Programme for Government health commitments, potentially ‘revolutionary’
The first sentence in the health section the new programme for government reads ‘this government is the first in the history of the State that is committed to developing a universal, single tier health services, which guarantees access to medical care based on need, not income’. The opening line of the full document refers to a ‘democratic revolution’ that took place on election day, how with the stroke of a pen the public had demanded change. Seven of the 64 pages of the ‘Government for National Recovery 2011-2016’ are quite detailed, ambitious plans to radically change the Irish health system.
The primary commitment is to a universal health insurance (UHI) system based on ‘the principle of European social solidarity’, where ‘the two-tier system of unequal access to hospital care will end’ and ‘access will be according to need’. While it is called an insurance system, in fact about 3/4s of the health budget will still come from tax revenue.
The programme has a big emphasis on primary care, delivering access to GPs without charge to the whole population by 2016, and in a staged manner to those who need it most in the interim ie those with chronic and long term illnesses.
They promise more primary care staff who will focus intensively on the management of chronic diseases outside of the hospital setting. Everyone will have to be registered with a GP and GPs will be paid a rate for having a patient on its books rather than a fee each time they come. These are all sensible plans which should improve people’s health and well-being.
Under UHI all citizens will be ‘guaranteed access to care in public and private hospitals’ by 2016. HSE hospitals will become not-for-profit independent trusts. The VHI will be a public insurance company and everyone can choose between VHI and competing private insurance companies.
Those on low income will have their premia paid for by the State, those in middle incomes will be subsidised, while those on higher incomes will pay their own premia. State subsidies will be channeled through a Hospital Insurance Fund.
This fund will also oversee community rating and risk equalisation and fund hospital care not covered by insurance such as ambulances and Emergency Departments. In co-operation with the minister, the fund will determine the package of care to which all citizens will be entitled, it will ‘control health care costs for which central control is most effective’ and will ‘assist hospitals in remote locations’. It is unclear what exactly how these two latter points will be achieved.
The new minister plans to reclaim much of the power handed over to the HSE in 2005, to have a ‘special delivery unit’ in the Department of Health which will reduce waiting lists and oversee a major upgrade of IT facilities. A new Patient Safety Authority will be set up, which will include HIQA.
The HSE will cease to exist however the vast majority of the staff will be working for hospitals; a new Integrated Care Agency where most other health care staff will go; a new Children’s Agency where child welfare and children’s services were be housed; the Hospital Insurance Fund; and a new Hospital Care Purchase Agency. This agency will combine what is currently the NTPF and the HSE purchasing wing for the interim five years while UHI is being established. It could be argued that the new programme abolishes the HSE and is setting up five new State bodies. All of this takes enormous co-operation, time, energy and capabilities. Many of the people involved have already gone through ten years of never-ending health service ‘transformation’ and must be wary of more change.
There is no mention of ‘pausing’ the reconfiguration of hospitals or the abolition of prescription charges for medical card holders, however both have been committed to verbally by the new minister. The only mention of the controversial childrens’ hospital is that it ‘will be built’ although government has said it will review its location. The programme pledges to review the Nursing Home Support scheme and to provide additional money for older people’s services each year.
There is no mention of reduced staff numbers apart from overall public services numbers; the only mention in the health section is to build up staffing in primary care and mental health services, both welcome and required. Much of the plan is dependent on the successful negotiation of new contracts for GPs and consultants which will be hard won as it should result in them being paid less.
James Reilly is the new minister and he comes to the office with as much gusto and determination to reform as he does baggage from his previous time in health politics, having played various leadership roles in the Irish Medical Organisation.
Roisin Shortall, the first junior minister with responsibility for primary care, will bring fresh energy to an area that has always lacked leadership and attention. Likewise, Kathleen Lynch has a new remit with responsibility including disability and mental health. She will need to work hard with the other health ministers to ensure mental health services are not relegated to their usual place at the bottom of the pile.
Ireland has an appalling track record for introducing and pulling off effective reform. Making these plans a reality while not losing the progress now being made in areas such as the clinical care programmes will be critical to success in the months and years ahead. The remaining ‘known unknown’ is the macro economic situation. This entire project is predicated on an improved fiscal situation.
Nonetheless, if, and it’s a big if, James Reilly, Roisin Shortall and Kathleen Lynch can deliver the change promised, Irish people’s experience of the health services could actually be revolutionised, significantly for the better. The realisation of quality, universal healthcare for all, free at the point of delivery by 2016 would bring Irish people a step closer to the ideals of a democratic republic as envisaged by our leaders 100 years ago.