Mr. Tony O'Brien:

I thank the Chairman and members. I appreciate the opportunity to be here. I am joined by my colleague, Liam Woods.

Approximately one year ago, The Sunday Business Postran an extensive article, entitled "Inside the HSE", in which I was quoted as saying that we do not have a single collective national understanding of what we want from health care, particularly when it comes to how much we want to spend and invest in our system. One year later, I am genuinely delighted to be before this Oireachtas committee to provide input on what I hope will be a major step in developing clarity for the first time in terms of what we, as a nation, wish to achieve, how much of our overall Exchequer funding we are willing to invest and what we can realistically expect from our health services.

To my mind, this clarity and consensus has never really been achieved at societal, political or health service level. This has resulted in the progressive evolution of a platform whereby health has become a political football - political in the sense of using both a small and a big P. Fully 80% of services are of a very high standard, such as those seen recently on the RTE documentary "Keeping Ireland Alive". However, these services are often overshadowed by the 20% of services that are not delivered as well as we would all like. This arises to the extent that many people describe our health services as third-world in nature without stopping to consider the excellent services that are delivered day in and day out by staff in hospitals and in communities throughout the country. It is important to acknowledge today what is working well. I am keen to step beyond the usual headlines - to use RTE's strap-line from the programme – and paint a picture of our health care as it is delivered currently and the positive impact it is having on patients, service users and staff.

My focus today is not on structures. I am of a view that over the decades there has been an overemphasis on the importance of structures to the detriment of putting the patient at the centre of all we do, integrating how we deliver care and ensuring that patient safety and care quality is our utmost priority. My focus today is more on a number of important themes, principles and considerations, such as the need for a decisive shift from the acute hospital sector to the primary and social care setting due to changing demographic profiles, the impact on our health services if we fail to make this shift and some suggestions on how such a significant shift could be funded.

As I mentioned earlier, 80% of our health system is of a very high standard. Despite the resource constraints faced by the health services over the past six years, numerous improvements - too numerous to mention today - have occurred throughout all areas of the health services. Stroke treatment is an excellent example. Each year, more than 500 stroke patients receive thrombolysis to dissolve clots in arteries that cause strokes. In addition, some 150 people have had thrombectomy procedures, whereby obstructing clots were removed from large brain arteries to prevent devastating strokes. This places Ireland in the top three countries in Europe delivering acute stroke therapies. We are seeing similar positive outcomes for people with major heart attacks. Approximately 85% of patients received primary angioplasty within 90 minutes. This compares singularly well internationally.

Our success in diagnosing and treating cancer is well known and follows a difficult centralisation programme that, like many other areas in health care, became a political football for many years. However, thankfully, the views of the clinical experts prevailed and the outcomes are positive today. I have no doubt that we will face other decisions in health care very soon that will be equally contentious and will involve situation where local views diverge from those of clinical experts.

Another major success in the Irish health service is the improved uptake of childhood and school immunisation programmes. The figures compare well with World Health Organization targets. For example, in 2015 over 65,000 children were immunised. For the 6-in-1 childhood vaccine, there is a 95% uptake. For the MMR vaccine at 24 months, the uptake is 93%.

While we continually hear and read criticism of our mental health services, significant improvements are seldom mentioned. For example, the numbers on the child and adolescent mental health services waiting lists continue to decrease. Furthermore, in 2015, 95% children were admitted to age-appropriate child and adolescent inpatient units, compared with 25% in 2008. Moreover, one in every 100 adults in Ireland is estimated to have received suicide prevention training through applied suicide intervention skills training and safeTALK.

I could spend the entire 20 minutes discussing other improvements, such as the success of the quit smoking initiative, the increase in numbers of community intervention teams throughout the country and so on. However, I wish to move my focus to the horizon and to the future of health care in the country.

The positive examples I have outlined show that despite the challenges faced by our health services over the past six years, which was a recessionary period, there has been a positive trend in awareness, early detection and the provision of the right care in the right place at the right time. This means we are living longer, ageing better and learning to live with ill-health. In fact, these improvements to our health care system in recent years mean that we are adding approximately 20,000 people over 65 years of age per annum to our population. This figure is projected to increase by 4%, or approximately 188,000 people, between now and 2021.

Furthermore, the Irish longitudinal study on ageing, TILDA, reports that 64.8% of this over 65 age cohort live with multi-morbidity.

This is defined as the presence of two or more chronic conditions. Treating an older population with the presence of chronic disease is costly and getting more costly. A graph in my written submission shows the relative cost of inpatient treatment by age category last year and projected to 2022.

While it is good news that we are likely to live longer, it carries with it new challenges in the required changes to our health service. Unless we plan for these changes now, we are going to run into significant difficulties in ten years' time. In fact, we are facing those difficulties already, as we can see in the 5% to 6% increase in the presentations to our emergency departments year on year and the impact that this is having on our acute hospital system and, in particular, available bed capacity for elective work. Our data show that we are doing more emergency work and less elective work each year. It goes without saying that, as the number of emergency admissions increases, there is reducing space for elective activity. This trend is set to continue unless something changes. If it continues, all work will be emergency work and we will be unable to accommodate elective work.

Committee members will have heard many times in the course of their work witnesses highlighting the need for us to shift our planning away from the acute hospital setting towards primary care. However, this necessitates a "decisive" shift towards primary care and for us to be clear about what we actually mean when we say this. To me, this means doing things in acute care settings that can, and should, only be done in acute care settings. Historically, we would have engaged in a simplistic restructuring exercise to achieve this.

As we are all well aware, the HSE was created with a big bang. Politically and legislatively, it was easy, but it was not necessarily a good idea and not well thought through. The rationale behind the establishment of the HSE was to centralise operations. This type of structure, coupled with an unexpected economic recession, led to a command and control-type system that disempowered those tasked with service delivery. It also tended to stifle the creativity and innovation required of a sustainable, adaptive organisation. Overall, we have learned that 105,000 staff cannot be managed from a central location.

Following a decision by the Government in 2011, we are now at a stage of advanced progress in slowly unwinding much of that. Seven hospital groups, nine community health organisations and the National Ambulance Service have been established. While not a perfect structure, significant consideration has been given to these new health care delivery organisations, which are premised primarily on patient population flows. These new organisations now require to be left alone and given time to embed and grow as the main operational delivery arm of the health service. Whether these structures are the most optimal has become less important than the need to implement them fully, including by providing them with sufficient management capacity and then allowing them a period of at least five to seven years to bed down properly before evaluating them and considering any further change.

In much the same way that restructuring does not provide the easy solution, simply increasing the numbers of acute hospital beds is not the easy solution either. The committee will have heard many people, including representative bodies, calling for an increase in our acute bed stock. If I may, I will put this in context. The health system uses 3.5 million bed days per annum. When adjusted only for demographics for the next 30 years, this number of bed days will have to grow to 6.4 million. That would be unsustainable in cost and staffing terms. There would be a requirement to add in excess of 300 beds per year. The current cost of the public hospital system is €5.3 billion per annum and we would require double this spend to deliver a doubling of capacity as well as providing capital funding for new facilities. We would do far better to invest in the development of primary and social care services to support people in their communities.

To achieve the decisive shift away from the acute hospital setting to primary care and social care, a significant additional resource is required. However, such a resource will take time to develop, given how we are funded currently. To overcome this, a considerable rethink is needed of some of our existing policies, particularly in terms of how to fund sustainably the type of supports that we need as we grow older, whether that be long-term care, home care packages, home help hours or aids and appliances. It will also require a rethink of our capital funding investment. A change to multi-annual service planning and budgeting would also assist in supporting longer term planning for the demands on our resources.

Currently, we have a health planning environment that is tied to an electoral cycle as well as a 12-month fiscal public service budgeting cycle. Both of these factors essentially drive short-term decision making and their resultant outcomes. The change cycle in health is longer than 12 months. An annual budget-service plan cycle hampers, rather than facilitates, improvement and reform. Instead, we need a capacity to plan that allows and supports longer term decision making and promotes an environment of strategic thought based on evidence.

Closely aligned to this, and a matter on which I have commented publicly in the past, is the need to build a general public consensus concerning the maximum appropriate and feasible investment in health and social care for the next 15 to 20 years. In other words, how much are taxpayers willing to hand over for the health service they want? This consensus would have to bear in mind the realities of the economic cycle at any given point in time and competing pressures for Government funding.

I will turn to the issue of a fair deal for primary care. Our population is getting older and their care needs are becoming significantly more expensive. How do we sustainably resource this into the future? We tackled part of this problem a number of years ago through the introduction of a successful scheme that gave a good degree of assurance for the older population around their long-term care, namely, the nursing homes support scheme, or fair deal. It is a fair question to ask why we do not have such a scheme or level of assurance around care that is not long term.

One of the policy issues that should be considered as we examine the future of health care is whether we are going to put in place a demand-led funded environment that guarantees the supports for people moving on from the acute phase of their care to live their lives where they wish to, which by and large is in their own homes. Such a scheme would allow the likes of expensive home care packages to be funded into the future, but we need to reach a settled view on that. Otherwise, our system will become increasingly unsustainable.

The HSE's programme for health services improvement has 12 major programmes under way, constituting in the order of 500 subprogrammes. For the most part, these are patient-centred projects that will happen over three to five years and are designed to enhance service delivery to patients and service users.

There exists a perception that the health services can undertake these major improvement programmes for free or, to put it another way, carry out such major transformation while continuing to provide the same level of services as last year without getting any extra money. This does not happen in large industry, and it has dawned on health systems internationally that transformation programmes need to be funded.

The committee will have heard from many witnesses about the number of transformative processes that are under way in our health services with varying degrees of success. To date, all of these programmes have been funded from within existing resources, but then we question why we have not seen a quantum shift in health care performance in Ireland. This is one of the reasons that we have been talking for decades about a decisive shift towards primary and social care, but not actually achieving it.

I wish to tell members about a health service where this issue is being taken seriously. In the state of New York, a major health service reform, called the delivery system reform incentive payment programme, DSRIP, is being undertaken. The aim of DSRIP is to improve significantly the way Medicaid beneficiaries receive their health care in order to reduce that cost and deal with the issue of chronic disease through integration and the avoidance of hospitals. The aim over the five-year implementation period is to cut costs by $17 billion. However, it is recognised that, in order to make that saving, there must first be investment. An overstretched system cannot easily move resources from one part of its service to another in order to effect change. We know that we must move resources and spend out of the acute sector and into primary care, but if we were simply to do that now, we would probably collapse our overall system.

New York calculated the saving over time and decided to invest up front part of that saving against a clear roadmap and clear deliverables, as a result of which the service providers in the state participating in this programme have been provided over the five years with $8.5 billion to fund the cost of transformation. This is the reality of health care transformation. DSRIP will promote community-level collaborations and focus on system reform, specifically on a goal to achieve a 25% reduction in avoidable hospital use over five years. All DSRIP funds will be based on performance linked to achievement of project milestones, thus paying for value.

In the UK, the King's Fund reached similar conclusions about what was necessary to effect effective transformation in the NHS. In Northern Ireland, a recently published expert panel report, entitled "Systems, Not Structures - Changing Health and Social Care", recommended that a ring-fenced transformation fund be established to ensure its transformation process was appropriately resourced.

I make no apology for saying that if ongoing and future transformation is not funded in this jurisdiction, particularly in an overstretched and growing health care economy, we will not achieve the transformation which members expect or desire. It is as simple as that.

Another important consideration that is often overlooked when we discuss deficiencies in our health service is the level of annual capital funding. Members will be aware of some of the mega-projects in health such as the children's hospital. Through other committees, many will be aware of some of the lesser-known capital projects, including the upkeep and repair of many existing buildings and pieces of equipment in the health sector. We will spend approximately €375 million on capital developments in health this year across primary care, mental health, acute care and a wide other variety of services. Of great concern to me is the amount of money available to us between 2017 and 2021 in the capital space to pay for our ambulances, x-ray machines, MRIs and all those types of equipment on which we critically depend. That sum is €2.25 billion. However, that sum does not meet the €3.64 billion that is required to meet the long list of priority replacements to maintain safety and quality in our health care system. We have, therefore, an immediate problem. There is a mid-term review of the capital programme in 2017 and health needs to be very high on that agenda. I will seek to ensure that all those who have the responsibility for carrying out that review are aware of this capital challenge.

Looking at the next ten years, we need to be spending in the order of €9 billion in health capital to address issues of infection control and ageing equipment. This takes cognisance of the fact that we replaced a lot of equipment at the height of the economic prosperity, most of which is now ageing very rapidly. This includes critical equipment such as our ambulance fleet. As this exists as a quality and safety concern it becomes even more of a priority.

Often forgotten within our capital budget is the funding of e-health. I will not spend too much time on this as members have previously heard from the CIO, Richard Corbridge. Health, like every other sector, needs ready access to good information to improve and sustainably deliver quality cost-effective services. The delivery of integrated care, with a strong primary care focus, is predicated upon having effective technology to allow for easy access to the appropriate clinical advice independent of the care setting and across care settings. In other industries in Ireland this is a given. The farming sector, for example, has an electronic record to trace animal identification and movement for all sheep, goats, pigs and bovines. We need to redesign our systems at every opportunity to ensure that the true benefits of an e-health programme are available to patients and staff. The current electronic health record business case envisages that, by 2020, clinicians will be able to access digital information about patients appropriately, and by 2025 we will see a digital fabric throughout the health system including a system that is also accessible and in the hands of the people of Ireland.

This is a ten-year journey which will put in place a set of solutions built around the individual health identifier. It is not a big bang but an evolution of today's systems. It is not an immediate large investment but rather a commitment to incrementally evaluate the success of digital over a ten-year period and continue to add to the investment as benefits can be seen and success is clear.

Obviously, health care cannot be provided, nor can space and equipment work, without people. Despite considerable attention, attracting and retaining certain cohorts of our staff remains a considerable challenge at both national and local levels. Recent OECD reports identify that the health system in Ireland has a low number of doctors when compared with other jurisdictions. The work of the clinical programmes within the HSE has demonstrated this at a specialty level in Ireland, in specialties such as orthopaedics, obstetrics, ICU and neurology. Typically, we need to double our number of doctors to deliver on the models of care set out for our population. As part of the development of hospital groups, future recruitment of medical staff will be part of the group structure. This will allow for significant flexibility in the rotation of staff across hospital sites and allow for an enhanced training experience for doctors and will reduce the vacancy level of sites with traditional recruitment difficulties.

A committee appointed by the HSE regarding reform of the processes for creation, approval recruitment and appointment to consultant posts has concluded its work and developed a paper, Successful Consultant Recruitment and Retention, which is available and which we have shared with the committee. Recruitment in the health sector is and will remain an ongoing challenge for the foreseeable future. Policy decisions regarding the level of training places, salaries, terms and conditions for health sector workers are required in order for the Irish health services to remain an attractive destination for our most qualified staff.

In conclusion, I thank all members of the committee for the invaluable work that they have undertaken. I am sure the evidence given to this committee so far has been an eye-opener for some members in terms of how complex and challenging the delivery of health and social care services can be. The simple-fix solution may not be as simple as it first seems. I am of the belief that, with the correct strategic approach and a close re-examination of some of the policy constraints within which we are obliged to function, we can better meet the challenges that face us with an ever-increasing demand for our services over the next ten years. This is especially so in relation to seed funding for our major transformation programmes to allow us to be able to invest now to generate more efficiencies later. It also applies in relation to the need for multi-annual planning and budgeting. The level of capital investment in the health sector is an area that also requires close consideration. Above all, it is important that we all work together to build the best health service that we can and that we can restore the public's confidence in the services that we deliver.

I will close out by taking the opportunity to thank all of my colleagues who work so diligently delivering services right across the country in such challenging circumstances.