A critique of government progress to date

Posted in Blog by saraburke on November 24, 2012

This morning I spoke at Fianna Fail’s first annual policy conference as an independent commentator, the morning of which was dedicated to discussion of health policy. Here is the script of my speech…Good morning everybody and thanks for inviting me here today

I was asked to talk about current government health policy, to outline its main components, to critique progress to date and outline challenges that lie ahead for the government, for us as citizens who use the health services and for you as members of Fianna Fail. It is hard to do this and ignore the previous 14 years of government, so while most of what I say is in relation to current Fine Gael/Labour policy, I always draw attention to health policy developed and implemented under 14 years of Fianna Fail in government.

The Programme for Government agreed by Fine Gael and Labour lays out quite radical plans for health policy, seven pages of them, which if implemented would be the most radical health reforms in the history of the State. Their opening statement on health in the Programme for Government is (in italics are direct quotes from the Programme for Government):

This Government is the first in the history of the State that is committed to developing a universal, single-tier health service, which guarantees access to medical care based on need, not income.  By reforming our model of delivering healthcare, so that more care is delivered in the community, and by reforming how we pay for healthcare through Universal Health Insurance, we can reduce the cost of achieving the best health outcomes for our citizens, and end the unfair, unequal and inefficient two-tier health system.

This is ambitious by any benchmark.

They plan to do this through a range of measures – some of which are clearer than others.

Key commitments in Programme for Government

  • Universal health insurance (UHI) was outlined by Brian Turner, is a central plank of their policy, but I won’t deal with as I was asked to talk about the bigger picture.
  • UHI will be designed according to European principles of social solidarity… social solidarity will underpin all relevant legalisation… UHI will not be subject to European or national competition law
  • UHI is the main pillar of their policy and according to them the main way to achieve equal access to care for all… where there will be no discrimination between patients on grounds of income or insurance… where the two tier system of unequal access to hospital care will end
  • The government will act speedily to reduce costs in the delivery of both public and private healthcare and in the administration of the health system
  • A Special Delivery Unit will be established
  • The Minister for Health will be responsible for health policy and implementing this ambitious programme for reform and cost control
  • HSE will cease to exist overtime, its functions will return to Minister and Department of Health
  • Free GP care for all by 2015
  • Hospitals will become independent trusts which will be organised in groups
  • Money Follows the Patient – pay for treatment not lump sums as is largely case now
  • Investment in more and better care for older people in the community and in residential settings for older will be a priority for this government
  • Additional funding will be provided each year for older people… more residential places, more homecare packages, more home helps and other prof community care services
  • Reference pricing and greater use of generics – to bring down the price of drugs
  • New GP and consultants contract ‘remuneration will be reduced’
  • Capital budget – will be a priority, especially primary care centres, step down, long term and day care facilities for older people
  • Range of mental health commitments including ring fence €35 million annually to develop mental health teams
  • Under bioethics section, they commit to legislating; to clarify law on assisted human reproduction, to regulate stem cell research; for post mortem procedures and organ retention; organ donation
  • AND they do not commit to legislate for the x case – what they say is
  • We acknowledge the recent ruling of the European Court of Human Rights subsequent to the established ruling of the Irish Supreme Court on the X-case. We will establish an expert group to address this issue, drawing on appropriate medical and legal expertise with a view to making recommendations to Government on how this matter should be properly addressed.

Last week James Reilly published a 50 page document called Future Health – originally it was meant to be a road map and was one of the major areas that Roisin Shortall fell out with Reilly on because she could not get him to put pen to paper on his actual plans for health. She has said publicly since she resigned, that in summer 2011 she began to get him to write down his plans as his ideas and proposals changed each time they spoke. There was a draft in Springtime that was very short and vague, which has been subsequently worked up by Department of Health officials and Reilly’s advisor Sean Faughnan.

So let’s start with what’s good about it and then revisit the key planks of the government’s policy.

What’s good about it – the Programme for Government does seek to introduce a one tiered health system where access is based on need not ability to pay. No government has ever tried to do that. There are many problems in the Irish health system but the biggest one in my opinion is the unequal access for public patients where access is often determined by ability to pay not medical need.

And with my health policy analyst hat on that was your biggest crime in health during 14 years in government that you never even tried to create an even playing field for public patients and in fact much of what happened while Fianna Fail and the PDs but also the Greens were in government was to exacerbate the two tier system.

You oversaw the health system between 1997 and 2007 when health spending quadrupled from €4 to 16 billion yet you did not even attempt to introduce a universal health system. You failed to introduce a common waiting list for all patients in Quality and Fairness which would have been the first crucial step to undo the apartheid that currently exists within the health system. Then when the consultants contract came up for negotiation, which took four years to agree, you negotiated and agreed a contract which fuelled rather than undid that inequality.

So I think I certainly have to give credit to this government for that intent. I don’t have time to go through all aspects so I will pick out a few five areas

  • Free GP care
  • Driving down the cost
  • The HSE ceasing to exist
  • The Special Delivery Unit
  • Minister and Department of Health reclaiming power

Free GP care

There are two central parts of this – one is the extension of free GP care to different population groups and the second is the need for more GPs and primary care staff to deliver on these commitments. Roisin Shortall had secured money for both yet we know that these were pulled, that the day before she was due to announce 300 additional primary care staff, much needed OTs, community nurses, physios etc.. that she was told not to announce it and Reilly even suggested that such staff could be hired privately by GPs.

Critically the government have failed to deliver on free GP care for the 70,000 people on the long term illness scheme. Speaking at the launch of their strategic framework last week, Alex White confirmed that none of the extra staff would be delivered this year but they would be next year as would the extension of free GP care. He said he was working closely on the legislation which was going to extend free GP care through the GP only card for those on certain illnesses. However to do any of this they need to negotiate a new contract with GPs and as of last week these negotiation had not begun. Whether the much required additional staff will be delivered, free GP care extended and a new contract negotiated remains to be seen.

The Primary Care Centre debacle is another worrying example of current government form. The details of this were well washed in public but in short Roisin Shortall and the HSE developed criteria largely based on deprivation to decide the location of PCCs. This then went into the minister’s office and came out as a very different list, crucially with two PCCs in his constituency in the top 25 although even though they had been no way down on Shortall’s list.

Today’s Irish Times confirms that the criteria do not exist and the locations of Balbriggan and Swords were a political choice rather than made through a rigorous evidence based selection process.

Driving down the cost of the health system

The government has failed spectacularly in this area – central to this was transferring care from hospitals to the community but in the absence of additional capacity in the community that’s very hard to achieve and yet what we see them doing is the opposite of this.

This is evident in the failure to deliver extra Primary Care staff but also if we take homecare as a straw poll, the Minister himself has said that he wants fewer older people in residential care and more living in the community. Central to this is the availability of homecare services, also specified in PfG. Yet if we look at hours, what we see between the HSE 2012 service plan and the additional cuts announced in August that 950,000 hours have been cut out this year and that in 2012 there will be at least 2.5 million fewer home help hours than there were in 2008 – at the height of health spending/your reign.

Another example of this is the failure to deliver on other programme for government commitments to renegotiate GP and consultants contracts and reduce their remuneration.

Another area this is evident is drugs – we pay more for drugs than most other OECD countries – this is largely due to bad deals negotiated under your reign. But as you say, ‘we are where we are’ and this government committed to ‘bring down the price of drugs’.

The HSE 2012 Service Plan planned to save €112 million on drugs in 2012, a PQ response to Tommy Broughan in October specified that the new agreement with the IPHA would save €16 million this year, €116 next year, €136 in 2014, €150 in 2015. However it also specifies that the costs of new drugs allowed for in the deal is €210 million over three years which means that the net savings between 2012 and 2015 is €96 million. If form is anything to go on, even this €96 million saving for next three years is ambitious.

Actions to date have failed to drive down the cost of care and the current plan is just not viable if the cost is not driven down.

Quite clearly the fact that the HSE was €399 million over run on a service plan and budget agreed and signed off on by the minister is evidence of this. Despite multiple denials of the need for a supplementary budget, we hear this week that there will be one.

The HSE ceasing to exist

Depending on what way you look at this you could say government has been quite successful. They have abolished the board, got rid of CEO, there are 9,000 fewer HSE staff than there were in 2008. They are about to introduce new directorates. All we know about this is that there will be seven directorates

  1. Hospitals
  2. Primary care
  3. Mental health
  4. Social care
  5. Health and well being
  6. Corporate/shared services
  7. Child and Family Support Agency to be started in Jan 2013

Directorate Heads are currently being appointed.

But very rationale for integrated services was to provide a seamless service for people, most of us will need more than one of these services and if Money Follows the Patient which is another of the governments big ideas then how does that actually work. If I am in hospital due to a chronic disease and I return home, am in need of community services where is my budget or how does the money follow me. I have asked this question repeatedly and have never got an answer. Quite honestly I think they do not have an answer either.

What happens the 70,000 staff who currently work for the HSE outside of hospitals, we have no idea. How will the different directorates link? What are the interim governance structures? What happens these services post 2014/5?  The HSE is not ideal but it’s working.

It is well known in the health services research literature that major reform like setting up the HSE or dismantling it takes five years to get to the start line again, we are three years over that line for the HSE, do we really need another five years of disruption and paralysis dismantling a service that we have no idea how it will structured and governed?

The Special Delivery Unit (SDU)

SDU has been set up to reduce trolleys in EDs and reduce waiting times for elective care for public patients. They have had some progress in this area. We constantly hear James Reilly say that there are 23% fewer people on trolleys in EDs in the first 9 months of this year when compared to last. And this is true, However, there were still 45,000 people waiting on trolleys during this time. And they do not publish figures about how long people wait in EDs despite having a 6 hour max target.

There is also some progress on waiting times. In September 2011, there were 2,435 people waiting over nine months for treatment, on 1 October 2012, there were 415, the target was not achieved but the numbers were significantly reduced. And also there were reductions in those waiting over three months (from 14,078 to 12,782) and six months (from 8,728 to 6,907). These are positive developments.

However, the waits are still too long and do not include the 385,462 people waiting for that initial appointment with a specialist. These new figures also show that of these 46,000 were waiting over two years for this initial appointment and over 11,000 waiting over four years. These figures are a damming indictment of the failures of Fianna Fail in government.

Progress in hospitals waiting list have also been achieved to the detriment of growing waiting lists in the community which in turn put more pressure on hospitals.

Also in my opinion they have largely been achieved as a direct result of the clinical care programmes, the clinical care programmes are the quiet success story of health service reform in Ireland. Initiated in cancer under Tom Keane, hired under your stewardship and applied across all services for all conditions.

There are now 22 clinical care programmes and they are resulting in better care, in shorter length of stay, in same day surgery, more day cases and according to Barry White the clinical director up until now, the saved bed days from them have allowed hospitals to treat more people more quickly.

Minister and Department of Health reclaiming power

This has happened in a very pro active way. James Reilly has handpicked his overpaid advisors, the new DG designate Tony O’Brien, there is a new secretary general of the Dept of Health, a new CEO and chair of the VHI board, a new minister of state for primary care – you could call it a purge of all health leaders who perhaps had different ideas to the minister.

Not only that but much of the power that lay with the HSE is being brought back into the Dept of Health. There are many reasons to be critical of the HSE but it did take the politics out of health. If you ask me much of what James Reilly has been doing is putting the politics back into health. This is evident in his handpicking of the people around him, of the selection of primary care teams and what might prove most critical, the determination of hospital groups.

Hospital groups

The government promised a report on the role of small hospitals before last summer. It is now promised that it will be published when the minister publishes the report on hospital groups, which crucially is meant to determine which hospitals will be grouped with which but also which services will they provide.

We have seen the reaction to people in Waterford and Navan in this respect. I recently asked when the report would be published and what criteria were being used to determine their role and location and I got the following answer

The Prof. John Higgins Group will be reporting to the Minister in November. The report will be submitted to Government for consideration before the end of the year. The Government will decide the make-up of the Hospital Groups. The objective is that they will be formed as early as possible in 2013.

The Government will decide the make-up of the Hospital Groups. To me this is terrifying because it opens the door or pushes it further open for political interference, for health policy that is not based on need or evidence but purely on the whims of a minister who has shown himself to blunder and bluster his way through so called health reform.

So what are the challenges?

The challenges are immense –

  • How to keep or grow confidence of the public in the public health system
  • How to provide more services to more people with fewer staff and less money (which the HSE have done year on year for the last four)
  • How to not to demoralise further already demoralised staff
  • How to maintain services, hold on to progress made especially in clinical care programmes, transition to a universal system and take another billion out of the health budget

One senior health official I bumped into at the Future Health launch said that’s all very well but where’s the budget to do it?

But this is not just about the money, it is also about the capacity, the capacity to lead, the capacity to bring about the radical change they have committed to in the Programme for Government.

If we look at their form to date, there is little evidence that James Reilly or the people around him have that capacity to pull off the radical reform they have promised.

Your job as a party in opposition and my job as a journalist and policy analyst is to hold them to account, to ensure that they deliver what they have promised.


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