WE CAN HAVE ONE OF THE BEST HEALTH SERVICES IN THE WORLD
Dr James Reilly TD, Minister for Health
The political, social and economic crises of the last few years have made two things very clear: we live in a Republic which has failed its citizens in a number of crucial respects and we have allowed our health system to evolve in such a chaotic manner that it has also failed our citizens on too many occasions.
At the core of both of these developments is a political system which has lost its way over the decades and has failed to sufficiently reform and modernise our state. A profound conservatism, reinforced by the power of certain vested interests, has meant that change in Ireland has been both slow and minimal – when it has happened at all. As Minister for Health I am committed to fundamentally reforming our health system and creating a genuine, patient-centered model of healthcare. The status quo is simply not acceptable.
As a citizen who is also very proud to be Deputy Leader of Fine Gael, I am convinced that we must build a new Republic in Ireland that will put the citizen first. Indeed, I would argue that the creation of a single tier health system, which treats all citizens equally is perhaps the most important step we can take on the road to securing that new Republic.
Fine Gael, as we all know, has traditionally been very reluctant to use the language of the Republic, even though it was the party which established the state in 1922 and the party that declared it a Republic in 1949. Instead it has tended to use the language of the Just Society when articulating its vision for Ireland, a language first used by the party in its general election manifesto of 1965. However, while the Just Society did not base its analysis on the concept of the Republic, its language was distinctively republican as this excerpt illustrates:
“Fundamentally”, it stated, “we are concerned with making a reality of two concepts, freedom and equality… We seek office to work towards a society in which freedom and equality are not concepts from an academic textbook but are expressed in real and tangible conditions which all our people can enjoy.”
It is my belief that Fine Gael, and indeed all of us as citizens, must now reclaim the idea of the Republic from those parties and organisations who have sought to monopolise it in the past. The Republic cannot belong to any one group or section of society. It must belong to all of us – or it will end up belonging to none of us. I am very happy to be both a member of Fine Gael and a proud republican, in the truest sense of that word.
There are, of course, many different views as to what values should underpin a modern republic, or indeed a modern health system. However, a good starting point might well be the three fundamental principles of Liberty, Equality and Fraternity or, in more modern language, solidarity. While the political right has traditionally emphasised the idea of liberty, and the left has focused on the goal of greater equality, the Just Society correctly argued that both values are absolutely essential in any modern democracy. I believe in a Republic where hard work and risk taking is rewarded, where setting up your own business is seen as both personally fulfilling and a socially useful undertaking. But I also believe in a Republic which is both fair and just, a Republic with real equality of opportunity, a Republic that enshrines the concept of fraternity, the idea of society. In the battle between left and right, between the state and the market, the role of society has all too often been ignored; because people are not just clients of the state or consumers in a market. They are, first and foremost, citizens, citizens with rights and responsibilities, citizens who become ill and must be cared for. That care should be in a high quality health system that is open to all and funded by those who can best afford it. Citizens live in a society with a diverse range of needs, aspirations and beliefs. This could not have been more apparent than during the long debate on the Protection of Life during Pregnancy Bill.
The principal role of the state in any Republic must be to give the citizen the skills and infrastructure they need to live their lives to the fullest possible extent so that they can make real choices for themselves as part of wider society. It’s no use telling 18-year olds that they are free to make their own choices if they haven’t got a basic Leaving Cert and have no prospect of finding a decent job even when the economy improves. That’s not real freedom. That’s phoney freedom. The state must ensure that all citizens enjoy high quality education so that all can reach their potential and none are left behind. It’s no use telling a young man or woman on welfare that they are free to look for work if the welfare system then penalises them once they get a job. That’s not freedom. That’s the state undermining the individual. Recent changes to rent supplements are a welcome move to change this system.
It’s also no use talking about freedom of choice to a 40-year old who has been addicted to cigarettes ever since he or she was a teenager. Addiction is not a choice. It’s a possible life sentence. The state must ensure that the tobacco companies are not allowed to target our young and trap them in a life of addiction. That is why I am committed to the goal of a smoke free Ireland, while accepting that adults must still be given the choice to smoke if that is their informed decision. But remember this. All of the evidence suggests if you haven’t smoked by the age of 21 you are very unlikely to start. Tobacco companies know this – that’s why they target our young.
The state also has an absolute duty to create a health system which is fair, efficient and high quality. The current two tier system is, in my view, completely alien to any notion of a just society or a decent Republic. When Fine Gael’s Just Society document was published in 1965 it promised a “complete re-organisation of the Health Services” including a move to an insurance-based funding system. Is it not astonishing that this mammoth task is only now being tackled, almost fifty years later? Remember if you don’t have access to good health then you may not be able to avail of the education that can allow you reach your full potential – health is a cornerstone of any Republic.
This Government is currently engaged in possibly the biggest reform of a western health care system since the formation of the UK’s NHS – the NHS which was built from the rubble of the 2nd World War when people were on ration cards. The reason for this reform is very simple: modern medicine is allowing people to live healthier lives for longer and society is all the richer for it. But we are delivering 21st century medicine in health systems that owe more to the 19th century than the new millennium. This combination of scientific progress on the one hand and institutional lethargy on the other hand is driving up healthcare costs across the globe, including Ireland.
There are only two possible responses: either large-scale rationing of healthcare, which is socially divisive and economically damaging or radical reform of the way in which healthcare is delivered.
The Government’s Future Health reform programme is, of course, not the first attempt to change the Irish health system. The creation of the HSE almost a decade ago was also presented as a major reform. In reality the changes made were mostly superficial. The inefficient, hospital-focused model of healthcare was largely preserved and all key decision-making centralised into a “command and control” system of governance.
The health system became fixated on measuring inputs – the number of beds, the number of procedures, the hours worked – and did too little to measure what matters most: outcomes for patients – how many treated, how long they waited, how many re-admitted because they weren’t treated properly the first time?
Future Health is specifically designed to dismantle this failed model of healthcare and hand power back to patients and professionals. In order to help turn this vision into reality the Government has decided, for instance, to reorganise all of Ireland’s adult public hospitals into six groups which will over time become self-governing trusts. It will be the biggest change in how our hospitals are managed since the foundation of the State. The objective is to create networks of hospitals which are big enough to offer patients a full range of high quality services safely, yet small enough to be flexible and adaptive to the local and regional needs of the people they serve.
The response from healthcare professionals to date to these and other proposed changes has been extremely encouraging. People working in the system know better than anyone that change is required. And, as importantly, they want to be involved in that change. But more importantly again, patients need to be involved. Perhaps the best way to review this on-going process of change is to examine it through the prism of the three key principles I have outlined: Liberty, Equality and Fraternity.
Let’s start with LIBERTY.
A health system which truly respected the principle of liberty would be one in which services were constructed around the patient, in which patient choice was not regarded as some optional extra but as a key organising principle. Freedom of choice must be a core principle. However, even a cursory review makes it clear how far Ireland is from having such a patient-centred health service. There is currently:
Under the Government’s Future Health reform programme all of this will change. For example: we will publish on the internet individual consultants’ waiting lists, morbidity and mortality figures. We are creating a new model of integrated care in which an increasing number of people are treated outside hospitals. 95% of all care can and should be delivered in the community. Any new GP contract must reflect this.
I am working closely with Minister Kathleen Lynch to move our system towards much greater use of individualised plans for citizens in social care. Universal Health Insurance will deliver increased choice for the individual while in the future patient quality indicators will be built into all hospital contracts. Once the HSE is abolished, a new Healthcare Agency will be established which will commission services from providers such as the hospital and primary care groups. We will also develop outcome measures for both primary and community care.
Like a lot of people I have been concerned by the results of recent studies in the UK which raise some profound questions about the safety of their patients. But we also know from previous safety issues in Ireland and recent revelations about some of our own hospitals that we have problems here which must be addressed. That is why I am committed to the establishment of a new Patient Safety Agency to start on an administrative basis later this year having examined other systems including in Canada and Denmark. It is why my department is currently working with other key stakeholders to develop a number of quality and patient safety indicators, with the intention of publicly reporting these indicators. It is also why I am announcing today the formation of a special advisory group on patient safety whose membership will be composed of leading experts from both Ireland and abroad. It will be asked to present a report to me, by the end of this year, looking at how we can make our health system safer for everyone, taking into account the lessons we can learn from here at home and from other countries. Details of this group will be published in the next few weeks.
The second key principle which should underpin our health system is EQUALITY.
The current two-tier health service which divides people between public and private is completely alien to the principle of equality. A two tier system essentially means that some people get preferential treatment based on their financial resources rather than their medical needs. The Government’s proposals for Universal Health Insurance are specifically designed to replace the current system with a fairer, more efficient single tier model of healthcare. The goal is to start introducing Universal Health Insurance in 2016, a process which I have acknowledged on a number of occasions will take up to five years to complete.
As a first step, we will introduce GP care without fees in the term of this Government and detailed work is currently on-going within my Department. I am working closely with Minister White to expedite progress in this area. Our initial focus is on how we can give young children access to free GP care. I do not want any parent to be in a position where they have to decide between buying the groceries and bringing their child to the doctor. This would be another important step along the road to Universal Health Insurance.
Prior to the introduction of Universal Health Insurance we will also reduce overall waiting lists and times significantly but do so in a way that there is greater equity in access to health services. Significant progress has already been made. The number of people on trolleys in 2012 fell by 24%. They have fallen a further 10% so far this year. While progress on in-patient waiting lists has been slower, the goal is still to ensure that, by the end of this year, no one waits longer than 8 months for treatment.
Staying with the issue of equality, the neglect in the treatment of women is a particular concern to me and to this Government. Consider the issue of the Magdalen laundry women, the Neary women or even the protection of life during pregnancy for women. These are issues which were for so long disgracefully ignored by previous governments. I am proud to be a member of this Government which is addressing these matters. We cannot undo the harm but the arrangements we are putting in place can be the start of a healing process.
The final key principle we need to address in health is FRATERNITY.
The Irish health system, as exemplified by the HSE, is one of the most centralized, top-down systems in the OECD. This has resulted in a model of care that is not only inefficient, but has hugely disempowered both frontline staff and the patients and frustrated them in delivering the excellent care they are so capable of and want to deliver. I want to see a health system where power is truly devolved, where professionals on the front line are given more autonomy and patients are given more control over their own treatment – the empowered, informed patient is a safer patient –where groups from outside the formal health system are invited in.
I visited Letterkenny hospital a few days ago and was struck by the huge number of volunteers assisting the doctors, the nurses, the porters after the recent flooding. It was real fraternity in operation and I want to acknowledge and salute the work of all the community who were involved and indeed, our friends in AltnagelvinHospital in Derry.
I also want to create a health system that protects and nurtures the people who work within it. In particular, I want the crucial role of nurses to be recognised and supported. That is why I recently announced, for the first time in the history of the health system, the creation of the post of Chief Nursing Officer at Assistant Secretary level in the Department of Health. It is also why I am determined to change the role of NCHDs or junior doctors in our system. The current situation, where NCHDs are abused by our system and feel devalued, must be changed. We again have allowed a perverse and immoral situation to evolve where we push our brightest and best out, forcing them to emigrate, while robbing the third world of its badly needed doctors and nurses.
Legitimate concerns have been raised – both inside and outside the health service – as to whether the system has the capability to implement the changes proposed. The reform agenda for the next three years is particularly complex and requires the health system to introduce a series of reforms which have taken other countries much longer periods of time to implement. The recent establishment of a new directorate structure in the HSE, combined with the creation of a Programme Management Office in the Department of Health and a Systems Reform Office in the HSE, are specifically designed to assist in the implementation process. But is this enough? No it’s not. I will, as a result, be announcing a number of further initiatives over the next few months to help ensure that the reforms announced are indeed implemented.
In conclusion, I came into politics to do one thing and one thing only – to create a health system that truly puts the patient at its centre. We’re not there yet – far from it – but there is indeed light at the end of the tunnel. We have made major progress. We can and must give the Irish people the kind of patient-centred health service that they both need and deserve.
We can and must give the Irish people the kind of citizen-focused Republic without which our nation cannot prosper. We are a young Republic but an ancient nation.
The challenges we face now are daunting – in our economy, in our education system and in our health service. But we have faced bigger challenges in the past and we have prevailed.
The tragedy of the Celtic Tiger is that for many years it was real. There was indeed a genuine economic miracle in the 1990s. And then we lost control. We built houses and apartments we didn’t really need in places where nobody wanted them. We have an excellent building industry. We need to get people back to work building hospitals, primary care centres and factories that we need and not more apartments and houses we don’t need.
It’s time to wrest back control of our economy, our Republic, our health system.
We have some of the best doctors and nurses in the world. Why can’t we have one of the best health services in the world? I don’t just think we can, I know we can. Not today maybe, not by 2016. But certainly in the next term of Government and before the 100th anniversary of the foundation of the State. But this can only happen if we have the courage to think radically and act decisively, if we have faith in ourselves and in each other, if we decide that we will settle for nothing less than a Republic and a health system that are truly based on the principles of Liberty, Equality and Fraternity.
For 800 years, our forebearers dreamt of freedom – they kept that vision alive until it was realized. The problems we face today are enormous but they fade in comparison to what those before us overcame. That’s why I know we’ll succeed. It’s in our genes.