themselves and requires doubling the number of consultants working in our hospitals. It is clear that change of this nature cannot be delivered under the existing contract. It is my wish to have substantive negotiations commence at the earliest opportunity. Progress in this regard would be in everyone’s interest, not least your consultant members and I again call on all parties to engage immediately in these negotiations.
Public Health Doctors and Population Health
A key concept of the Health Strategy was the development of a population health approach in support of the first national goal namely “Better health for everyone”. This approach to health aims to improve the health of the entire population or sub-groups within it and, in particular, the development of policies aimed at reducing health inequalities. The population health approach has the potential for reorienting government policy towards health. The core population health functions include:
- Policy development and service planning
- Co-ordination of intersectoral policies
- Health impact assessment
- Health protection including communicable disease control, environmental health and emergency planning
- Health promotion.
An important aspect of this is the role of the Public Health Doctor. Over the last year, IMO and health service officials have been busy implementing the recommendations of the 2003 Public Health Doctors Agreement. 10 Principal Medical Officers have been appointed to oversee the Community Health stream, while we are in the process of increasing, by 22, the number of Specialists in Public Health Medicine. In addition, an increase in the number of Senior Area Medical Officers to 94 is at an advanced stage. This year will also see an increase in Specialist Registrar posts by 6. I am also hopeful that this year will see the introduction of an out-of-hours service as a result of the current negotiations in the LRC. These changes will help to improve the level of expertise in this area, and the service provided to the public, while providing a more structured career path for Public Health Doctors.
One of the most significant events which has occurred since I spoke to you a year ago was the extension of the Clinical Indemnity Scheme to personal injury claims taken against consultants. It was always my own hope and expectation that we would have been able to bring consultants into the Scheme on an agreed basis. Unfortunately that did not prove to be the case. The Government decided that it had no option but to take the decision that it did in the interests of doctors, patients and taxpayers.
In the meantime intensive efforts have continued to resolve the problem posed by historic liabilities. I believe that significant progress is finally being made. You will appreciate that I am very restricted in what I can say at this delicate stage in the process.
When these problems have been resolved I am certain that doctors will agree that the Government’s decision in 1999 to establish the Clinical Indemnity Scheme was an enlightened and far-sighted one. One only has to look at Australia and some European countries to behold the chaos and confusion that could so easily have overwhelmed our health services if that decision had not been taken. There is now effectively no insurance market for medical malpractice risks. In a system such as ours a State-provided indemnity is the only solution that makes any sense.
I hope that we can move on from here and begin to look at the ways in which the CIS and its associated clinical incident reporting system can be used to help prevent the very mistakes which ultimately result in doctors and hospitals being sued by their patients. That is the real gain to be made here.
The establishment of the CIS was never just about finding a more efficient mechanism for managing claims. It was, and is, fundamentally about patient safety. The enhancement of patient safety is something we all have an obligation to work towards.
An important element in health reform will be general practice, which is the gateway to the service. In view of the changing nature of general practice generally, and with a view to addressing the cost and delivery of services provided by GPs through the GMS, my Department would like to engage with the IMO in a wide-ranging review of general practice which would look in a fundamental way at the relationship between GPs and the public health system, including a full review of the current contract. The review would also take full account of the structural changes taking place in the Health services, the Health Reform agenda, and the Primary Care Strategy. I would ask all general practitioners to be open to such a review, which aims to achieve a modern patient-centred service appropriate to our primary care needs.
GP Manpower Issues
My Department recognises that the nature and role of the GP service is changing. Demographic trends and the changing nature of services demanded from GPs have put pressure on some practices. Changing work arrangements at GP level have also raised issues on recruitment and retention needs of general practitioners. In order to address these issues, my Department is consulting with the Irish College of General Practitioners in an effort to address the situation and is considering with them how an early increase of up to 50% can be achieved in the number of training places available.
Developments in Primary Care
Since I approved their establishment in 2002, the initial group of primary care teams have continued to develop and are now demonstrating to service users and providers, the benefits of multi-disciplinary team working in Primary Care service delivery. Many of these benefits are evident in improved access to therapy and nursing services and their provision locally for the service user.
I recognise that moving to the interdisciplinary model of service delivery poses a range of challenges for those involved. I would therefore like to take this opportunity to acknowledge the commitment of the general practitioners, other front-line health professionals and health board personnel who have worked hard to ensure the successful development of their teams.
I would also encourage other general practitioners to learn from the experience of their colleagues and to embrace and participate in the development of further examples of multidisciplinary teamworking in primary care.
Between 2000 and 2003, €46.5m was allocated to health boards under the heading of general practitioner led out-of-hours co-operatives. In 2004, the amount exceeded €24 million. At present there are co-operatives covering parts of all health board areas with most offering a full out of hours service to both private and medical card patients.
Decisions in relation to the expansion of the co-ops to other parts of board areas are the responsibility of the relevant board. These decisions are made mindful of the available funding and the list of priorities, which include medical need, demographic and other factors.
Latest figures suggest that there are 1200 GPs participating in out-of-hours co-operatives.
I am pleased to note that the Department has recently been in a position to advance a number of outstanding issues of interest to GPs, including provisions in respect of Paternity and Maternity leave under the GMS GP contract, and implementation of the findings of the Third Party arbitration on the re-calibration of over-70’s fees. My Department is also seeking to finalise revised funding arrangements in respect of Directors and Assistant Directors of Vocational Training Schemes in conjunction with Health Boards. In relation to the GP workload in respect of non-EU nationals, it has accepted that certain GP practices are experiencing difficulties and the Department is presently seeking to address this in consultation with relevant boards. My Department will examine these areas in particular in the context of finding an appropriate solution.
While the complexity and interdependence of many of the items I have mentioned cannot be denied, I sense an underlying effort amongst all parties to adjust to the changes required to introduce these developments. Any problems which arise, and there will be problems, can be overcome through consultation, dialogue, partnership and a pro-active approach to change. After all, we share the vision of a modern, high quality competent health service that maintains at heart a humane approach towards our patients.
The consolidation and progression of our goals is reinforced by interactive events such as this conference, which I hope proves stimulating and constructive. Once again thank you for your invitation and I look forward to our continued partnership in the delivery of a top-quality health service into the future.