Mr. Liam Doran:

It is the view of congress that there is a growing consensus across Irish society that a single-tiered public health service which treats all citizens equally is in the common good for communities and our economy. I remind members that congress represents 750,000 workers and their families and has debated the issue of health extensively over its last number of biennial conferences. We believe there is significant unease about the current two-tiered health system where money buys quicker access to many services. There have been many examples of this. However, despite the many limitations with accessing our public health service, patients report a very high level of satisfaction with the quality of care and treatment they receive. This high level of performance, once the public health service is accessed, must be maintained as we transition to a public health service which is resourced, structured and available to all citizens equally. Access and equality must be the two measures against which progress is measured. Against this background congress wishes to stress that the transformational change required must be commenced against a number of guiding principles. These include the point that the change to a single-tiered, universally accessible public health service will require far more than a decade. Moreover, the change process must involve a long-term multi-annual commitment for the provision of ring-fenced core funding for the public health service at a minimum of 10% of GDP per annum. In addition, there will be a requirement for a significant capital programme to improve existing infrastructure and provide for new services and all funding should be provided through a system of progressive general taxation with a declaration that the State will, over time, cease to fund or to subvent any form of private health care provision. This will require the phased elimination of all tax reliefs for private health care insurance and direct subventions, that is, to existing private nursing homes. Another principle of the transformational programme must be that all existing public health services are maintained and, where necessary, enhanced until the alternative models of service, with much greater emphasis on community-based services, are established and fully operational. The programme must also lead to a simplified, integrated and readily understood organisational structure with clear lines of accountability and transparency and the single-tiered public health service must also be an employer of choice, offering all staff the opportunity to utilise their skills and talents in an environment which encourages innovation, autonomy and excellence.

On primary care, a cornerstone of a new health service must be universal eligibility for all health services, beginning with primary care services, provided by directly-employed health professionals. Staffing should be on the basis of seven-over-seven opening and centred on a team approach. The public must access the full range of health professionals who can cross-refer from one colleague to another based upon the needs of the person presenting for support or care. There can be no artificial structural barriers to a fully integrated primary care service. Such services, available on this seven-over-seven basis, must be provided on the basis that they can offer sufficient diagnostic and other support services so that the majority of persons attending can have their needs met without referral to the hospital or secondary care service. The shift to primary care will require, in addition to investment, a massive reorientation, not only of health professionals and staff but equally, the public. In that regard services must be capable, in a seamless fashion without lines of demarcation or limitations to access, of ensuring all health professions are fully utilised; chronic diseases can be managed away from the acute hospital; vulnerable people can access care, advice, support and guidance near their home; and significant investment in managing lifestyles to maintain positive health. It must be noted and accepted that a public health service must be enabled and resourced to promote the maintenance of good health within the community and not just be left to deal with ill-health and poor lifestyles.

On acute hospitals, an immediate requirement within our existing public health service is additional acute beds in a number of locations across the country.

As we indicate in our written submission, the latest OECD bed-to-population ratio confirms that Ireland, at 2.8, is significantly below the international norm of five beds per thousand of population. In essence, we have currently the perfect storm of too few acute beds to cater for demand, with wholly inadequate primary care services, which might, if they were resourced, provide a viable alternative to hospital care. In the context of a major investment programme to deliver the required additional acute beds, many of which can be five-day or day beds to reflect changing models of care, we also need to transform the role played by senior clinical decision makers, that is, consultants, who should be employed to work exclusively in our public health service.

The transformation programme, which should begin immediately, must see consultants on new contracts rostered over an extended day, on a seven-day-week basis. This will in turn require a significant number of additional consultants in the core specialisms of medicine, surgery, paediatrics, obstetrics and emergency medicine. While moving to this consultant-delivered service with less reliance on non-consultant hospital doctors, there must be a significant reconfiguration of the roles played by other health professionals to optimise their contribution to patient care. This, as we have said regarding primary care, must involve more autonomous roles, cross-professional referrals and greatly enhanced team working.

In the context of structures, congress broadly welcomes the establishment of the seven hospital groups and the potential it offers to provide optimum patient pathways, minimise duplication and streamline decision-making. However, congress also believes, in the context of commencing this transformational programme, no existing acute hospital service can be discontinued unless or until an alternative service which enjoys the confidence of the public is readily accessible and available.

In the context of this country's demographics, we face two major challenges regarding the provision of services and care to older people arising from the following: it is a fact that the number of senior citizens will steeply increase over the next 25 years. There has been a 21% increase in the number of persons over 65 since 2010 alone. Linked to this increase in the number of older persons will be a significant increase, estimated at 4% to 5% per annum, in the number of people presenting with multiple chronic conditions requiring ongoing intervention, care and support. At this stage, I remind the committee that the number of people attending emergency departments has gone up by 5.3% this year to date. The vast bulk of those are frail elderly, and this increase will continue unless we provide alternative pathways for those people to present to deal with their changing chronic conditions. Regardless of how effective we make primary care services, it is a reality that long-term care will be necessary for significant numbers of our senior citizens. In that regard, congress is absolute in its belief that the State must declare that, over time, it will return to being the main direct provider of long-term residential care for older people. This will require significant State investment in terms of physical infrastructure in residential surroundings. All moneys currently spent on direct State provision to private nursing homes, which can be estimated at up to €20 million per week or over €1 billion per annum, should be phased out and redirected into public direct provision.

Regarding mental health, congress must begin by highlighting its concern that both budgets and services have been severely cut in recent years. Furthermore, it appears that funding earmarked for mental health has for various reasons been utilised in other areas of our public health system. As recommended by the WHO, it is imperative, as we transition to a single-tiered service, that funding for mental health be set, at a minimum, at 12% of the total health care budget. In addition, service provision, as part of the transition, must be integrated within primary care. It must be accessible by the service user on a seven-over-seven basis, and in major urban areas on a 24-7 basis, through dedicated staff in major emergency departments. I think we all know the problems mental health is presenting at the moment and the hidden hurt and damage it is causing. Congress also believes that, in properly resourcing mental health support services, necessary funding must be provided for preventative programmes. We must also recognise that a wider range of professional staff, including teachers - in schools and colleges - as well as all health professionals, must have training in the identification of early signs of mental health difficulties.

Congress asks the committee to recognise, acknowledge and accept that funding for disability services in this country has been subject to major cuts over the last seven years. This has been done in a way which has had a major impact upon the quality of services available and the range of services that can be accessed in different parts of the country. This negative development has also been exacerbated as many services are provided by a range of entities which, while independent, rely almost exclusively upon State funding - section 39 agencies, for example. It is the view of congress that all disability services should be provided through direct provision, with directly employed staff and in a manner which ensures that access to necessary supports is available regardless of income or location. In making this point, we acknowledge the excellent work done by many not-for-profit organisations. However, in order to ensure equity of access and service provision, congress believes direct provision is the model for the future. In the context of moving to direct provision, there must also be a continuing process of integration into community-based living and working opportunities for the disabled person as we minimise the need for more traditional residential-type living environments. This must be provided for in the capital development programme referred to earlier.

Regarding miscellaneous matters, congress is acutely aware of the need for openness, transparency and accountability from those who manage and deliver services to the citizens of this country. That is why congress supports strong regulation to govern how all professionals practise. For the public to have confidence in those providing care, it is essential that clear regulatory standards apply and are seen to apply. Congress also recognises that any such service must be subject to constant review and examination by a wholly independent inspectorate.

Congress believes that an absolute cornerstone of a world-class, single-tiered, accessible health service is the employment of highly motivated health professionals and support staff. This must be within an environment in which innovation is encouraged and staffing levels, as determined by an evidenced-based approach, are maintained and guaranteed. In that regard, the transformation programme we all seek must recognise that our health service in the future must provide excellent remuneration, reward and recognition systems. It must also provide continuing development programmes so that staff are fully equipped for the ever-changing environment which will inevitably exist within every health service.

The establishment of this committee and its report can, in the view of congress, be an absolute watershed moment for this country and its approach to the provision of health services to its citizens. In that context, congress believes that this committee should clearly state that an overarching goal of this process, in the interests of communities and the economy, is a move to a universal, fully integrated, single-tiered public health service that guarantees access and quality of care regardless of income. This can only be achieved by guaranteed minimum funding in addition to significant capital investment, which must be removed from the uncertainty of the political, electoral and budgetary cycles. Congress recognises this is not an easy challenge, but it must be obvious to all of us that declaring a budget for the health service in October for the coming year makes forward planning all but impossible. The reality of our two-tiered health system, with its illogical and contradictory incentives for key players, makes the journey to a single-tiered system all the more difficult. That is why congress believes the change process will take at least 15 years and will require significant, sustained and increased investment. Congress also believes there is no option or alternative to this reality when one takes into account existing contractual arrangements, existing service limitations, growing demand, changing demographics and societal expectation with regard to treatment. Congress also believes that this journey will require clear, determined and unambiguous leadership across the political system and within the health service itself. The goal must be that when we reach 2030 the citizens of Ireland will live in a country which promotes the maintenance of good health but which responds to ill health in all its forms with efficiency, effectiveness and professionalism, regardless of socio-economic status or where one lives. This is a demanding objective but one that can, and must, be realised.