Mr. Phelim Quinn:

On behalf of HIQA, I thank the Committee on the Future of Healthcare for the opportunity to address it this morning.

In the conduct of our work, we witness at first hand the significant pressures and challenges facing the health and social care system. These range from familiar demographic and fiscal stresses to workforce and infrastructural issues. From HIQA's point of view, the disjointed and reactionary approach to health service reform is leading to increasing instability in the system. There is a failure to assess current requirements and plan for the future health and social care needs of the population. There is also a reticence to actually recalibrate the current focus on acute hospital services to the provision of health and social care services in more appropriate ways such as through primary and community care.

HIQA believes a ten-year plan for health policy creates an opportunity to include a vision not only for health services, but for an integrated health and social care system. In my opening statement, I will outline what we believe to be the main priorities for inclusion in the strategy.

Starting with the concept of commissioning, many of the major problems currently evident in our health and social care system could be addressed through the introduction of a strong commissioning model. Good commissioning puts people using services first and, at a local level, involves them, their families and carers in the decisions that affect them. Effective commissioning arrangements at both local and national levels not only ensure services are designed and delivered to meet the needs of individuals and communities, but also instil a culture of accountability in the health and social care system.

Commissioning is only at a developmental stage in Ireland, but is already well established in other jurisdictions, including Northern Ireland and England. While I acknowledge these jurisdictions have their challenges and there are significant structural and policy differences compared to health and social care in Ireland, commissioning has improved strategic planning of services based on population need, strengthened performance management arrangements, placed protection of vulnerable individuals at the centre of service design, improved governance and accountability arrangements, enhanced financial efficiency and maintained a focus on the physical infrastructure needed for the delivery of 21st century services design and provision.

Commissioning arrangements explicitly define and separate the roles of purchaser and provider of services. Currently, both of these functions are usually performed by the Health Service Executive, HSE. An effective commissioning body is responsible for purchasing health and social care services from providers. Procurement in this model is always based on an agreed strategy, assessed need, best available evidence of service efficacy, value for money, and the capacity and capability to deliver a safe and effective service. While recognising that resources are finite, quality and the delivery of safe services should be the primary goals.

Implementing a national commissioning approach would involve a radical review of the current health and social care service funding model and allow for the discontinuation of the ineffective practice of legacy block funding. Commissioning frameworks can provide for national, regional and local procurement arrangements which are person-centred and address local needs. While procurement decisions are made locally, the service itself is delivered in the most effective, efficient manner, whether in the community or at a national level. This means that some commissioning decisions will result in the rationalisation of services and will require courageous choices.

Local commissioning involves community and primary care professionals and, most important, people who use services. Local commissioning in turn informs national commissioning arrangements. A strong, national commissioning model would contribute to effective medium to long-term planning by gathering evidence of current and future service needs. The introduction of a standardised framework to commission services would help, by way of example, with the implementation of national clinical care programmes and strategies such as the national maternity strategy.

Such a framework would allow for effective oversight of service provision and hold providers accountable for the delivery of safe quality services. Strong and clearly defined performance management structures, as well as clear accountability arrangements, are essential components of good commissioning models. Critically from HIQA's perspective, the emphasis of these structures would not only be on financial or activity metrics but on metrics that reflect the quality and safety of services.

The committee has already heard from other contributors about the importance of moving to an integrated health and social care model. Integrated care takes a holistic approach to a person's health and delivers care in a co-ordinated, person-centred fashion as close to their home as possible. Similar models across the world have led to improved efficiencies, better health outcomes and lower costs. One important element of ensuring more seamless integration of care between primary and secondary services is geographical and service alignment. Aligning primary and secondary services will ensure care is co-ordinated, managed and comprehensible for patients in terms of care pathways. There is a consensus that Ireland needs to move away from the current hospital-centric model of care and to introduce integrated care pathways across primary, community and secondary health and social care structures. HIQA believes this should be expedited.

HIQA's primary aim as a regulator is to protect the most vulnerable in our society. We believe now is the right time to introduce safeguarding legislation to protect at-risk adults from abuse and neglect.

While national safeguarding protocols are in place following recent high profile revelations of abuse, these do not go far enough to ensure the safety and rights of vulnerable people. In developing a ten-year strategic plan, we must grasp the opportunity to introduce statutory measures to protect the health, human rights and well-being of individuals who are at risk of abuse, neglect or harm. While HIQA currently has statutory powers of enforcement and prosecution, other health authorities do not have statutory powers to protect vulnerable adults from abuse. The introduction of safeguarding legislation will provide for explicit powers of investigation and prosecution, define the roles for statutory agencies and give clear definitions of offences in respect of abuse of vulnerable adults.

An effective commissioning model can be used to support safeguarding. As commissioning is person centred, it can help ensure that the rights of vulnerable people are respected. In England, the Care Act 2014, which is concerned with the provision of social care, places a statutory duty on local authorities to promote the health and well-being of individuals. This pertains to commissioning as well as care and support and safeguarding and it means that any decision a local authority makes about an adult must promote that adult's well-being.

HIQA also supports and will contribute to the work of the national inter-sectoral safeguarding committee and is committed to working with the Department of Health and the Oireachtas to drive forward safeguarding legislation and the promotion of awareness within civil society about the nature of vulnerable adult abuse and how and when to intervene.

Closely related to safeguarding is the protection of people being cared for in their own homes. HIQA believes measures need to be taken to ensure people being cared for at home are receiving safe and high quality care. The Minister of State with responsibility for mental health and older people recently announced a consultation process on establishing a new statutory home care scheme. Moreover, a Private Members' Bill debated in the Dáil last week sought to expand the provision of home care services. While HIQA advocates the extension of home care packages, we are aware of the specific vulnerabilities of people in receipt of personal care and support services in their homes. Therefore, we must extend statutory regulation to cover all domiciliary care services and other community based social services to ensure vulnerable people are safe and receiving the best possible support.

In recognition of our ageing population, the rapid increase in chronic conditions and the health care costs associated with these developments, society needs to explore alternative models for the delivery of social care services. Consideration must also be given to ways of supporting older people and people with disabilities to remain in or as close as possible to their homes. These alternative models for the delivery of services for older people and people with disabilities would potentially provide incremental pathways of support and care aligned with the changing needs of the person, thereby allowing him or her to be supported to stay longer living at home and nearer family and friends. This process would be supported by local commissioning arrangements.

The rationing of care is an inevitable consequence of a fixed health care budget. Finite health care resources means choices must be made. Owing to opportunity cost, deciding to invest in a new drug may mean the health care service cannot provide another intervention for patients. Currently, we have a system characterised by rationing by delay, crudely manifested in the form of waiting lists. Health technology assessment or HTA is evidence based research widely used internationally to assess the costs and benefits of health care treatments. Using the best available evidence on the clinical benefit and cost-effectiveness of technologies, including drugs, medical devices, public health programmes such as cancer screening and the organisation of services, maximises outcomes for the population and health service. The aim of HTA is to guarantee the best use is made of resources through rationing by design. This ensures the right health care is targeted to the right patient at the right time in the right place, delivering the best outcomes for the individual and the most efficient use of the health care budget. Since 2007, HIQA has carried out health technology assessments to inform major health policy and health service decisions.

If universal health care is to be implemented effectively, agreement must be reached on what treatments and technologies should be included in the standardised basket of care to be provided to all patients. Expanding the use of health technology assessment in the health care system would ensure this decision-making process is independent, rigorous, transparent and based on high quality information. HTA optimises health outcomes for people, enables access to new and better treatments, fosters innovation by the health technology industry and ensures the financial sustainability of the health system.

I note that the committee’s second interim report stated that support for the implementation of e-health solutions came through strongly in submissions to the committee. HIQA recognises the role that e-health can play in significantly reducing clinical errors, improving patient safety, creating efficiencies and, if properly implemented, reaping economic benefits. Many of the areas highlighted in the second interim report depend on having e-health solutions in place. For example, integrated care for disease management requires technologies such as individual health identifiers, e-prescribing and electronic health records. In Ireland, health care is delivered through a range of providers that are both public and private. Therefore, when planning e-health solutions, we should take a patient centred, standards based approach to enable interoperability.

While there are many benefits to implementing e-health solutions, there are also challenges, particularly in terms of information governance and upholding the privacy of individuals. Good information governance practices and effective legislation are needed to support the sharing of information and enhance patient safety. The ten-year strategy should include a commitment to furthering and adequately resourcing Ireland’s e-health strategy to help achieve these goals. In addition, further legislation is required to enable the sharing of electronic health records and to advance the e-health agenda in Ireland. Progress will also require the buy-in from front-line staff and senior health care management. Both evidence based decision-making and e-health are essential components of effective commissioning.

We have an opportunity to transform our health and social care system into one that truly serves the Irish people. Central to any new strategy must be evidence based decision-making; the use of e-health systems; the protection of vulnerable people; the introduction of integrated care; and the use of alternative care models that allow people to stay in their homes. Moreover, the development of a strong commissioning model will help ensure that our health and social care system cost-effectively delivers safe and high quality care. If these proposals are implemented, it will lead to better decisions, safer services and better care. I thank members of the committee for listening to us. We will be pleased to answer any questions they may have.