Speech by the Minister for Health and Children, Mr Micheál Martin T.D., at the IHCA Annual Conference
I welcome the opportunity to address you this evening, at a time of unprecedented change in the entire health system. I speak to you as partners in that change process, key stakeholders with the capacity to influence the environment for change and to support the successful passage and migration to the type of health system of which we can all be proud.
The Health Strategy – Quality and Fairness was published in November 2001. It has become fashionable to question and comment on the commitment of the Government to its implementation. In fact it forms the framework within which all of the supporting analysis and sectoral strategies which emerged over the past 18 months have been developed. Full implementation of the Health Strategy was always seen as a longer term project. It quite deliberately set out to get away from short-term thinking and piece-meal policy-making to create a longer term overarching framework, with clear goals, objectives and action points which would guide day-to-day and year-to-year decision-making over the period of implementation. I am re-stating this evening the Government´s commitment to full implementation of the Strategy – albeit over a longer period than originally envisaged – and it is in that context that I would like to discuss a number of current and pending developments with you.
The Programme of Reform
On the 18th of June the Government announced the most extensive reform programme for the health system in over 30 years. The programme´s focus is improved patient care, better value for taxpayers´ money and improved health care management. The reform programme includes measures which will impact on every element of the health system and work has been ongoing in recent months to plan the programme of change envisaged.
The Government recognised that to succeed it would be necessary to clearly set out its vision of reform to all within the existing health system. As many of you will be aware, over the summer months we have conducted the first part of a communications programme around the Reform Programme. Inevitably, there are questions and concerns, both personal and professional – we will reflect upon these as we get into the detailed planning and implementation of the transition to the new structures. Despite those concerns, the message coming through is that those working in and interfacing with the system not only welcome the reforms, they see them as badly needed and are anxious for action to begin.
The Secretary General of my Department and I met directly with members and staff of each Health Board during July. In addition, the Office for Health Management undertook a structured communications process and will be reporting to my Department on the outcome of the ongoing consultations with staff throughout the health service very shortly. Early feedback indicates that this approach has been extremely well received by stakeholders and will yield dividends in the longer term.
The next steps to be taken are the appointment of a National Steering Committee to oversee the implementation process and the establishment of a Board for the Interim Health Service Executive. I am considering possible nominees for both bodies at the moment and I intend to report back to Government very shortly with proposed appointees, in consultation with the Minister for Finance.
In addition to this activity,
- The terms of reference and membership of Action Projects to advance specific aspects of the Programme are almost finalised and these groups are beginning to meet. The projects are centred around the new structures envisaged, the development of a governance framework and the introduction of strengthened financial management and accountability. An important input into the thinking of these Action Projects will be the feedback from the consultation process with stakeholders.
- Work on a model of programme management to advance the reform programme has been developed to provide an overall structure within which individual projects can be planned and interlinked.
- A project office to support the programme is currently being established and key staff to lead and support the development of the programme have already been appointed.
Ultimately, the purpose of the Reform Programme is to:
- Streamline functions, roles and responsibilities;
- Improve governance, planning and financial management;
- Remove obstacles to integration and the delivery of appropriate care in the appropriate setting; and
- Maximise value for money.
But if the reforms do not achieve any real change in the experience of the patient they will have been for nothing. That is the purpose of the change programme. It is a concept that I know everyone working is the system believes in – I believe that together we can achieve this most important objective of all.
At present, many hospitals depend on NCHDs working long hours to provide a range of emergency services. The European Working Time Directive, the need to introduce a consultant-provided service and reforms to medical education and training will necessitate a new approach, one which will improve patient care and the working conditions for the NCHDs themselves.
I will shortly publish the Report of the Task Force on Medical Staffing. It will mark the beginning of a new way of organising hospital services. The Task Force has set out a series of principles for the organisation and delivery of hospital services nationally while making detailed recommendations regarding the organisation of acute hospital services in two regions.
Evidence shows that patients receive better treatment in hospitals that have the required numbers of specialist staff, high volumes of activity and access to appropriate diagnostic and treatment facilities. It is therefore justified on evidence-based criteria to concentrate emergency care in our major hospitals. Reorganisation of hospital medical staffing and our acute hospital services, however, offers the potential for a wider range of safe effective, high quality care to be offered in smaller hospitals, something which we cannot afford to ignore. I believe that a number of smaller hospitals have the potential to provide an increasing volume of elective procedures and the kind of multi-specialist day and outpatient care that is currently performed in the larger hospitals.
The Task Force also sees a role for a ´General Hospital´, in areas where, for geographic or demographic reasons, access to emergency hospital care is problematic. Acting as part of an integrated network, General Hospitals could provide a range of specialties, including 24-hour emergency surgery, medicine, anaesthesia, and appropriate diagnostic and laboratory services.
While the Task Force does not recommend the provision of a General Hospital in either of the pilot regions, the case for such a hospital elsewhere will be explored as we further examine the organisation of acute hospitals in the rest of the country.
This process will bring services closer to patients while ensuring that those services are both safe and sustainable. This process will be one of transformation and development. It will harness the strengths of all hospitals so that they can best meet the needs of patients.
As I have indicated, this report will be published in the coming weeks. I understand the anxiety of all hospital doctors and the IHCA to progress the necessary changes following publication. Both I and my Department are determined to get on with the next steps as a matter of urgency.
New Consultants´ Contract
In order to meet the challenges presented by the reform of the Irish health service, it will be necessary to modify existing work practices. For consultants, these modifications will be reflected in the introduction of a new common contract. Negotiations on this have, to a large extent, been overtaken by the aforementioned reports, with both management and the consultants’representative organisations recognising the need to take account of the implications of these before entering into substantive talks. Once the reform programme is underway, however, I will be pressing for a rapid negotiations process culminating in a new contract whose form matches its function.
Clinicians In Management
A key area of the reform programme will be more clearly defined accountability by all working in the health system. In the case of the Clinicians In Management programme, I wish to acknowledge the work done to date and especially the examples of best practice that have developed. I must state, however, my disappointment at the slow pace of the ´roll out´ of this programme and the reluctance of some clinicians to participate. Now is a particularly opportune time to revisit and revitalise CIM, to identify its outcomes, and to ensure that these outcomes justify the monies invested. The re-negotiation of the common contract provides an opportunity to embed CIM as a key responsibility for all consultants.
Progress on Heads of Bill for Medical Practitioner´s Act
To ensure high standards and appropriate levels of performance by the medical profession, it is necessary to ensure that legislation is updated and amended to meet the requirements of today´s health service. To this end, the Department of Health and Children has been undertaking a thorough review of the Medical Practitioner´s Act 1978. Issues being examined include changes in public representation on the Council and its committees, a new committee structure and improved efficiencies in the Fitness to Practice function. The importance of having responsive and proactive legislation in this area is fully recognised. I acknowledge that this work has taken longer than expected, however I expect that the Heads of Bill will be published before Christmas.
High Performance / Competence Assurance
The establishment of a Competence Assurance scheme, on a mandatory basis, will be included in the Medical Practitioner´s legislation. This scheme is closely related to public confidence and to the maintenance of high standards by medical practitioners. Recent highly publicised and seriously disturbing cases have further illustrated the importance of, and necessity for such a scheme. In the absence of such a scheme, an environment is created in which, to quote a consultant colleague of yours, “a poorly performing consultant . . .can go undetected”.
The competence assurance programme developed by the Medical Council involves a number of different complementary levels which will ensure that doctors are up-to-date with international best practice in medicine. Currently, participation in the programme is voluntary and compliance with the ´roll out´ has been, to date, at best, limited. Certain categories of doctors in independent practice are recording very low participation rates. This lack of proactive engagement is of concern to the Medical Council and also to me. I believe that participation in this programme is necessary and will clearly indicate to the public that this matter is being taken very seriously.
The maintenance of high quality standards also impacts on the cost of professional indemnity cover for consultants. Enterprise liability in the form of the Clinical Indemnity Scheme came into effect on the 1st of July 2002. The Scheme has since provided cover to health boards, hospitals and their staff. As you are all aware it was decided at that time not to immediately dismantle the existing indemnity arrangements for consultants, instead providing time for consultants to join the Scheme by agreement. Since then my officials and I have been involved in intensive discussions with the IHCA in order to resolve this complex issue.
I appreciate that the change to enterprise liability is a major one for consultants. Traditionally, doctors have indemnified themselves through membership of the two mutual defence bodies. The State, however, reimbursed much of these subscriptions, while also funding the separate indemnity arrangements for NCHDs, among others. It also funded the insurance cover for health boards and hospitals. The increasing cost of these arrangements necessitated the introduction of a scheme based on the principle of enterprise liability.
I believe that enterprise liability will provide health boards, hospitals and their staff with a secure State-backed indemnity for all of the work which they undertake within public institutions. This includes private practice conducted on public hospital sites. This is a very valuable concession to consultants which has not been granted under similar schemes in the UK and elsewhere. Claims against hospitals or consultants will be managed by a specialist unit at the State Claims Agency. I know that consultants have had concerns that the Agency would settle claims easily in order to avoid court costs. Nothing could be further from the truth. The Agency has quickly established itself as a robust defender of State bodies’ interests and reputations, as exemplified in recent asbestos cases.
Of course the Clinical Indemnity Scheme will not cover private work undertaken outside the public hospital. Consultants will need to buy their own indemnity cover for this aspect of their practices. I know that consultants have concerns about the future affordability of that cover. I have often spoken of the interdependence of the public and private healthcare systems in Ireland. Indeed the complementary role of the two sectors is explicitly referred to in the Health Strategy. The establishment of the Clinical Indemnity Scheme is not intended to, and should not, have adverse consequences for either the independent hospital sector or for consultants who work in it. As you are aware the Government decided earlier this week to approve proposals designed to ensure that professional indemnity cover remains available at reasonable cost to consultants who work on either a part-time or full time basis in the private sector.
Probably the greatest concern to consultants at present is the possibility that some of them may not have any cover for claims arising from before the establishment of the Clinical Indemnity Scheme. The Government also agreed this week to lend the State’s support to a strategy designed to ensure that consultants are not left without cover for claims arising out of past events. I believe that these developments provide ample evidence of my own and the Government´s commitment to addressing the two major concerns of consultants in relation to membership of the Clinical Indemnity Scheme.
I know that adequate resourcing of the health system is of concern to IHCA members – this is a concern that we share. In fact, an extra €1 billion was provided for my Department in 2003. This accounts for 66% of the growth in public expenditure on services in 2003. As a % of GNP, gross non-capital health expenditure in 2003 is estimated at 7.93%, which is the highest figure, nationally, in almost 20 years. In international terms, Ireland has moved from 5th from the bottom in the EU to above the EU average in terms of the per capita spend on health.
The evidence of widespread investment is readily seen in, for example, the substantial increase in staffing generally, including consultants, producing a substantive increase in the activity of the health services, delivered across the board. I acknowledge that there remain significant pressure points in the health services. However, the pace at which these can be treated is dependent upon our economic growth. This said, I am committed to ensuring the best possible outcome for the health services in the 2004 Estimates programme.
Despite the substantial increase in resources over the last six years, some Dublin hospitals have been experiencing difficulties at their Emergency Departments particularly in relation to their capacity to admit patients. One of the main causes for the current pressure on emergency services is the reported number of delayed discharges in acute hospitals. To resolve this issue, I recently allocated €3.8million to the ERHA and €1.7 million to the Southern Health Board under the Bed Capacity Initiative to facilitate the discharge of patients from the acute system to an alternative care setting. This funding will allow for the discharge of some 200 patients over the coming weeks. Furthermore, an additional 20 A&E consultants and 18 consultant anaesthetists have been appointed since 2000.
The ERHA is closely monitoring the present situation and is actively engaged with hospital management who are working closely with consultant and nursing staff to address the current problems. This is one area where my Department will continue to monitor the situation over the coming months. I can assure you that all possible steps will be taken in order to manage the inevitable pressures on A&E services over the Winter months.
Waiting Lists / National Treatment Purchase Fund
While over 560 additional beds have been commissioned on foot of a detailed National Review of Bed Capacity, I also established the Waiting List Initiative and the National Treatment Purchase Fund to provide access to services to those waiting longest for admission to hospital. Some 6,500 patients have already received treatment through the Purchase Fund to date mainly in private Irish hospitals. Significant progress has been made. The latest set of published waiting list figures for the quarter ended 31st March 2003 support this claim, indicating that the total number of adults waiting more than 12 months for in-patient treatment in the nine target specialties has fallen by 8% in the period December 2002 to March 2003, a total fall of 35% since June 2002. Similarly, the number of children waiting more than 6 months for in-patient treatment in these specialties decreased by 35% over this period, a total fall of 56% since June 2002. I do accept, however, that while the figures reflect an improved performance, there is still much to be done for public patients who are on long waiting lists.
While we may disagree from time to time on individual issues, we share a common position on the overarching issues which relate to the general health and well-being of the population. I appreciate the strong endorsement of many consultants not only for the Health Strategy objective of ´better health for everyone´ but also for the initiatives aimed at meeting this objective. It is widely acknowledged that the single most significant action that the Government can take to improve the health of the population is to address the scourge of smoking. Chief among the Government´s initiatives in this regard is the prohibition on smoking in all places of work from January 2004. The primary purpose of this ban is to protect the health and safety of workers and the public from toxic environmental tobacco smoke. In addition, a recent report from the Office of Tobacco Control indicates that the cost to the state of smoking amounts to around €5 million per day. Draft regulations have been published and these will be signed in the coming weeks. Although recent fiscal and environmental initiatives in this area have led to a reduction in smokers of 100,000 since 1998, I am confident that these regulations will contribute to further reductions and significant health gains.
New Cancer Strategy
One of the areas upon which we have put much emphasis in recent years is in the development of a modern service for cancer. Again, there is ample evidence of a significant gear change here – in the number of oncologists appointed, for example, and in the greatly increased number of diagnoses and treatments which are now possible. This is a tribute to the highly skilled and motivated teams appointed as well as to the level of investment made.
I sometimes wonder how success stories such as this do not receive the same prominence as the bad news and the crises. Maybe that´s an area where both the Department and consultants could work together to talk up in an honest and balanced way some of the real achievements of the system.
While it is important to reflect on the progress made to date in the fight against cancer, it is also necessary to look to the future. With this in mind, I would like to draw your attention to the work of the National Cancer Forum which, under the chairmanship of Professor Paul Redmond, is currently developing a new cancer strategy in conjunction with my Department. The new National Cancer Strategy will set out the key areas to be targeted for investment over the coming years.
While the developments of the last twelve months have been momentous, the next twelve will be even more so and will see us moving towards a more pro-active health service, one that will be responsive to each one of its clients´ needs. To ensure success, however, it is important that consultants help to champion these reforms. The degree of proactive support with which the IHCA and its members greet the reform programme will establish a benchmark for other health service employees. I know that you, as an organisation, and as individuals, have been closely involved in developments to date and that you will not be found wanting in this regard. We look forward to working with the Association, in partnership, over the next twelve months.