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Announced by Minister for Health Simon Harris to great fanfare on 1 June, the Committee on the Future of Healthcare was established to agree an all-party 10-year plan for the future of the health service; to identify a pathway towards a universal single-tier health service; and to achieve consensus on a new healthcare model based on need.
The Committee will make its recommendations to the Dáil based on its examination of available research, analysis of written submissions received, and oral evidence delivered during public hearings. It is required to present a final report to the Dáil by 23 January 2017 and, given the volume of work to be undertaken in a very short timescale, the Committee has agreed that it will initially meet on a weekly basis and keep its focus tight.
Committee Chair Deputy Róisín Shortall has said the work of the Committee is a unique opportunity for cross-party consensus in developing a coherent and meaningful healthcare strategy to be implemented over the next 10 years.
The first meeting of the Committee took place on 23 June and it held four subsequent planning meetings where the Committee received technical briefings on a number of topics, including a factual overview of the role of the Department of Health, and the organisational structure of the HSE and related health and community services.
The Committee also published an interim report last month, which outlines its proposed goals, work schedule, and approach.
The Committee has held a number of briefing sessions with relevant stakeholders to help plan its work streams, including health policy experts from Trinity College Dublin, representatives of the HSE and Department of Health, researchers from the ESRI, and Dr Eddie Molloy, management consultant.
Senators not invited to the party
Concerns over the absence of Senators from the Committee have been raised by some, including members of Fine Gael.
“There is no reason whatsoever why we can’t become full members. It’s a very simple process,” Fine Gael Seanad Spokesperson on Health Senator Colm Burke told the Medical Independent (MI).
“There is no reason why we shouldn’t be allowed to sit at the Committee. An amending motion could be put to the Dáil once it resumes to include Senators [on the Committee].
“There is huge expertise in the Seanad that is being excluded from the process.”
Senator Burke said he was annoyed that the Committee’s interim report citied ‘Houses of the Oireachtas Interim Report’.
“Now, how can you call something that, when there are no members from the Seanad on it?” asked Senator Burke.
“We feel like we are just being used to rubber stamp what they are doing.”
Senator Burke has exchanged a number of letters with Deputy Shortall over the issue, including a “fairly strong letter” that he wrote.
He insisted that the Committee having had a number of meetings already does not mean Senators could not join at this stage. He said that Senators could read themselves into the issues very quickly.
“There is huge experience in health in the Seanad. These are people who are being excluded from the process,” he maintained.
A meeting between representatives of the Committee, including Deputy Shortall, and Senators is expected to take place shortly about this issue.
Previously, a spokesperson for the Committee told MI that “As it stands, the Committee have already undertaken a substantial amount of work, including public hearings, expert briefings and a public consultation process and have released their Interim Report.
“As the work of the Special Committee moves forward, however, it is the Committee’s aim to have a structured engagement with Senators in the future.”
Speaking to MI last week, Deputy Shortall said the reason there are no Seanad members on the Committee is because it was formed through a Dáil vote before the Seanad elections and appointments.
As the work of the Committee was already advanced when the Seanad was in place, it was decided by members that it was too late to include Senators.
Any change to membership would also require a vote of the Dáil, according to Deputy Shortall.
She added that any suggestion that Senators, such as former Minister for Health Dr James Reilly, have been deliberately sidelined from the process is absolutely incorrect.
“The vote took place when there had been no mention of the Taoiseach’s nominees to the Seanad,” Deputy Shortall said.
“Who was to know that James Reilly was going to be appointed to the Seanad? It is really petty stuff that is going on, I have to say, and it is an attempt to derail the Committee.”
Deputy Shortall described the driving ambition of the Committee as devising a model for a universal single-tier health service “and critically to ensure the implementation of our recommendations”.
At its meeting on 20 July, the Committee also held its first public hearing to receive evidence from the Health Reform Alliance, a representative group of patient organisation. This month it kicked off a schedule of weekly public hearings that will run until November.
The Committee sought submissions from the public and interested parties by a closing date of 26 August. Over 150 submissions have been received to date, a number of them passed the original closing date with the final number still being logged, a Committee spokesperson told the Medical Independent (MI).
Some of the submissions have already made waves. As MI revealed in our last issue, the submission by HSE UL Hospitals Group suggests that GPs should provide out-of-hours cover in small groups in the evenings and during weekends, instead of through GP co-ops.
HSE UL Hospitals Group
The submission claims a “partial reversal of the recent trend that family practice cover outside 9am- 6pm, Monday to Friday, is provided by large co-operatives who undertake the call obligations so that the on-call doctor may never have had contact with the patient, may not be from the immediate locality, has no access to their notes. and is not in a position to confer with the regular GP, is required”.
While the submission states that “we cannot return to the single-handed practitioner 24hr, seven-day a week model”, it says “a hybrid model whereby small groups of family physicians, were organised to provide cover in the twilight hours, ie, 6pm-11pm and 8am-8pm Saturdays and Sundays, would be a better system. Cover outside these hours to remain on the large co-operative model”.
The submission document also suggests increasing GP access to diagnostics and allied health professionals, but cautions: “However, high-quality and cost-effectiveness must be incorporated in such an arrangement and advice from GPs as to how this might be achieved should be sought.”
It also notes that if access is increased through GPs it may only result in greater resource utilisation without any decrease in hospital beds. “Therefore, if GPs are going to be given resources there will need to be an accountability system based on quality-of-care and outcomes including hospital avoidance.”
The IHCA’s submission to the Committee questions “whether significant changes in the sources of funding for healthcare services, which are broadly similar to those used in other countries, are practical in the current economic situation or whether they would deliver sustainable benefits in terms of improved patient care given the risks in changing the model, while substantial operational and service delivery issues and problems need to be addressed”.
On a universal single-tier health service the IHCA says that it “cannot be regarded as a healthcare end in itself, but must be viewed in the light of the healthcare benefit that will accrue from its implementation”.
“The priority should be to definitively address the current unacceptable waiting lists,” maintains the Association.
It also recommends that existing governance arrangements in the health service need to be strengthened significantly to be fit for purpose and to enable the development of an integrated, effective, and efficient health service.
“Appropriate governance together with proper resourcing are required to address the existing critical capacity constraints that are restricting the provision of timely, high-quality healthcare to an increasing number of patients,” said IHCA President Dr Tom Ryan, on the publication of the Association’s submission.
“To be successful, the long-term plan and strategy must be properly resourced taking account of present and future anticipated levels of demand.”
The IMO made a detailed submission and among the main priorities it highlights is the need for a new GP contract.
“The IMO is calling on the Department of Health and the HSE to agree a strategy with the IMO for the development of general practice in Ireland over the coming decade,” reads the submission.
“Priority must be given to negotiating a new GP contract with the IMO that is properly resourced and fit for purpose for a 21st century health service.”
The IMO also looks at the wider issue of the two-tier system in its submission.
“The IMO believe that with significant increases in resources, both capital and operational and with careful planning the goal of universal healthcare can be delivered under an expanded taxation model or eventually under a system of social health insurance,” says the Organisation.
“Whatever changes are introduced to health coverage in Ireland, the process by which change is brought in must include informed public debate, consultation with all relevant stakeholders, including patients and doctors, [and] detail of the proposed model including cost and funding sources. Analysis of current and future manpower resources needed for implementation [and] a realistic timetable for implementation.”
In respect of consultant staffing, the IMO recommends that integrated medical manpower planning occur at national level, which takes into account the number of consultants and specialist training posts required to deliver a consultant delivered service.
“Measures must be taken immediately to improve training pathways, recruitment and retention of our medical workforce including the full implementation of the recommendations made in the report of the Strategic Review of Medical Training and Career Structures (‘MacCraith Review’) and the negotiation of new, fit-for-purpose contracts for both consultants and NCHDs.”
The crisis in hospital beds is also central to the IMO submission, which recommends a detailed assessment of the number of acute beds in the public hospital system to meet current and future demand.
“The reinstatement of the National Treatment Purchase Fund (NTPF) is not sufficient to alleviate waiting lists nor a sustainable long-term solution. The private sector does not sufficiently cater for frail or complex patients. When we include both public and private beds the number of acute inpatient and day-case beds falls well below European averages,” the submission adds.
There is a detailed 10-page submission from the NAGP, which makes recommendations on a wide range of areas in general practice.
“The existing system is failing because it is orientated overwhelmingly towards expensive and frequently ineffective engagement with episodic illness, but fails to manage the co-morbid patient, whose numbers are rapidly increasing,” says the Association.
“The relocation to community care will improve this situation dramatically.”
The NAGP outlines eight priorities including a few interesting specific ideas, especially around taxation.
“GPs, as independent contractors, have traditionally invested in their own practices and infrastructure. Since the financial crash this has largely ceased and there is a lack of economic confidence about inward investment.
“The NAGP would urge the Oireachtas Committee on the Future of Healthcare to explore the use of tax credits as a means of encouraging GPs to invest in their practices.”
The Association wants any 10-year strategy to place GPs at its centre.
“The NAGP supports the development of GP-led primary care and the shift of focus from our hospital-centric model to a community-based service.”
Like the IMO, the NAGP also has much to say about the need for a new GP contract.
“The new GP contract must provide for chronic illness and multi-morbidity management, on an agreed and not ad hoc basis,” says the NAGP.
“Flexible care pathways can be delivered by GP-led primary care…. A decisive shift to primary care can only happen by agreement and adequate resourcing. Clarity of responsibility must be central to any new GP contract.
“The NAGP will play its full part in the negotiation and implementation of effective chronic disease management.”
In its submission, the ICGP also calls for a new GP contract and a comprehensive community-based chronic disease management programme to be introduced as a priority.
The ICGP recommends resourcing Irish general practice in line with OECD countries, given historic underfunding and more recent reductions through FEMPI.
“The ICGP can work with Government to urgently address manpower shortages in general practice and primary care. The ICGP can increase GP training capacity from 174 to 274 GPs per year, with adequate resources,” according to the College’s submission.
“However, training GPs, only to see them emigrate to other health systems, is not cost-effective. Recruitment and retention of GPs begins with the provision of an adequately resourced general practice system. Increasing the present number of GPs from 4,000 to 5,000, will require significant investment in general practice, to retain our younger GPs and recruit GPs who have emigrated abroad. The ICGP can also collaborate with nursing training bodies, enabling the parallel training of additional practice nurses.”
Other recommendations by the College include the development of IT systems to allow better data extraction, the expansion of physcial primary care infrastructure, and better access to diagnostic services.
‘Who was to know that James Reilly was going to be appointed to the Seanad? It is really petty stuff that is going on, I have to say, and it is an attempt to derail the Committee’
Deep End Ireland
A new group of GPs working in economically disadvantaged areas, Deep End Ireland, has also made a submission. Among its recommendations, it calls for “recognition in any new GMS contract or primary care resourcing system of the need to incorporate some type of deprivation index that will allow additional support for practices to respond to those with greater medical need”.
The group also calls for the “prioritisation of primary care teams. Work in disadvantaged areas is greatly helped by a fully functioning primary care team”.
GP Dr Ronan Fawsitt and Clinical Director of St Luke’s Hospital in Kilkenny Prof Garry Courtney appeared before the Committee earlier this month on the Carlow/Kilkenny Model of Care. Speaking to MI before their presentation, Prof Courtney said it was essential greater integration is established between primary and secondary care regarding patient pathways.
“There is a lack of continuity so we want to link everything up together,” he said.
“The pathway is very confused at the minute and very slow. We want to make it very clear and very transparent. There are many people in hospital now that don’t need to be in hospital.”
Prof Courtney said there should be better links between Hospital Groups and Community Healthcare Organisations. In the Ireland East Hospital Group, local integrated care committees have been established, with representation from GPs in the area to provide this link.
“If it works, you would expect other Hospital Groups to follow suit,” Prof Courtney said.
“I would say, what is the alterative plan? I haven’t actually heard a different plan, except more of the same, which is more capacity. That is too vague a term. We need to be very specific about capacity. We have some capacity deficits in intensive care. But just to say we need more capacity, is not enough. There needs to be clarity about the processes to allow any new beds to function correctly. Is it day capacity? Is it stroke/rehab capacity? Is it critical care capacity? People should only get capacity if they are going to work in a new way. We do need some extra capacity, but in the meantime, the hospitals that show they are willing to change, should be rewarded.”
A number of organisations make more specific recommendations for their areas of healthcare.
The HSE National Clinical Programme in Dermatology in its submission calls for sustained expansion of the numbers of consultant dermatologists to at least one per 80,000 population.
“Promotion of dermatology training for general practitioners to expand the knowledge-base in primary care and support the management of more skin conditions in primary care,” recommends the submission.
“Development and expansion of the numbers and role of advanced nurse practitioners and clinical nurse specialists in dermatology.”
The HSE National Sepsis Programme says that “a national integrated approach embedded in the culture of the healthcare system is required to effect the change necessary to ensure that patients get the best and most appropriate care. This will take time and needs to be a fundamental part of the future healthcare strategy for Ireland”.
One of the key recommendations of the HSE National Clinical Programme for Acute Medicine, for which Prof Courtney is Clinical Lead, is to “adapt the National Acute Medicine Programme model of care in all acute hospitals”.
“Expand the reach of AMAUs/MAUs in all acute hospitals to divert acute medical patients away from congested and dangerous EDs.
“Support the role of the GPs as the senior decision makers with direct access to AMAUs/MAUs.”
Earlier this month, HSE Chief Information Officer Mr Richard Corbridge gave the Committee an update on the work of eHealth Ireland, including the latest progress on rolling out individual health identifiers (IHIs), the Lighthouse projects, eReferrals, and plans for an electronic health record (EHR). He reported that over 40 per cent of GPs used the eReferral service in August, with 10,733 eReferrals in the same month.
Mr Corbridge pointed to the need for investment and support of ICT within the Irish health system and the fact that Ireland lags behind most other Western countries in eHealth solutions. He noted that while the current EU average healthcare budget spend on digital solutions is just over 3 per cent, the HSE only has around 1 per cent of its budget allocated to this area.
“We have a very ‘lean’ team in comparison to other Irish Government departments and indeed other countries’ healthcare systems. There is one IT person supporting every 236 people in the HSE today. Compare this to other Government departments such as Revenue, where there is one IT person supporting every 11 resources, or in Social Welfare and Agriculture, where they both have one IT person for every 17 resources delivering their complex agendas,” he added.
In addition to its members, the Committee also has a research team, which is examining and aggregating healthcare research that has taken place in Ireland and internationally in recent years. Deputy Shortall said it was decided that it was unncessary for the team to conduct new research given the large amount of healthcare studies and documents produced over the last decade.
“As a Committee we want to be challenged with the key quesitions and that is why we are going to employ a project manager to bring together all of those key questions and work through them with the Committee,” she said.
Meanwhile, high profile health experts invited to address upcoming public hearings of the Committee include Prof Alyson Pollock, Professor of Public Health Research and Policy at Queen Mary, University of London, UK; Dr Josep Figueras, Director of the European Observatory on Health Systems and Policies and Head of the World Health Organisation (WHO) European Centre on Health Policy; and Prof Tom Keane, former Head of the National Cancer Control Programme.
More than a talking shop?
The key challenge for the Committee is to provide a strategic vision for the health service that all the major parties and politicians can agree upon, and, even more importantly, abide by.
“The big problem in this country is there is no agreement on the direction of travel for the health service,” Deputy Shortall said.
“That is the problem. So every time there is a new Minister, there is a new policy or a new plan. What we have seen over the last 20 years is a constant churn within the health service with no clear political direction being provided. That is extremely damaging to the health service.”
She believes the Committee is working well and is determined to succeed with its task of providing a vision for the future. She said any suggestion of it being a mere “talking shop” is false.
“Traditionally in this country there have been huge problems because of the lack of political agreement on the kind of health service that we need,” Deputy Shortall said.
“And there is a lot of vested interest in relation to health, who will try to scupper what we are attempting to do. The Committee is very serious about the work that it does. Members are putting in a huge amount of time and they are very committed to our objective.”
Concluding she said: “There is a real determination that we need to do something very fundamental and radical in relation to the health service.”