Speech by the Minister of State with responsibility for Children, Ms Mary Hanafin, T.D. at the National Economic and Social Forum´s Plenary Session on Health Policy (theme – Equity in Healthcare)
I am pleased to be here today to address this plenary session of the Forum on Health Policy. The theme – Equity in Healthcare – is one of the key issues with which we in Ireland as in many other countries are grappling. Its importance is underlined by the fact that it is one of the three main principles underpinning the 1994 national health strategy – Shaping a Healthier Future – an emphasis which is being continued and strengthened in the new national health strategy now nearing finalisation.
Equity in relation to health status
The concept of equity as applied to health and healthcare has many layers as your draft policy paper for this meeting makes clear. Our ultimate concern is with equity of health status, that is the elimination of those differences in health which result from factors which are considered to be both avoidable, unnecessary and unfair. Equity in healthcare is one, and an important one, of the determinants of health status. I don´t need to remind this audience of the many other factors which influence health status – genetic endowment, early life experiences, material conditions such as income and housing, education, psycho-social factors such as social support networks, health-related behaviour and biological risk factors. Remedying inequities in health status requires therefore a broad multi-sectoral approach.
The National Health Promotion Strategy 2000-2005 places emphasis on this approach. The National Health Promotion Forum recommended in that strategy is being established. Its composition and terms of reference are currently being finalised and membership will be widely representative to facilitate a multi-sectoral approach. The consultative processes we have carried out earlier this year for the new national health strategy and for the setting of health targets in the NAPS indicated that such a multi-sectoral approach and assessment of the impact of other policies on health should be a key feature of our way forward. It is my view that this is the broad framework within which we must address the issue of health equity. This view was also underlined in the 1999 Report of the Chief Medical Office on Inequalities in Health and is further underlined in his report for 2000 on The Health of Our Children just recently published.
Equity in healthcare
Within this broad strategy, equity in healthcare – the specific theme of your meeting here today – has an important role to play in achieving equity in health status for our population. Some researchers have estimated that in the USA for example medical care has contributed about a fifth to the 30 years of increased life expectancy seen during the 20th century. It can also be argued that the potential contribution of medical care to reducing mortality has increased over recent decades with the introduction of new treatments which produce substantial increases in life expectancy following disease development in areas such as heart disease and some cancers.
Equal access for equal need
Shaping a Healthier Future acknowledged that the achievement of an equitable health service has a number of dimensions. It stated that access to health care should be determined by actual need for services rather than ability to pay or geographic location. It went on to say that formal entitlement to services is not enough; those needing services must have them within a reasonable time period. It also acknowledged that the pursuit of equity must extend beyond the question of access to treatment and care and must examine variations in the health status of different groups in society and how these might be addressed. It also referred to giving special attention to certain disadvantaged groups.
In discussing equity in health care it is also necessary to add to equal access for equal need other dimensions such as equal utilisation for equal need and equal quality of care.
Talking about equal need raises questions about what we mean by need. This is most usually defined in terms of capacity to benefit from treatment or care – in terms of capacity for health and social gain, to use the language of Shaping a Healthier Future. If need is so central to our concept of equity then an important priority is to develop more sophisticated indicators of need for different services. This would allow need (carefully defined in terms of health and social gain) to be used more explicitly in the allocation of resources and the subsequent measurement of equity. The National Intellectual Disability Data Base for example has been an important factor in providing an indication of need and has increasingly supported service planning, phased increases in funding and monitoring in this service area. A Physical and Sensory Disability Data Base is currently in process of development. The implementation of the Strategy for Health Research, which was launched just recently, and the National Health Information Strategy, currently being developed, should considerably improve our knowledge base on health and social care needs. In a situation of limited resources, where every demand cannot be met immediately, health professionals play a key role in prioritising needs at the level of the individual. In many service areas we are working towards having individual care plans developed in conjunction with the patient or client and his or her family or carer.
A twin track approach to achieving greater equity
It is my view that improving equity in healthcare requires a twin track approach
- building up the capacity of the system and
- removing barriers to access to appropriate care.
In discussing equity of access what we are concerned with is access to the appropriate type of service at the earliest stage in the health illness continuum. This raises the question of the appropriate balance between different elements in our system, in particular the balance between acute and non-acute care. Health policy has long been criticised by many for being overly focused on acute care to the neglect of the non-acute side. This Government has sought to redress this situation because we view care for groups such as those with disability, children in need of care and protection, Travellers and many older people as an important equity issue. At present about 53% of resources are being committed to acute hospitals. However of the additional £2.6 billion in non-capital funding which has come on stream since 1997, over £900 million has been allocated to new service developments and of that, more than two thirds has been allocated to the non-acute sector. Little attention is paid by commentators to this fundamental shift in resource allocation to supporting our most vulnerable citizens in a community setting. Equity for those being cared for in a non-hospital setting and in very vulnerable situations which are not as highlighted as acute hospital problems is a matter of critical importance for this Government. Lip service has often been paid by administrations of every political hue in the past to better balancing resources between the acute and non-acute sectors. This is being addressed in a manner which recognises the need to get the balance right. Up to recently capital spending on the acute sector versus the non-acute sector was in a ratio of 70 to 30. Under the National Development Plan we are seeking to redress that imbalance so as to achieve a 50 / 50 ratio over the period of the Plan.
Most people’s first point of contact with health services is at primary care level and many more people use these services on an annual basis than avail of acute hospital services. The consultation process for NAPS Health Targets placed a strong emphasis on access to a comprehensive primary care service as a key element in efforts to reduce inequalities in health.
Given the potential of primary care in health promotion, disease prevention, early detection and provision of treatment and on going care at the lowest level of complexity and in the setting closest to people´s homes, I think it is appropriate that we are working towards giving it a more central role in our health system. I envisage an enhanced system of primary care as the main source of meeting health and social care needs and the new health strategy will place an increased emphasis on this area.
This will require considerable developments in our infrastructure and a movement from a relatively fragmented system as at present to one centred round the concept of multidisciplinary team working. This should enable primary care to take on a much greater role in health promotion, disease prevention and rehabilitation. Relevant reports such as the Report of the Cardiovascular Health Strategy Group are predicated on such developments. In terms of my own brief for children I am aware how important an enhanced primary care system is to the implementation of the National Children´s Strategy and of reports such as Best Health for Children and Best Health for Adolescents. The ultimate aim is that for the individual there is a more local, accessible, timely and responsive primary care service. We also need to have much better integration between primary and secondary care. An improved infrastructure at primary care level provides a better platform for achieving this. Such an improved infrastructure will not only make for enhanced access to primary care but should reduce unnecessary demands on our acute system and thereby improve equity of access to our hospitals as well.
The PPF contains commitments to develop our primary care services. This is to be achieved through a programme of refurbishment and upgrading of health centres under the National Development Plan and where new health centres are being developed, the Department is proposing to health boards that, where appropriate, they be multifunctional and provide a comprehensive range of services for different care groups. There is also a commitment to carry out at least four pilots of differing models of primary care delivery which will explore ways of moving further towards 24 hour seven day primary care.
Acute Hospital Care
Much media attention focuses on equity issues in relation to our acute hospitals. It is clear that there are inequities there in relation to waiting lists for elective procedures for public patients. This is an unacceptable situation and we are working on many fronts to remedy it. At the outset I should say that against the background of overall hospital activity of 870,000 in-patient discharges in 2000, the number of people on hospital in-patient waiting lists represents only 3% of all discharges.
The latest hospital waiting list figures – those to June of this year – have just been published. The hospital system has continued its high productivity performance in January to June 2001 by recording an overall rise of 5.1% activity increase (including almost 11% growth in day cases) or an extra 22,000 cases treated over the same period last year. They show that hospital waiting list figures have decreased by 16% since June 2000. The number of patients on waiting lists at 30 June of this year, as reported by health agencies, was 26,659, a drop of over 5000 on the comparable figure for 2000. While the June 2001 figure shows a small increase of 277 compared to March 2001, the number of adults waiting for more than 12 months for treatment and the number of children waiting more than 6 months for treatment in the target specialties have both fallen by 20% over the 12 months and reductions in waiting lists have been achieved across each of the eight health board regions in the same period.
There also have been significant reductions over the year in the waiting list for target specialties, for example:
- Cardiac Surgery down by 52%
- Gynaecology down by 35%
- ENT down by 30%
- Ophthalmology down by 23%
- Orthopaedics down by 14%
However, the growth in the number of procedures reflects a very high and unacceptable occupancy rate of 86%. This continuing upward trend across the hospital system disguises even higher occupancy rates in the major hospitals. There are obvious capacity problems which I refer to later.
A major review of the underlying causes of waiting lists was undertaken by the Department of Health and Children in 1998. The Expert Group established for this purpose make a number of short, medium and longer term recommendations relating to organisational and management issues in acute hospitals themselves and to the interaction with other parts of the system, including GP and community services, non-acute beds and long-stay services.
It is evident that good progress has been made by a number of agencies in putting in place the measures and processes recommended, although some of these may take time to bear fruit. Some of the options considered were more flexible use of existing capacity through longer theatre and day ward opening hours, cross-contracting arrangements, short term accommodation for those travelling for day procedures and better use of facilities during the of-peak summer period. In addition some of the longer term infra-structural issue are being addressed through the National Development Plan.
The Bed Capacity Review
A review of bed capacity was initiated last year in both the acute and non-acute settings, on foot of a PPF commitment and has been conducted in consultation with the Social Partners. Funding of £32 million was approved on foot of phase 1 of the review to help alleviate service pressures and to maintain services to patients in the acute hospital sector, particularly over the winter period. The second phase of the national bed review involves the development of a longer term investment strategy for the acute and non-acute sectors. The review involves a detailed assessment of need, including an analysis of future bed requirements by medical and surgical specialty. The review is being finalized in the context of the new National Health Strategy.
The Finance Act 2001
At present about 20% of public hospital beds are designated as private and about 23% of activity is private; however there is a higher proportion of elective patients who are private and this is being looked at in the new health strategy. The Finance Act 2001 includes measures which allow for the establishment of private hospital facilities under certain conditions. These include provisions to ensure that 20% of the capacity of such facilities would be made available annually for the treatment of persons who have been waiting for in-patient or out-patient services as public patients. This provision is subject to service requirements specified by the health board in whose area the facility is located. The private hospital concerned must provide a discount of at least 10% to the State in respect of fees to be charged in regard to the treatment of any such public patient as compared to the fees charged in respect of similar treatment afforded to a person who has private health insurance. The intention of these measures is also that the benefits in terms of additional beds should be captured for the public system. For every 100 beds developed in the private sector under these measures 100 private beds in public hospitals will be re-designated for public use. The aim is to reduce pressure on public hospital beds.
The Government will continue to focus on waiting lists and waiting time in order to ensure that services are available and accessible to those who most need them. Investment is at an all time high in addressing lists and in the public hospital system generally.
Removing barriers to uptake of services
In addition to building capacity in our services we must address barriers to uptake if we are to achieve greater equity. The Government is concerned that there be no financial barriers to the uptake of appropriate care. Our eligibility system is a key plank in our strategy to improve equity in healthcare. The objective of the medical card scheme is to provide free medical care for people who are on low incomes. In that regard the PPF contains a commitment that the health board CEOs would consult with the Social Partners in their review of the medical card scheme and that they would place particular emphasis on the needs of families with children, and on removing anomalies and barriers to take-up, including information deficits. The CEOs´ report is due to be completed very soon and through the consultation with health boards their views have been fed into the consultation process for the new health strategy.
One area where we need to make improvement is in clarifying entitlement to some community services such as day care, home helps, therapy services to remove geographical inequities which can arise currently in access to these services. This issue will be addressed in the new health strategy.
Other barriers to uptake of services can arise because people are not sufficiently aware of what they need or the services to which they are entitled. This is an issue of particular relevance to people in poverty or social exclusion. We need to be more proactive on this front in making information and in some cases skills to take care of their own health, available in ways that are accessible to people and that take account of diversity in our society.
The National Anti-Poverty Strategy (NAPS)
The links between poverty, social exclusion and ill health and the priority attached to achieving greater equity are reflected in the PPF commitment to develop health targets for the next phase of the National Anti-Poverty Strategy (NAPS).The Working Group on NAPS and Health completed its report in July, following an extensive consultation process. The report is currently being integrated with the NAPS reports from other Government Departments with a view to the adoption by Government of a revised NAPS Strategy later this year. Concurrently, the Report of the NAPS and Health Working Group is informing the new National Health Strategy.
The paper you are considering at this plenary session raises issues which are the subject of debate worldwide. The NESF is an important forum for such debate given its wide ranging composition and the broad spectrum of views which it can therefore bring to bear on issues such as this. Your agenda echoes concerns raised in the consultation process for the NAPS and for the National Health Strategy. Minister Martin and myself look forward to hearing the outcome of your deliberations and I wish you a successful conclusion to your work today.