Speech of the Minister for Health and Children, Micheál Martin T.D. The BUPA Ireland Health Summit
Developing and Reforming the Health System
I welcome the opportunity to talk to you this morning about development and reform in the health system. There are a number of themes which I´d like to cover but broadly, I want to look at what has been achieved in the health system – and there have been significant achievements in the last five years – and I also want to touch on the reform programme and how both of these fit into the strategic framework of the Health Strategy.
When we set about preparing Quality and Fairness in 2001, we took a conscious decision to put forward a fully comprehensive strategy that embraced all aspects of health and health services.
The Government adopted a comprehensive and ambitious strategy. A Strategy that is a mix of long term strategic planning and short-term tactical initiatives. It was a reflection of our understanding that the historic underdevelopment of some areas of the system were, and are, creating inappropriate pressures in other parts of the system and thereby diminishing the value of investment made in the past.
Popular commentary continues to set out an equation which suggests that health equals hospital services and nothing else – it doesn´t. The range of services provided within the health system is almost unique by international standards – covering everything from health promotion, disease prevention to acute hospital treatment and a wide spectrum of personal social and community services.
The ESRI review of the 1994 Strategy recognized the need to produce a more comprehensive and integrated strategic document with clearer goals, actions to achieve those goals and much improved evaluation of activity and outcome.
The public too, recognized the diversity of services and put “meeting special needs”, “community services” and “health promotion” up there right alongside acute hospital services in their list of concerns.
That is why the Strategy is balanced towards a broader and more long-term view of what “health” is all about, so that areas traditionally neglected would be developed in a balanced and integrated way.
Part of what was important to achieve was getting everyone to realize that health is about much more than health services. Many factors outside of the control of my Department influence health status. Homelessness, drug abuse, alcohol and road safety are just some examples of areas where health services are dealing with the outcomes of problems but are not directly involved in creating the solutions at source.
My own work in the area of tobacco control is an example of where we need to look outside of direct health services to get to the nub of the problem which tobacco use brings to the health system. Other areas like alcohol and road safety highlight the role of other Government Departments and agencies. The actions of others in both of these areas may do more to contribute to reduction in alcohol related disease and accidental death than anything the health service can achieve alone.
There have been achievements since 2001. I could keep you here all day describing where money has gone – but you don’t want to hear a litany. You will hear some of those details in the next presentation about specific areas. However, let me give you some food for thought.
In terms of cancer services:
- Overall, the cumulative investment in cancer service since 1997 has been €400 million in the development of cancer services, well in excess of the £25million initially envisaged in 1996 to implement the National Cancer Strategy. Access to a whole range of services has been radically enhanced – it´s not perfect yet but the improvement has to be acknowledged.
- Funding for the National Cancer Strategy has resulted in 80 additional Consultant posts, together with support staff in key areas such as Medical Oncology, Radiology, Palliative Care, Histopathology, and Haematology.
- Since 2001, €30 million euro has been invested in the development of symptomatic breast disease services. Activity for in-patient breast cancer procedures has increased by 37% nationally since 1997.
- In breast cancer screening we have achieved an uptake of over 70% among targeted groups, exceeding international standards.
- The implementation of the Cardiovascular Health Strategy since 2000 has created almost 800 new posts and broadened the range of services being sponsored to include health promotion, primary care, pre-hospital care, hospital care, cardiac rehabilitation as well as information systems, audit and evaluation.
- A specific example of the impact of investment can be seen in the cardiac surgery programme in St James´s Hospital where cardiac surgery waiting times have reduced
- from a waiting time of 5 years in February 2000, to a waiting time of 9 months at the end of December of the same year.
- At the end of December 1997, 77% of patients on the cardiac surgery waiting list were waiting longer than 6 months.
- At the end of December 2002 no one on that waiting list was waiting more than 6 months and the aim is to reduce that still further to that no one is waiting more than 4 months.
Waiting Lists versus Waiting Times
These are tangible improvements for which the health service gets little credit. It also shows that the debate about waiting lists isn´t the right one – the debate should be about waiting times – and we can show tangible improvements in cancer, paediatric surgery and gynaecological waiting times. These reductions derive at least in part from the treatment of over 4,000 patients to date under the National Treatment Purchase Fund.
Renal dialysis services are not available in all but one health board area and the remaining board will be commissioning a unit shortly.
It is also important to me that the achievements of all those who work in the health service are not undermined. Thousands of people have satisfactory experiences of the service, and successful outcomes. An Irish Society for Quality in Healthcare survey carried out in 2000 tested the attitudes of 1,800 patients who had been through the acute system. The results indicated that 93% were satisfied or very satisfied with the level of quality of care they received from the system. Other statistics in that recently published survey indicate significant satisfaction levels on a number of fronts from those treated in our hospitals.
Putting these facts forward is not an attempt to say that everything is perfect.
I recognise that there are areas where more investment is still needed and where targets set have not yet been achieved.
I have to acknowledge that the speed and scope of improvements have been limited by the economic situation. That doesn´t mean that we change direction – it´s about a change in pace -I´m acknowledging that.
I am also saying that investment must be coupled with system reform. Things do need to change. The Health Strategy recognised that change, as well as investment would be required and that brings me to the reform agenda.
Origins of the Organisational Reform Agenda
System weaknesses were identified in the Quality and Fairness. After all, the present structures in the health system evolved from a model developed over thirty years ago. During that time, the size, range of functions and complexity of managing the system have all grown dramatically.
Demographic projections for Ireland suggest that by 2011 the population aged 65+ will have increased in every region with a doubling of the very old population (those aged 80 and over). This is a factor of major significance in planning for the provision of acute hospital services.
Demand for healthcare is increasing, related to better education, increased expectations, economic prosperity and technological advances in healthcare, permitting earlier and improved diagnosis and treatment. Many successful medical interventions are now made in middle years, which yield longer life expectancy but also, typically, the onset of further illness later in life.
Combined with pay and non-pay inflation, these factors means that it is expensive just to stand still. From a cost viewpoint there is a cruel paradox in the fact that the more successful the outcome, the more expensive it gets.
One of the main conclusions of the Health Strategy was that while the system has served us well in many respects, it is not structured or functioning in a way which is responsive enough for existing demands, not to mind, anticipated future demands. It simply must change.
Principles of Health Service Reform
The Strategy goals were counterbalanced by six frameworks for change. These frameworks set out a reform programme for the whole system. Let´s consider some of these key reforms very briefly.
Primary care reform as heralded in the Strategy represented one of the most radical departures in terms of existing government policy. It is a long term plan. It requires detailed planning, testing of models and considerable change on the part of those working within the system – particularly general practitioners and other professional health care workers.
The development of primary care is being covered in a later session, but I want to emphasis how radical a proposal it represents – multidisciplinary teams operating at community level in a totally integrated way. It´s a long term project but already we have seen the development of GP co-ops in every region of the country – the beginning of joining up professionals at community level.
It is also clear that the system itself needs to change to reflect a configuration which favours primary care over the trend towards treatment in more specialised services.
Changes in acute services were also advanced. These include capacity, in terms of volume and quality but also relate to the thorny issue of service configuration. These plans also have considerable implications for professionals in the system and in particular the consultant contract.
Within the organisational reform programme we find specific reference to
- the need to ensure that current structures and functions are adequate to meet the new objectives of the Health Strategy; as well as a recognition
- that the Department itself needs to change.
Considerable development of information and communications systems were identified as key to ensuring fast, efficient flows of information. This is essential to support planning, evidence-based decision making, better evaluation of the system and an embedded system-wide quality system.
You can see from the above that the three reports that are pending will tie directly to the health reform programme and provide the flesh on the bones of it. The Government will be making decisions on an action programme based on the outcome of these reports very shortly. I am not in a position to elaborate fully on the outcome of these reports today but there are important principles of organisational change on which they are all based.
Audit of Structures and Functions
The Audit (Action 114 of the Strategy) was commissioned in order to ensure a proper alignment of the structure as a whole to the vision and objectives outlined in the Heath Strategy.
The outcomes sought are to ensure that the structures in the system
- Are the most appropriate and responsive to meet current and future service needs
- Constitute an adequate framework for overall governance of the health system
- Achieve an effective integration of services across all parts of the system
- Adequately represent the views of consumers in the planning and delivery of services
- Focus on the principles of equity, accountability, quality and people-centredness and the national goals of the Strategy.
This report is based on exactly the same premise as the Strategy itself.
- Health care is not just about hospitals – in fact, the primary care system needs to move centre stage within the system.
- Improving the system is not just about investment and more capacity, it is also about quality of care and outcomes.
- In developing the system we need to look beyond traditional boundaries – both in terms of professional silos and geography and finally that
- The standard of policy making must be matched by proper evaluation of policy execution.
Essentially, what the report does is move us from the diagnostic stage to the treatment plan for the system. The intervention proposed is radical. It involves risk. So why do it? The rationale for change of this order is actually quite simple. Our structures have evolved over 30 years. The tendency of successive Government has been to set up specialist agencies – often to give focus and to protect particular policy developments. There are now 58 agencies operating in the public health system. This is unmanageable. This multiplicity has resulted in a complex and fragmented system which has itself become an obstacle to achieving improvements.
Rationalisation, standardisation and much improved co-ordination are all required to overcome this fragmentation and to give me, as Minister a realistic span of control over the agencies I am responsible for.
A second issue which has arisen in successive reports in the lack of clarity about roles between the Department and the system; and also the tensions between local representation and decision making vis-à-vis national policy objectives. In a system as complex and as broad in scope, it is obvious that clarity about roles, accountability and “where the buck stops” must be completely clear.
A third set of issues relate to system process. The central importance of adequate planning processes have been highlighted again and again. Keeping people at the centre of care means that you must start with bottom-up needs assessment through a cycle which links planning of services to funding and activity.
Part solutions to these problems in the past have brought us some way forward but part-solutions, by their nature are limited. It is high time to devise a comprehensive and integrated solution for the whole system.
It is already clear that the need to significantly reform the existing delivery structure will be put forward as a major proposal. This will include the development of a unitary delivery system involving
- considerable consolidation of existing agencies;
- the configuration of services into two broad pillars, one centred an acute service delivery and the other on primary, continuing and community care; and
- the development of large scale shared services.
This unitary system is being advanced as the most appropriate way to support the individual strengthening of each pillar within the system, while at the same time, providing for a more structured approach to integration processes. The proposals also include the development of an improved system of governance and accountability, which clarify and create appropriate boundaries between the delivery system and the Department of Health and Children. This is intended to allow the Department to focus more actively on its role in policy development, population health planning and the monitoring and evaluation of the impact of the delivery system on health status.
The proposals emerging will support the commitments made in the Strategy in relation to reform of Acute Hospital Services and the likely changes required, in terms of configuration, anticipated in the Health Strategy. It will provide a more adequate unitary approach to the delivery of hospital services, which in turn, will support the more even and consistent introduction of consultant-delivered services in Ireland.
In looking at the report of the Brennan Commission, similar principles emerge. There is a realisation that in a complex, multi-layered system, financial accountability must be pitched closest to where decisions which drive costs are made. In addition, the financial management system itself must embed the checks and balances is such a way that managing and controlling costs is an in-built aspect of the system.
I am more anxious than anyone that we have guarantees that money is being well spent. I fully accept that the Government and, more importantly, the public need to have this assurance especially in times of financial constraints.
As well as these specific issues, the Brennan Commission also dealt with structural issues – its findings overlap with and are also easily integrated with the conclusions of other reports on system reform.
Finally, I want to mention the work of the Taskforce on Medical Staffing. The primary function of this group was to outline a plan to achieve the reduction in working hours for non-consultant hospital doctors required under the European Working Time Directive. They were also asked to include consideration of moving from a consultant-led to a consultant provided service as part of the exercise. It is interesting that in examing these issues they quickly came to the conclusion that the configuration of acute hospital services needs review. It is anticipated that the broad principles which the Taskforce will set out will also reiterate strategy commitments to a focused review of service configuration and will complement the overall structural reforms being proposed in the other two reports.
The principles which they are coming up with, are centred on high quality and optimal outcome. These “principles” (which I don´t think anyone can disagree with) are leading us to a debate fraught with difficulty. Ask anyone where they would like to be treated if they had to have a serious medical intervention. Would they opt for the nearest local hospital? No, they would want to be treated at a centre of excellence where multidisciplinary teams are equipped to deal with tertiary cancer, renal, cardiac or trauma care. They’d be right. International evidence demonstrates again and again that clinical outcomes for patients are improved when they are treated by multi-disciplinary specialist teams operating in units where there are high volumes of activity and access to diagnostic and treatment facilities. But it is neither practicable or realistic to suggest we can provide this within immediate reach of everyone´s home.
It´s time we faced up to these issues. As a society, we need to achieve a consensus about the reality of achieving high quality safe care in a country of this size and population.
What I wanted to illustrate today is, firstly, that things are being achieved in the system. Secondly, I wanted to show you that the detailed reform plans about to emerge are based within the strategic framework of Quality and Fairness. Finally, I wanted to remind you of the principles of reform – already well established in the Strategy – which we now have to face up to.
There is a significant challenge in taking on change of this order. Obviously it’s a personal challenge for me and my Department. But it is also a challenge for the system and the people working in it . We need to be creating an atmosphere conducive to change. More balance and perspective in how we view the whole health system is somewhat overdue. We’re treating more people than ever, quality is improving and productivity is increasing in a range of areas. That´s a credit to the people working in the system and it needs to be recognised.
Most importantly I think we all have to recognise, that with the plans there are challenges for society more generally.
Events such as this provide the opportunity for an informed debate. I hope the next 2 days provide that opportunity and I look forward to hearing feedback. Most of all I hope that in this great debate we can move from critique to a new phase – one in which all of the societal challenges I referred to – not just those internal to the system – are considered.