We Need to Move from a Reactive to a Proactive Approach to Health Service Reform
Phelim Quinn, Chief Executive of the Health Information & Quality Authority (HIQA)
I want to thank Joe Mulholland for his invitation to address the MacGill Summer School. This is the first time a CEO of HIQA has spoken at this prestigious event, and it is a privilege to do so.
The theme of tonight’s session is wholly appropriate, and while economic concerns are, of course, hugely significant, we cannot lose sight of what is of foremost importance – the rights and experiences of the people who use services.
The promotion of safety and quality in the provision of health and social services is my, and HIQA’s, primary concern. This evening, I would like to take the opportunity to engage with you on some of the challenges facing our health and social care services, and how I believe they might be addressed.
In spite of some of the distressing outcomes of many HIQA investigations and inspections over the last few years, tonight, I want to take a constructive, forward-looking view. I believe that we are at a critical juncture in respect of our health and social care services and it is my opinion that all stakeholders must play a productive role in improving the quality and safety of these services.
This is not to ignore the question of economics though; I am conscious that according to recent CSO figures, expenditure on health and social care in 2014 was €19.1bn. According to Eurostat, total Irish public expenditure on health in 2013 was the second highest in the EU.
Despite this, and considering Ireland’s young population and the high prevalence of private health insurance, Ireland ranks in the middle third of OECD countries as regards health outcomes. In fact, on some quality of care indicators, including avoidable hospital admissions, cancer survival rates and volume of antibiotics prescribed per person, Ireland’s performance places it in the bottom third.
Last year, HIQA published a report entitled “Linking the Learning to National Standards”. In this report, and indeed in our investigation reports, we highlight the need for service providers to take measures to avoid any unnecessary risk and create a culture of learning from patient-safety incidents. Mistakes happen, but what is inexcusable is the failure to learn from them and implement agreed change.
Tens of millions of euro have been spent trying to solve the issue, yet many of the problems of the dysfunctionality of the health service have little to do with money.
So where might the key dysfunctions exist?
Recent controversies, including HIQA’s enforcement actions against the Irish Society for Autism, have highlighted the need for more effective accountability when it comes to the provision of effective services and the transparent, fair and effective use of public money.
These practices are unacceptable and have starkly highlighted the enduring need for sharper focus on accountability within those organisations charged with procuring, and providing, services for citizens.
Governance and accountability are the cornerstones of any effective health and social care system. This is already an accepted concept embodied in the national standards for safer, better healthcare, and all other health and social care standards and regulations now endorsed by government.
But there is a lack of commitment to address persistent ambiguity in the governance of healthcare nationally, and locally.
Accountability must lie with the entity that not only provides, but also procures the service. Service providers have a responsibility to deliver a quality, safe service and as such must be held legally, and morally, responsible for how public funds are spent. Those paying for the service, that is the HSE on behalf of the State, must also be held legally, and morally, responsible.
One example of a constructive effort to get better accountability into the system has been the development of the concept of hospital groups, community health organisations and the regulation of designated services. In tandem with other health systems internationally, the model pushes accountability and governance systems to a more local level.
The jury is still out, as progress is frustratingly slow. The governing boards in hospital groups have yet to find their feet. As the project stalls, should we, as some are suggesting, go back to the drawing board, while applying the same governance principles in a more integrated way?
In a recent article, Professor Frank Keane focused on issues within current policy thinking and the impact on the structures of health services. He highlighted the fact that there is potential for some hospital groups to share or be associated with more than one CHO; up to five CHOs in one instance. He correctly pointed out that it would have a negative impact on care being coordinated, managed and comprehensible for patients in terms of care pathways. I believe he is right.
In addition, not long ago, the HSE’s first director-general, Professor Brendan Drumm, proposed a review of the group model in an effort to ensure that Ireland, in line with other countries, ensures its health and social care structures are integrated across the acute and community settings. Having come from the North of Ireland, my experience of working within an integrated system was a positive one. Whilst far from perfect, the coordination of care between acute and community is organised in a way that promotes consistency, and importantly, accountability.
Earlier, I stated that primary accountability rests with the provider of services. However, those who procure services on the State’s behalf are also accountable.
The idea of a national commissioning body is not new to Ireland, but as with all great ideas it is meaningless without action. The continued absence of a control mechanism in the form of a proper commissioning model is contributing to inadequate planning and poor oversight of service performance.
Robust commissioning can contribute to service efficiency and effectiveness as well as quality and safety. As referenced earlier, the absence of effective commissioning arrangements can lead to circumstances as witnessed in the Irish Society for Autism, and indeed in many of the services that HIQA has assessed as non-compliant over the past few years.
The introduction of a standardised framework to commission services would help as regards:
• effective service configuration
• implementation of national care programmes
• implementation of strategies, such as the new Maternity Strategy
• effective performance oversight of critical service provision.
Such a framework would also drive performance improvement and link payments to the achievement of agreed targets, where the focus is on the high-quality and safety of services. Commissioning is established practice in many other countries. These arrangements are not only being applied at national or regional level but the model is frequently replicated at local or community level through primary care commissioning structures. This enables services to be assessed and purchased in line with locally determined need.
If we are to introduce such a system in Ireland, it is important that we get the structures right. This may mean a radical review of the way in which we currently procure services under sections 38 and 39 of the 2004 Health Act.
The State distributes large sums of money every year to service providers, for example one charity in the news recently received €125 million a year in state funding.
The continued absence of a proper commissioning arrangement may in fact promote the perception that there is an element of “close your eyes and hope for the best”, whereby money is handed over without seeking evidence as to how it is spent or, more importantly, what it delivers for the person using the service. I believe that the introduction of adequate commissioning systems will not only drive efficiency and value for money in our services but will be one of the key enablers in promoting quality and safety.
Any future commissioning model, if it is to be effective, must be accompanied by a reform of approaches to the decisions on the delivery of healthcare services. These decisions need to be informed by a robust evidence base.
Cost-effectiveness remains a critical challenge to our healthcare system, particularly when it comes to the costs of drugs. The challenge is to spend limited and precious resources wisely. Investing in cancer care, for example, means there is less money available to invest in neurosurgery. Such investment decisions are crucial if we want to drive safer better care by maximising outcomes for the population.
In recent years, HIQA has been engaged in the delivery of high-quality Health Technology Assessments (HTAs) at a national level to inform major health-policy and health-service decisions. HTA independently assesses all of the available data and information about a new or emerging technology or health programme and estimates what clinical benefits it will deliver and whether it provides good value for money.
The need to ensure that scarce healthcare resources deliver maximum benefit for the populations served has ensured that HTA has become embedded in healthcare systems worldwide. Successful implementation of a ten-year vision for health will be driven by long-term planning informed by the best available data and evidence, not on crisis management. Health technology assessment is one tool that underpins evidence-based decision-making.
Unaddressed areas of high service-user vulnerability
In HIQA we are also concerned that certain areas of high service vulnerability remain unaddressed, particularly the area of homecare.
As the State’s health and social care regulator, HIQA is aware of the specific vulnerabilities of people in receipt of personal care and support services within their own homes.
The Programme for a Partnership Government outlines the desire to introduce a uniform service to standardize the quality of home provision.
This is a welcome move; however, it falls short of the need for statutory regulation of the sector, as pledged in the previous programme for government.
Ireland is clearly lagging behind other OECD countries in this regard. The regulation of domiciliary care is now well established in other western countries in acknowledgment of the vulnerabilities of those in receipt of such services.
The Health Research Board has been asked to identify and describe approaches to this issue in other relevant jurisdictions, a move which we very much welcome. However, we would like to see this work progressed, and prioritised, as soon as possible. HIQA will certainly contribute further to the development of such arrangements.
Another issue which I believe is in urgent need of address is that of adult safeguarding.
For those of you unfamiliar with the term, safeguarding is a term used to denote measures which protect the health, human rights and wellbeing of individuals. These measures enable at-risk adults to live free from abuse, neglect and harm.
This is unfortunately another area where Ireland has been slow to respond. It has been a neglected issue over the years and legislation and guidance is now long overdue.
We need to enshrine in law the safeguarding of vulnerable adults in acknowledgement of the State’s responsibility to protect and safeguard adults who may be at risk or subject of exploitation within a service, or as a result of limited cognitive capacity.
Such legislation would be closely aligned to the Assisted Decision-Making (Capacity) Act 2015, which provides a modern, statutory framework to assist vulnerable people with limited capacity in making decisions. Effective safeguarding legislation would provide for explicit powers of investigation and prosecution, distinct demarcation of roles for statutory agencies and clear definitions of offences in respect of the abuse of vulnerable adults.
In recent months in response to the circumstances exposed in Áras Attracta, a new national intersectoral safeguarding committee has been established. One critical objective of this committee is to influence the development of safeguarding legislation and the progression of a more effective range of national policies and procedures. HIQA is committed to working with the Department of Health and the Oireachtas to drive forward such legislation.
It is a disheartening feature of our health service that well-intentioned reform programmes are put on hold when the latest trolley or waiting list crisis hits the headlines. It is evident that we need to move from a reactive to a proactive approach to health service reform.
Political consensus on a long-term, strategic policy for the health and social care service is required, with the focus being on the safety and quality of care for people who use these services.
In this regard, I welcome the establishment of the Committee on the Future of Healthcare, whose role it is to reach agreement at a political level on the direction of health policy in Ireland, and I look forward to working constructively with the Committee in the near future.
I also welcome the intention to develop and adopt a ten-year plan for our health service. It is time to put aside the pursuit of narrow sectoral interests and work together on sustainable, affordable and future-proof models of health and social care.
In HIQA we have a very clear mission to improve health and social care services for the people of Ireland. HIQA cannot achieve that aim in isolation.
We need more than a shared political vision and agreement on a long-term plan for the health and social care service. We also need all stakeholders to “co-produce” the vision and guarantee its success.
So having highlighted the key dysfunctions in our health and social care services, what can we do about them?
I believe that the key to righting these dysfunctions, from HIQA’s point of view, are four-fold:
1. We need providers of services to clearly demonstrate real leadership and accountability in the areas of quality and safety, from the top down.
2. Policy makers need to ensure that future structural and regulatory reform processes are supported by legislation that enshrines in law the critical concepts of accountability and responsibility.
3. We need a commissioning model that clearly specifies, and manages, performance, and quality and safety. This model must be based on robust information and sound economic appraisal.
4. Finally, and most importantly, we need to listen to the voices of the public and those who use our health and social care services.
In all the noise created by the litany of controversies, the political carrousel and the perennial debates on how best to restructure our health service, we cannot lose sight of what is, or should be, at the core of our health and social core services – the person using the service.