Simon Harris (Wicklow, Fine Gael) | Oireachtas source

I am delighted to before the joint committee today. As the Chairman stated, I am joined by the Secretary General, Mr. Jim Breslin, and Ms Laura Casey, also from the Department of Health.

I am grateful to have the opportunity to discuss the Sláintecare report with the committee. I will set out the process that we are engaged in to act on the report and will outline some of the steps already taken to advance recommendations in the report.

I wish to reiterate some general things I have said since the idea of the all-party committee was first mooted. I believe them even more so now that the committee has completed its work. The establishment of the committee provided a unique opportunity and space for all parties to put aside political ideologies and policy differences, and to work together in the best interests of the people they serve. The committee members did not sidestep this important task and lived up to their mandate. I again take this opportunity to acknowledge and thank the committee members and all those who engaged in consultation with them throughout the process.

This is the first time in our history that we have achieved consensus at a political level on the future direction of our health system. These opportunities do not come around too often and I am determined to harness this political consensus and to work with colleagues across the political spectrum and with all stakeholders to move forward on a programme of health reform that will ultimately benefit the health of our citizens, those who work in our health service and our society.

The process of reform will only succeed through the commitment and buy-in of all stakeholders to a shared vision. We have started on a solid foundation of unprecedented political consensus and must now seek to build consensus across the system, including clinical consensus and buy-in to the necessary reforms.

We are all aware of the challenges of implementing change in our health system. Health-care delivery is a complex endeavour and we in Ireland are not unique in encountering a variety of challenges. We now have an opportunity to learn from our own past experience, as well as international experience, and to design a programme of reform and the necessary supports to engage stakeholders across the system and sustain momentum over the coming decade. Moving towards a universal health system for all citizens is a transformational change in the Irish context. Every party in this Oireachtas has now signed up to that. We want to create a universal health care system and it will take ongoing commitment. Our continuing motivation will be our shared and agreed ambition to better serve the people of the country and to help shape a healthier future.

It is important to set out the context for the Sláintecare report. The Committee on the Future of Healthcare was established in recognition of the fact that our current health system, despite notable achievements, is not well placed to meet the demands of future generations. We need to design a system today to meet the many challenges now and into the future.

These challenges are well cited: our population is rising and the increase in those in older age groups is particularly relevant; there is a growing prevalence of chronic disease; health inequalities and unmet need are increasing; and there is an ongoing challenge to attract and retain the right skills mix and numbers in the workforce.

Committee members will have seen the report recently published by the ESRI, Projections of Demand for Healthcare in Ireland, 2015-2030. The picture painted in this report is stark and highlights the challenges that face our system in the next decade and reinforces the case for change. The main findings of this report are that over the years 2015 to 2030, the population of Ireland is projected to grow by between 14% and 23%, adding between 640,000 and 1.1 million people to the population. Furthermore, the share of population aged 65 and over is projected to increase from one in eight to one in five and numbers of people aged 85 and over are projected to almost double. It is a very welcome development that people are living longer but we need to be cognisant of it.

Because of these changes in demographics, demand for health and social care is projected to increase across all sectors, with the greatest increases for services for older people. Demand for home-help care and for residential and intermediate care places in nursing homes and other settings is projected to increase by up to 60%. Demand for public hospital services is projected to increase by up to 37% for inpatient bed days and up to 30% for inpatient cases. Demand for GP visits is projected to increase by up to 27%.

We also know that the nature of the illnesses faced by the Irish population is changing. Now approximately 60% of Irish people have one chronic disease and around 25% have two or more chronic diseases. Chronic disease requires a different type of care that is preventive, ongoing - not a once-off treatment - and managed close to home.

Ireland is not unique in the challenges that face our system. It is clear that the world around us is also changing rapidly and similar demographic and disease challenges face countries worldwide and particularly in western Europe. Rapid changes in mobility and technology present new challenges such as the spread of infectious diseases and the risk posed by antimicrobial resistance. The development of knowledge and technology also presents opportunities to fight diseases that were previously debilitating and to access new therapies and better medicines. As the world will continue to change in ways we cannot yet imagine, we must have the flexibility, ability and leadership to respond. We must be innovative in thinking about how to best serve the Irish population into the future. The work of the Committee on the Future of Healthcare in producing the Sláintecare report has provided us with the collective space to reconsider our direction and start to plan for a healthier future.

I will now turn to the report itself. The recommendations in the Sláintecare report are grounded in eight overarching principles that I fully endorse. These support a reorientation of the health service towards a high-quality integrated system providing care on the basis of need and not ability to pay; a universal system providing the right care in the right place at the right time, provided by the right people. The principles describe a system that is modern, responsive and integrated, comparable with other European countries, one that inspires long-term public and political confidence. In order to achieve this system the report highlights the need to place the patient at the centre of a system that delivers care which is timely, provided free at the point of delivery and provided at the most appropriate, cost effective service level with a welcome emphasis on prevention and public health. The report also points to the need to create an enabling environment for reform. This is an environment where the workforce is appropriate, accountable, flexible, well resourced, supported and valued, with accountability, value for money and good governance at the heart of the system. I believe that this describes a health-care system that will command the support of the people of Ireland and will meet their needs.

It is also important to highlight that a number of the recommendations in the report are supportive of current policy developed by successive Governments. A number of initiatives are already in train. In particular, the report strongly supports a real shift in our model of care, moving away from a hospital-centric approach to one which is focused on providing the majority of care in the community. Ministers for health have been talking about this back to the days when Dr. Rory O'Hanlon was Minister for Health. Many of these ideas have been around but perhaps we have not pulled them all together and had a real consistent programme of reform. That is the major benefit of the Sláintecare structure.

A range of other ongoing initiatives are given strong endorsement in the report including: the Healthy Ireland strategy, the eHealth agenda, integrated workforce planning - I was delighted to launch our new national strategic framework for health and social care workforce planning last week - a robust clinical governance framework, enhanced community nursing, integrated care programmes, and current strategies in the areas of maternity care and mental health. The report has highlighted that these issues should form the basis of creating the health service we all want to build. The support for these initiatives is helpful and can add greater impetus to their successful delivery.

I will now outline decisions taken with Government and work that is under way to develop a programme of reform to take forward the proposals in Sláintecare. When I spoke in the Dáil Chamber in June during the debate on the Sláintecare report, I was clear in my conviction that the publication of the report would come to mark a critical milestone in the history of our health service. I was also clear, as is the report, that we needed to allow time to reflect and deliberate on the findings of the committee and consider how best the vision and spirit of the report can be realised. This process of consideration is well advanced.

In July, the Government agreed to move forward with the establishment of a dedicated programme office and specifically the recruitment of a lead executive for that Sláintecare reform office. This marks a critical first step in gearing up for a significant programme of reform and demonstrates our commitment to this process. Budget 2018 allocated €1 million for the Sláintecare office in line with the report’s recommendation of €10 million over ten years, €1 million a year.

The recruitment process for the head of this office is under way and is being managed by the Public Appointments Service. The Public Appointments Service has actively begun the searches it needs to do to ensure we have the best person to do the job. It is essential that we are positioned to attract candidates of calibre for what will be a considerable reform programme. An extensive national and international executive search is being undertaken as a first step in this recruitment process, with the aim of attracting very senior candidates with a strong track record in implementing large-scale programmes of reform. In following the debates of the Committee on the Future of Healthcare I am very conscious that getting the right person with the right skill set is a key challenge. It is appropriate the Public Appointments Service is carrying out a national and international executive search to ensure we have the right person in place.

In parallel with this process, I have also been tasked by Government and the Oireachtas with developing a response to the report and a draft implementation plan for consideration by Government by the end of this year.

People ask where is the draft implementation plan. The report tells me to produce it by the end of the year and I will have it by the end of the year. This process is seeking to translate the Sláintecare report into a programme of action for the next ten years. The report itself recognises there is a need to take the vision and plan and put it into a programmatic series of concrete actions. This is why it asks me to put in place an implementation plan. It will also consider issues that arise in designing such a programme, including key actions, deliverables, costings, timelines, and interdependencies. It is widely acknowledged in the Sláintecare report that more detailed consideration of these issues would be required, and this work is under way and it will be delivered on time.

This process is being led at the most senior levels in the Department and the HSE, and also involves close engagement with the Departments of the Taoiseach, Finance, and Public Expenditure and Reform. The involvement of these Departments was a key recommendation of the report, as we need strong cross-Government political leadership. We do not need Sláintecare to be just the job of the Department of Health. We need buy-in and investment from other Departments in terms of a whole of Government approach, and this is what is happening. In recognition of this, the Cabinet held a special Government meeting in Cork last month, focused specifically on health care reform and the Sláintecare report. This is quite important. When I was appointed Minister for Health, I read a column which stated those who become the Minister for Health are often treated by the rest of their Cabinet colleagues as though they have Ebola, and that it is that person's job to fix the health service and no one else will go near the Minister in case he or she gets infected by all the challenges of health. The fact the Government itself held a dedicated meeting on Sláintecare and health reform in Cork I hope sends out a very important message on how seriously we are taking this and about the fact the Taoiseach, Deputy Leo Varadkar, wants to see a whole of Government approach on this. This is a view shared throughout the Government.

Later this week, there will be further discussion at the Cabinet committee on health, chaired by the Taoiseach, on the development of the implementation plan. Sláintecare and the development of an implementation plan is the specific agenda item at the Cabinet committee on health this week chaired by the Taoiseach. In fact, it will be held tomorrow. At the meeting in Cork, I was tasked with continuing the process of developing a response to the report for the Government's consideration. I was pleased to receive Government approval to move ahead with a number of actions recommended in the report. These include the initiation of an impact study on the removal of private practice in public hospitals. One of the transformational recommendations of the Sláintecare report is that we would move towards a universal system of health care, which would address the current inherent unfairness in our system when it comes to accessing care. The report rightly points to the issue of private practice in public hospitals in this regard. The committee acknowledges that it will take time to change this system, that careful consideration will need to be given to the impact of such a change, and that there will be a considerable price tag attached, but we cannot shy away from the core issue that when the public system is under severe strain, when emergency departments are full and waiting lists are in a challenging position, it is hard to defend an arrangement whereby private practice continues unquestioned in public facilities.

In its report the committee asked that I carry out an impact study and I am pleased to say this is under way. I have appointed Dr. Donal de Buitléir as chair of an independent expert group to examine the issue. The review group will be strong and balanced, bringing extensive experience and expertise in health care, including in hospital management, and also in governance, finance, human resources and employment law. Membership of the group will be finalised in the coming days, when I will publish the names of all of its members. The group will specifically examine the potential benefits and the potential adverse consequences that may arise in the separation of private practice from public settings. I will be asking the group to pay particular attention to the existing nature, level and role of private practice in public hospitals; the negative and positive aspects of private practice in public hospitals including access to health care, equity and the operation of public hospitals; what practical approaches might be taken to the removal of private practice from public hospitals, including a timeframe and phasing; possible impacts, both direct and indirect, immediate and over time, of removing private practice from public hospitals, including but not limited to impacts on access; hospital activity, including specialist services, funding, recruitment and the retention of personnel; and any legal or legislative issues that might arise. The group will conclude its work within nine months of commencing and by the end of next summer.

I am conscious we are having this meeting this morning in the aftermath of an "RTÉ Investigates" programme, and while I have clearly outlined the actions I have taken in relation to implementing the recommendations of Sláintecare in this regard, I want to say most consultants and doctors I meet in the Irish health service, and most people I meet in the Irish health service, do not just work the hours they are contracted to work but work well above them. We all know doctors in the health service about whom we are not worried about underworking but overworking. Equally, what we saw last night on our television screens in the case of some doctors was immoral, unfair and brazen and it needs to be rectified. Not just on foot of last night's programme, but for the past number of months, the Department has been engaging with the HSE on the need for a more robust monitoring system. If a nurse turns up late for work or does not work his or her hours, if a health care assistant does not work his or her hours, and if people in the public sector or private sector do not work their hours, they know all about it. We cannot have a continuation of a culture of deference to anybody working in our health service. Immoral, unfair and brazen is how I would describe what I saw last night, but I want to say this in the context of acknowledging it is a minority of people working in our health service. I expect the HSE as the employer will now formally investigate each of the cases shown on television last night. I expect this to happen and I am aware it will happen. We cannot have a situation where people are paid for hours they do not work. It would not be tolerated in any other workplace and it would not be tolerated in the health service at any other grade. The culture of deference towards consultants in some hospitals must end. I say this in acknowledging the fact many of our doctors work well above and beyond their contracted hours and it is important to say this.

A public consultation on the future alignment of hospitals groups and community health organisations, CHOs, will take place. The Sláintecare report endorses the need to achieve greater alignment between hospital groups and CHOs. I spoke about this when I appeared before the committee. We all know that different health service management structures have been put in place over the years, and we all know that while finding the ideal structure will not suddenly solve all our problems, having the wrong structures will certainly undermine our chances of successfully developing a coherent, efficient and integrated system.

I welcome the emphasis on integrated care that is embedded in the report, and I believe that aligning our delivery systems will ultimately help the system to move towards a population-based approach to service delivery that will help provide a more integrated service for the citizens of this country and help those in the system to better understand and manage health outcomes. Having hospital groups and CHOs operating on this basis will facilitate collective performance and accountability arrangements based upon pre-arranged and shared goals, budgets and incentives.

I am conscious that structural reforms can be disruptive and that we need to avoid unintended consequences. For this reason, I have agreed to undertake a consultation process to hear the views of people working in our health service, of those who represent them, and, most important, of patients. I will commence this consultation process by the end of the month.

There are also plans to establish a governing board to oversee HSE performance. I spoke about this when I appeared before the Sláintecare committee. I am very pleased it appears in the Sláintecare report. We need to re-establish a board in relation to the HSE. This will require legislation and I hope to have a board, with very strong competencies across key areas, established in 2018. Current governance structures in the HSE are not appropriate. They were only ever to be there as an interim measure. The director general of the HSE has spoken about this, as have I, and as has the Sláintecare committee. I intend to publish very early in 2018 legislation to establish a board based on competencies that can bring greater accountability and governance structures to our health service. With the support of the parties in the House we could pass that legislation quite quickly and ensure the board is populated and in place with proper skills and expertise as early as possible in 2018.

Taken together with the consultation on alignment of hospital groups and CHOs, these are significant foundation steps in moving towards an evolution in our health care system. I am very aware of the need to bring decision-making closer to the point of care delivery and provide a counterweight to unnecessary over-centralisation, which impedes service responsiveness, but I am equally aware of the need to maintain a national-level focus in certain areas. It is a balance. What we can do locally in the region we should do and what we need to do nationally, in terms of standards and performance, we need to do. These matters are under consideration as part of overall reform proposals.

It is important to mention that funding for new initiatives in budget 2018 was closely aligned with proposals in Sláintecare. This allocation of funding shows the commitment of the Government to supporting key actions necessary for reform. These include a new primary care fund of €25 million. In his speech on budget day, the Minister, Deputy Donohoe, was very clear that this investment represents the start of a period of multi-annual investment in primary care and a GP contract. There is additional funding of €25 million for home care and transition beds, which is an important element of the Sláintecare report, reductions in medicine and prescription charges costing over €17 million, which will see prescription charges and the monthly drug payment scheme costs fall in January, targeted funding for waiting list reductions and, as has already been mentioned, funding to establish the Sláintecare programme office.

The agreement of capital expenditure allocations over the next four years has also allowed me to increase significantly the financial investment in ICT. The topic of ehealth was a very important part of the report. This will increase from €60 million next year to €85 million in 2019, €100 million in 2020 and €120 million in 2021. Thus, the budget for ehealth will more than double over its current level, allowing for significant expansion in digital health and ICT systems.

I also announced that in 2018 I will undertake a process of engagement with representative bodies of contracted health professionals, such as GPs, pharmacists, opticians, dentists, aimed at putting in place a new multi-annual approach to fees, commencing in 2019, in return for service improvement and contractual reform and in line with Government priorities and Sláintecare priorities for the health service. This will support the development of a new modern contract with GPs and other primary care providers, and is in line with emphasis on this area in Sláintecare and issues raised at this committee over recent meetings.

I have heard from many understandable frustration with the pace of the response to the Sláintecare report. We all want to reform the health service but it is a ten-year plan. There is a great deal of ground work to do to make sure we can succeed on this. We can all agree that sometimes the pace of policy making and decision making is not what it should be, but in this case I do not believe that the criticism is fair or realistic. I am firmly of the view that a careful and proper process of consideration is vital so that this does not all fall over when we hit the ground running in 2018. The proposals in Sláintecare represent one of the largest programmes of reform not just in the health sector, but in the public service more generally. They reach into the very operation of our health care system, and into our systems of entitlement and access. Neither the change that is required to deliver on these proposals nor the challenges that will be encountered in making them a reality should be underestimated.

We need to properly consider these challenges and seek to learn from past reform mistakes - this is not the first time we have tried to reform the health service - and we need to look at past reform in this regard internationally as well. Our success will very much depend on the formulation of an effective implementation path. Implementation requires planning and identification of strategic decisions. It requires putting the right people in place. This is the process that I am engaged in at present with Government colleagues, my Department and the HSE. Having read commentary in this regard, I personally attest to the commitment of all those, most particularly, my Department, involved in this work. In recent days, there have been challenges to the bona fides of this commitment and I want to refute that in the strongest possible terms.

The Government has charged me and my Department with developing a draft implementation plan by the year end and that is what we will do. We are deadly serious about it. I am receiving the wholehearted and enthusiastic commitment of the civil servants in the Department of Health in the detailed implementation planning which is under way. I thank my staff for that. We have started extensive staff briefings to inject a degree of excitement and enthusiasm across both the HSE and the Department of Health that, when I am gone, when new Governments come and go, this is the plan that we all signed up to and that we will deliver collectively over the next ten years.

I look forward to returning to Government with a detailed response and the draft implementation plan. I very much look forward to coming back here when I have that, perhaps in January or whenever the committee wishes, so that we can discuss the detail of the implementation plan, the timelines and the progress we will make in 2018 and in subsequent years.