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The Committee to end them all?

“I regard the establishment of the Committee as the single most important policy development in the history of the Irish healthcare system.”

These were the words of HSE Director General Mr Tony O’Brien at the recent 13th National Health Summit in Dublin, when commenting on the Oireachtas Committee on the Future of Healthcare. This Committee was established by the Dáil in June 2016 to achieve consensus on a long-term plan for healthcare.

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Mr Tony O’Brien, HSE Director General

In the event that anyone would charge Mr O’Brien with overstatement, it is worth nothing that several other Summit speakers also heralded the significance of the Committee.

“It is the most important and the most significant political and medical event probably of our generation,” said Dr Ronan Fawsitt, Kilkenny GP and Chair of the ICGP-St Luke’s Liaison Committee.

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GP Dr Ronan Fawsitt

Moreover, CEO of the RCPI Mr Leo Kearns told delegates that the work of the Committee was “fundamental” to the future of Irish healthcare.

“We are not going to find our way out of this crisis by tinkering around the edges; it’s going to have to be fundamental and radical change. If we don’t make that change, it is going to get worse.”

If the Chair of the Committee was feeling under pressure to ‘deliver the goods’ against the backdrop of such expressions of high expectations, Deputy Róisín Shortall (Social Democrats) was not showing it when she spoke to the Medical Independent (MI) (see panel, right).

Deputy Shortall told MI that she had no worries that the work of the Committee was “not getting much in the line of headlines”.

In fact, she insisted that it has “not set out to get headlines”.

“Media outlets maybe tend to pursue the issue of the day rather than the longer-term planning. That doesn’t bother us in the slightest.”

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Ms Róisín Shortall TD, Chair of the Future of Healthcare Committee

The Committee is charged with the not-insignificant task of achieving cross-party consensus on a single long-term vision for healthcare and the direction of health policy in Ireland, and to encapsulate this in a report and hand it over to the Dáil.

While some may speculate that the chances of achieving an agreement from everyone on the political spectrum on long-term policy may be slim, Deputy Shortall was confident about the Committee’s chances of reaching agreement when she spoke to MI.

“I think it is fair to say that all members of the Committee have a determination to reach a consensus,” said Deputy Shortall. 

“There is a very clear recognition that we can’t continue the way we are and we have also taken a very strong evidence-based approach.

“So we spent six months listening to the evidence and the evidence leads us in one direction and there is no denying that — that is, we need a universal, single-tier health service and that we need to take steps immediately to start the process of changing to that new system.”

The original plan was for the Committee to complete its final report in January 2017. But that optimistic target was always going to be difficult to meet, considering the scale of the workload. Unsurprisingly, the Committee sought and was granted an extension from the Dáil.

The completion date for the final report is now 28 April. A spokesperson for the Committee did not specifically rule out the possibility that a further extension could be requested, but told MI that “all indications are that Committee members all want to achieve this target”.

To date, the Committee has held around 20 formal meetings — both in public and private — and has heard from 20 groups, experts and individuals. In total, it has received more than 150 submissions.

“In addition to this, the Committee participated in a number of technical briefings in private session, with the Director General of the HSE, Secretary General of the Department of Health, health economists from the ESRI, the Adelaide Health Foundation, and management consultant Eddie Molloy,” said the Committee spokesperson.

The Committee has engaged a team of health academics from the Centre for Health Policy and Management in Trinity College Dublin, holding three workshops with them in late November and early December to further explore the issues.

MI has been informed that the Committee has not received an invoice for this work as yet, but total budgeted costs for this phase are €24,700.

‘This is a once-off historic opportunity’

How will a Committee with such diverse political opinions as Fine Gael, Fianna Fáil, Sinn Féin, Labour, the Anti-Austerity Alliance — People Before Profit, among others, agree on a long-term health policy?

Most parties and politicians have specific policies and opinions on health, including Chairperson Deputy Róisín Shortall, who recently addressed a meeting of her own Social Democrats in University College Cork, titled ‘Building an Irish NHS’.

However, Deputy Shortall told MI that strong opinions, including her own, have been left at the Committee room door.

“So people didn’t come [with] political ideologies or preconceived notions. We actually from the very beginning decided that people needed to leave their politics at the door,” she said.

“It was very interesting; at one of our sessions we had a speaker from the OECD over to speak to us, and afterwards I was talking to him. He advises health committees across the world and he said it was the first time he was ever at a committee where he couldn’t identify people’s politics.

“I think that is a very good reflection of the Committee. We did our utmost to keep our preconceived notions and political ideas at the door and we came in to listen to that evidence.”

Deputy Shortall added that the chances of agreement are increased because there should be “no great surprises” in the report.

“The fact [is] that all parties are represented on the Committee and obviously we are not working in isolation, we are keeping in touch with the Minister and other political parties in terms of briefing them on where we are at and the conclusions that we will be reaching,” she said.

“People aren’t going to be bounced into anything. There won’t be any major surprises. The aim is to work very closely with all party leaders and their representatives to reach a consensus on this and hopefully we will be able to pull that off.”

The former Minister of State for Primary Care said she has not seen anything like the Committee in her “over 20 years as a TD”.

“I think we are all acutely aware of the unique opportunity we have,” she said.

“This is a once-off historic thing and it’s a huge challenge for members to commit to the thing. They have done that very well; the attendance at the Committee has been exceptional, I would say. We have long sessions every Wednesday and there is a lot of reading outside of that and we are moving now into the drafting phase and it will be even more intensive.”

Deputy Shortall pointed to the roll-out of the National Cancer Control Programme as a development that had received wide political support and proved effective.

“We need fundamental reform towards a single-tier universal health system and we need to re-orientate the health service.”

Budget

This newspaper has also learned that the Committee has a further budget of €130,000 plus VAT to cover all aspects of consultancy support, drafting and completion of the report. 

Many may regard this budget figure as relatively modest, especially if the Committee succeeds in creating cross-party consensus on a 10-year strategy for health and social care policy in Ireland.

But what if Committee members do not agree?

The Committee’s spokesperson clarified that there is no possibility of any official “minority” report from Committee members unhappy with the final agreement.

“There will be no minority report,” said the Committee spokesperson.

 “While the option is always there for a member to bring forward their own report, the generally co-operative and collegiate approach which has been evident to date suggests that an agreed report is the likely outcome.”

The public sessions are largely over. The Committee is currently working on bringing together all of the presentations, submissions and documentation received.

What will be in the final report?

Although the Committee has only begun drafting the final report, there are already strong indications of some components that will be in it.

A shift towards primary care is one obvious theme.

Deputy Shortall said there is a “strong consensus on the fundamental role of primary care in managing the vast majority of care needs” and a recognition that primary and community services “must be in place and able to deliver in order to bring about a decisive shift away from our current hospital-centric system”.

She added that there was an “overwhelming consensus” on the critical importance of health promotion.

There is further “broad support” for the delivery of services based on need and not on ability to pay.

The importance of ensuring patients’ different care needs are met in an integrated way as they move from primary care to the hospital and perhaps on to community care was also mentioned by Deputy Shortall.

The Committee is also looking at the challenges around recruitment and retention of doctors and others, issues that have been raised by the medical representative organisations in their public submissions.

However, it is unclear what the final report will say on other significant challenges, such as the structure of the HSE or the establishment of the new Hospital Groups and wider funding issues.

Transitional funding

Speaking at the recent National Health Summit, Mr Tony O’Brien urged those in health and politics not to ‘nit-pick’ over the report once it is published.

“Whenever the Committee does publish its report, there will inevitably be the tendency that we have to find fault with it,” warned Mr O’Brien.

“To say ‘oh yeah, 80 per cent of it looks great but the other 20 per cent I would do something different’… let us not let perfection be the enemy of the good. There will never be a single plan that every single person will instantly say, ‘that’s exactly the way I would do it’.

“But if there is a plan that has that degree of political consensus, I think it behoves everyone to get behind it. Because the one thing we know is that the way our health system is currently designed is not fit for today’s requirements.”

However, the HSE Director General admitted that specific funding would be needed to facilitate the change to any new system envisioned in the Committee’s report.

“Transitioning from the healthcare model that we have now to the healthcare model that we will need to have will require transitional funding if it is to be effective.”

Mr O’Brien did not give any specific figures for how much he thought would be needed.

From the front lines of general practice, Dr Fawsitt agrees with Mr O’Brien on the need for transitional funding.

“I think a very clear message from this State would be that we have put away €500 million a year to support the shift away from hospital-centric care back out into the community,” said Dr Fawsitt.

“I think that kind of funding and commitment at a political level is actually what is needed. I would love to see this as one of the recommendations of the Committee.

“We need new funding to transition to a better service. So the rhetoric must get real, funding must get real. We need transitional funding; we cannot ‘eat the hospitals’ dinner’. That needs to be delivered by the Oireachtas and it needs to be ring-fenced.

“The primacy of hospitals is over. The era of primary care has arrived; the era of the patient being first has arrived. I believe that general practice can lead that charge.”

But while Dr Fawsitt said that funding for a shift towards primary care is vital, other challenges remain, principally the need for progress on a new GP contract.

“We need a new GP contract that resources general practice and it needs to reflect that GPs have been leaving in their hundreds over the last number of years and that we don’t have enough GPs,” said Dr Fawsitt.

“We need to bring them back, and that requires confidence and clarity around a new GP contract, which was made in the 1970s and based on a sickness model. But we now need a wellness model.

“The new GP contract must deliver resourced chronic disease management, otherwise it’s a ‘pup’. We need more nurses, we need more GPs and we need more access to diagnostics.

“Everybody who is in general practice needs to be in that [negotiation] room. All representative bodies need to be there as equals; we need to iron it out and get it right. We have one chance.”

Let’s all meet up in the year… 2027

At the recent 13th National Health Summit in Croke Park, Dublin, leading figures from health were asked what they thought the health service would look like in 10 years’ time. These are just part of some of their replies. 

“We have a very clear 10-year plan in relation to children’s health services. Everyone of course asks me about the [new] hospital, but it is just one element of our plan… it is an integrated care programme for health for children. It is a cross-divisional plan that is population-focused, integrated and multidisciplinary in its approach and it will take 10 years to implement and does require additional resources and funding.”

Ms Eilish Hardiman, CEO, Children’s Hospital Group. 

“We have a 10-year plan, a 10-year vision of a national electronic health record (EHR) and that EHR will be in the acute sector and the community. It will be an overarching portal, a shared-care record that will become our integrated platform. Why this vision? Well, we recognise that we are at a very low base when it comes to IT, so we implemented over 900 projects last year in IT. They are all silo projects, unfortunately, they are not integrated, so we need to get to a point where we integrate our systems together.”

Ms Yvonne Goff, Chief Clinical Information Officer, eHealth Ireland. 

“As people get older, they get sicker, they require much greater healthcare and that brings up significantly claims costs. So when we look at it, I think the biggest challenge we are facing as country — it’s the demographics time-bomb that is coming down the road… So if we struggle today with our healthcare system’s insurance provision, well, we have huge challenges not too far down the road.”

Mr John O’Dwyer, CEO, Vhi Healthcare.

“I think one of the big failings of health policy in the past is that it has changed not just with each government, but with the change in health Minister, which is often quicker than government… They [Future of Healthcare Committee] have set themselves an extremely difficult task, but a task that if they are successful really does have the opportunity to provide a real agenda for change… Once in a generation there is a little opportunity and if that is seized, it has an impact for 10 or 20 or 30 years… I am quite optimistic that we are in a position to steer the system in a much better way, where we provide universal access to high-quality care for all citizens on the basis of need.”

Dr Sara Burke, Health Policy Analyst.

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Ms Eilish Hardiman, CEO, Children’s Hospital Group

Irritating

Mr Leo Kearns, CEO of the RCPI, also told the Summit that there was a need for serious long-term planning for the health service and the Committee’s work was “fundamental”.

“One of the most damaging things about the health service is that there has been no long-lasting, clear strategy,” said Mr Kearns, who was formerly HSE National Lead for Transformation and Change.

“It is incredibly damaging and irritating for those who work in the health service when we are constantly changing direction.

“There are lots of good things [in the health service], but everyone knows we are in deep crisis.

“We are not going to find our way out of that crisis by tinkering around the edges; it’s going to have to be fundamental and radical change. If we don’t make that change, it is going to get worse. Demographics and costs are against us. So therefore we must make that change.”

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Mr Leo Kearns, CEO, RCPI

Mr Kearns said that any new plan for healthcare needed to orientate around the patient.

He added that recruitment and retention of doctors “is a fundamental challenge to our health service and has to be a key part of how we resolve our problems”.

“The 10-year prospective is fundamental, but we are unlikely to come up with any radically new ideas. 

“But it is a failure to implement change that has really damaged us over the last number of years. So we have got to focus on how we ensure that this change gets implemented.”

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