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Future of Healthcare report: New horizons or a false dawn?

“This is an historic day.”

These were the opening words of Chairperson of the Oireachtas Committee on the Future of Healthcare, Deputy Róisín Shortall (Social Democrats), at the official launch of the Committee’s report last week.

 “We hope that, from today, health and issues associated with health will cease to be a political football,” said Deputy Shortall.

She said Sláintecare (the official name for the plan) would result in a “universal, single-tier health service that will ensure timely access to quality services for all”.

“Our health service has evolved over many years in a very ad hoc way and it has developed into a very unfair system.”

However, she said “long hours spent down in the basement in the Committee room” had ended with a report supported by all parties (except for Solidarity TD Mick Barry).

The report is 187 pages long and detailed. The much-anticipated shift from secondary to primary care is certainly central, as is a restructuring of the HSE, the end of private services in public hospitals, free GP care for all, maximum waiting lists guaranteed by legislation and hospital management held accountable by law. The total bill is €5.8 billion over the next decade.

If implemented, Sláintecare will have a huge impact on all doctors. However, with the focus on primary care, GPs are very much at the centre of the report’s vision.

A snapshot of Sláintecare’s key proposals

The phased elimination of private care from public hospitals. Everyone will have entitlement to access public care in public hospitals — those who have private health insurance will still be able to purchase care from private healthcare providers.

A Sláintecare Implementation Office should be set up under the auspices of An Taoiseach by July 2017, with the remit to oversee and enable the implementation of this plan.

The introduction of a Cárta Sláinte, which will entitle all residents to access a comprehensive range of services based on need, at no or reduced cost.

Expansion of capacity in primary care and social care, investment in community diagnostics, primary care teams and mental health teams, services for people with disabilities, home care services and free GP care.

Waiting time guarantees of 12 weeks for an inpatient procedure, 10 weeks for an outpatient appointment and 10 days for a diagnostic test.

The HSE in future will become a more strategic ‘national centre’, carrying out national-level functions and regional bodies will be established to ensure timely access to integrated care, with regional health resource allocation.

The e-health strategy should be strongly supported, with provision of the necessary funding for timely roll-out of the Electronic Healthcare Record (EHR) system.

Full copy of the report at http://www.oireachtas.ie/parliament/media/committees/futureofhealthcare/Oireachtas-Committee-on-the-Future-of-Healthcare-Slaintecare-Report-300517.pdf.

Reactions

The two-hour-long media launch of Sláintecare was not even completed before reporters’ phones began buzzing with some less-than-glowing reactions from medical representative bodies (see panel on page 5). However, one of the report’s authors — Co Clare GP Dr Michael Harty TD — said he understood why the representative bodies and GPs have concerns.

“I think the GP contract is critical really,” Dr Harty told the Medical Independent (MI) following the launch.

“This report will have to drive these contract negotiations forward, because the whole emphasis of the report is to shift from a hospital-based service to a primary and social care service.

“And if you are going to give a phased expansion of entitlements to GP care over five or six years, then obviously that is going to have a significant increase in workload. It’s giving more than 50 per cent of the population, on a phased basis, free access to general practice services.

“This has to be funded properly,” continued Dr Harty. “I think there is going to have to be a mixture of capitation and specialised items of service so that practices will be encouraged and incentivised to deliver primary care and look after multimorbidity in general practice.

“I don’t think it can be a completely capitation-based service; built into it needs to be an incentivised service of specialised consultations to reach targets and to deliver quality of care.”

Unity

There was a very public show of political unity at the launch of the report. All members of the Committee, apart from Solidarity TD Mick Barry, signed the final report. Speaking at Leinster House, Deputy Barry said the “report misses a golden opportunity to advocate for the introduction of an Irish National Health Service”. He said he wanted an Irish version of the British NHS funded by higher taxes on big business and the wealthy. While he said the report had some “significant progressive reform proposals”, he added that it “fails to recommend specific actions to separate church and State in the health service”.

However, among those who did sign up, there was vocal support. Deputy Kate O’Connell (Fine Gael), a pharmacist by profession, said “the system is grinding to a halt as it stands”.

“Nobody can deny we have to re-orientate our health service. Recruitment is a key issue.”

Labour party Spokesperson on Health, Deputy Alan Kelly, told journalists “we are representatives of our parties. Our parties will have to answer why this isn’t implemented if that happens. This is a test of Irish politics, it is a unique situation…We will hold our own parties to account into the future to ensure that this is implemented.”

Speaking to MI, Deputy James Browne, Fianna Fáil Spokesperson on Mental Health, defended the report from some criticism regarding costings.

Deputy Browne, who sat on the Committee, said: “We had the Trinity [health economist] team who were advising us right through. I know there were a couple of people raising issues about why is it not independently costed. The reason we said it did not need to be independently costed is because effectively, it was by the health economists in Trinity and they are the best in their field.

“So I think it has been costed insofar as it can be. I think the difficulty is that the HSE lack data themselves on a lot of their own work and programmes.”

Deputy Browne said he thinks there is a  “clear pathway” in the report

“There is a lot of ‘if this, then that’ in it. So you can’t proceed with the first step until other steps are carried out,” he told MI.

But Deputy Browne said there would be much to do for the new Taoiseach, from the very first days in their new post.

“We want a number of ‘early wins’, and we wanted the wins that kick-start the report into action. That’s why the implementation body is so crucial; if the implementation body is not put in place by the Government quickly, it will be difficult to implement the report.”

Yet although this is an all-party report, Deputy Browne said there would still be political debates if Sláintecare is not implemented.

“One of the reasons we did set out a lot of steps for the first couple of years, is so that the Government can be held accountable on it,” Deputy Browne told MI.

“If this report is not being implemented, you will still have that element of politics, in terms of holding the Government to account on implementation. I think what it does do, it takes a certain type of politics out of it [health], which is where everybody says that they have a magic solution.”

Threatened

Meanwhile, in terms of the impact on doctors, Dr Harty told MI he understood why there may be nervousness among some medical professionals.

 “I think general practice is going to feel threatened by this, with the expansion of free GP care to everybody,” he said.

“We did hope we could get a co-payments system into the delivery, but that was not politically acceptable. But within the GP negotiations there is going to be flexibility when it comes to looking at that again or certainly bolstering a GP’s income by developing a STC [Special Type Consultation] structure that incentivises good-quality care.”

The Co Clare GP said that he believes that Sláintecare will “give career certainty” to young GPs, “although it might not look like that at the beginning”.

“GPs will know that their source of income is the public purse, and they can develop their system and staffing and numbers in their practice to cope with that. 

“That will absolutely have to be properly funded, but I do think it will give GPs who are coming out of GP training schemes an incentive to look at general practice as a career. But unless that is properly funded, the whole transformation programme can’t be completed.”

Future health service: How much — and how?

Having considered different funding models, the Committee recommends that the system “should continue to be funded primarily by general taxation, with some earmarked funding, all flowing into a National Health Fund”.

The plan calls for ongoing investment in the region of €2.8 billion over a 10-year period to build up the necessary capacity and expand entitlements.

Added to this, a transitional fund of €3 billion to support investment across the health system in areas such as infrastructure, e-health and expansion of training capacity is recommended.

“The total price tag for Sláintecare over 10 years comes to €5.8 billion spread over a decade,” Deputy Shortall told reporters.

“There is also a need for a separate, independent implementation office to be established. We are calling for this office to be established pretty well immediately.

 “We want to ensure that this office would be independent and have its own budget.  We are proposing a budget of €10 million over the course of the 10 years of the strategy.”

Salaried

Asked at the launch about the role of private practice GPs, Committee Chairperson Deputy Shortall said “we would see that continuing where that is appropriate. But we are also providing for a new category of salaried GPs,” she told journalists.

“We know that a lot of GPs who train in this country who end up going abroad do so because in order to set up practice, they need capital behind them to provide their own building and facilities and so on.

“Really, that isn’t what general practice is about. People who train in general practice want to be GPs out there providing healthcare. They don’t necessarily want to be business people as well. We want to ensure that there are conditions provided through the expansion of primary care centres where highly-trained doctors can provide services in the State sector and don’t have to worry about providing accommodation for themselves.

“The analogy I would make is that we would never for a moment suggest that teachers have to provide their own schools. Why should we expect doctors to provide their own surgeries?”

Talks

Speaking to MI at Leinster House, Dr Harty indicated that GP negotiators should enter talks now armed with this report and build on its recommendations.

“Built into this plan is a huge change in governance and huge change in accountability and answerability,” said Dr Harty.

“That goes into GP negotiations as well. There has to be a direction that they go in, they have to have an aim. I think what is happening at the moment is cloak and dagger negotiations.

“There is a lot of antipathy from both sides. Really, if we are going to have a properly-funded health service, all sides have to sit down and negotiate as adults and not negotiate from entrenched positions. There has to be a whole-of-government view of how the health service goes forward. I think there has to be cultural change in the HSE, in the Department of Health, in hospital systems and structures in how they are governed and how they have answerability.

“And also in general practice. It is challenging all those elements of the health service to have a bigger view.”

Private

But it is not only in primary care where change is afoot.

Fianna Fáil Spokesperson on Health, Deputy Billy Kelleher, told journalists at the launch that the report outlines the “importance of disentangling public and private healthcare”.

Deputy Kelleher described the report as “ambitious, not aspirational… we looked at the need to move private healthcare completely out of the public system.

“That in itself will be a loss of revenue for the hospitals; as it stands, I think on an annualised basis, about €645 million is paid to public hospitals from private insurance. That is simply eating up capacity.”

Deputy Kelleher noted that the loss of private funding in public hospitals will cost money and that is where the “transitional funding” comes in.

He did not downplay the challenges that lay ahead. In particular he mentioned retention of staff,  “primarily in regional parts of the country in attracting and retaining consultants; that is going to be a key challenge for the public health system over the next 10 years.”

Wary responses from medical organisations 

The immediate reaction to Sláintecare by medical representative bodies was swift and somewhat lukewarm.

“The report contains many useful proposals,” said IMO President Dr Ann Hogan, “but its credibility is seriously undermined by a failure to recommend realistic funding in respect of many of the principles of the report.”

The union said it was “startling” that the report does not recommend significant increases in bed numbers.

“In particular, the failure to sufficiently and credibly address the capacity issue across the services both in terms of staffing and infrastructure is a major flaw,” said Dr Hogan. 

“Unless and until we have the basic elements required to deliver a functioning health service in place in the short term, we cannot seriously commit or even aspire to delivering a universal system in either the medium or long term.”

The IMO also claimed that the introduction of free GP care to the whole population over five years is not achievable, “given the current problems with capacity and funding in general practice”.

The NAGP also noted that “free GP care may only be considered when capacity is addressed, resources are provided and a new contract is agreed with general practice”.

While welcoming many of the principles in the report, the Association said Sláintecare could not be implemented without a new GP contract.

“Progress on a new GP contract has been too slow and fragmented,” said Dr Emmet Kerin, President of the NAGP.

“At the current rate, we are unlikely to see a new contract agreed within three years. A new fit-for-purpose contract would underpin much-needed reform in our primary care health service. Failure to produce a timely new contract would be an unforgiveable obstacle to the delivery of the vision set out in this report.”

The ICGP said it welcomed the political consensus that a properly-resourced primary care service can provide community-based healthcare for all. However, the College warned that there would need to be a significant increase in the number of doctors, practice nurses, administrative staff and physical infrastructure in primary care to cope with increased demand.

“The Government needs to understand that we are already experiencing difficulties in filling training places for family doctors, and that some medical card lists cannot be filled; getting a locum doctor to enable holidays or sick leave is also a problem for many practices,” said Dr Karena Hanley, National Director of GP Training at the ICGP.

“We need to make general practice a more attractive option for younger doctors and ensure that set-up costs and barriers to establishing new practices are removed.”

The IHCA moved quickly to highlight concerns it had with Sláintecare, especially the removal of private care from public hospitals.

“It is disappointing that the report does not contain an annual commissioning plan to put the necessary acute hospital beds and other facilities in place to end dependence on trolleys and continuously-increasing waiting lists, once and for all,” said Dr Tom Ryan, IHCA President.

“Hoping to provide care to an increasing number of patients in the public health system without sufficient capacity is not a realistic strategy.’’

Dr Ryan said that despite the report’s suggestion that the phased elimination of private care from public hospitals will expand capacity, “in effect the contrary will apply”. He said it will actually reduce hospital capacity, as the loss of €700 million annually in health insurance income to public hospitals will prove impossible to replace through increased taxation.

The report has much to say about disentangling public and private care, but the Private Hospitals Association (PHA) called it a missed opportunity.

“The report is fixated on public hospitals and public health systems, while a highly-efficient private system is ignored, even though it operates alongside it with a similar spread of services across the country,” claimed Mr Simon Nugent, CEO of the PHA.

Boulders

Despite the overall message of hope and unity at the launch of the report, other members of the Committee also outlined the challenges ahead.

“I think today is fairly historic, because we are proposing a single-tier health service,” said Independents 4 Change TD Joan Collins.

“I do think there are loads of boulders on the way, there are vested interests who will try and stop this. There has to be money put into this and ultimately people have to buy into it. And I will be out there at public meetings arguing with people that this is something worth fighting for.”

Deputy Shortall said that six individual pieces of legislation would need to be introduced to underpin the plan.

“First, to legislate to restore an independent oversight board to the HSE. There is obviously a gap there in terms of corporate governance,” she told reporters in Leinster House.

“Secondly, we are proposing that there will be legislation to establish a national health fund.”

There would be further legislation on maximum waiting times and legislation on accountability for management in the healthcare system and for national standards across the system.  

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