Mr. Liam Doran:

On behalf of the Irish Congress of Trade Unions, ICTU, I wish to begin this submission by formally thanking the Chairman, Deputy Harty, and members of the committee for their invitation to participate in this discussion with regard to the Sláintecare report and the expansion of primary care.

ICTU, which represents over 700,000 citizens and their families, has welcomed the Sláintecare report, which recommends the introduction of a single-tiered, universally accessible and quality assured public health service. It is our view that this Sláintecare report, which enjoys almost universal political consensus about how our public health services should be structured, funded and maintained, offers a real opportunity for radical reform of the current inequitable two-tiered health system, leading to a properly resourced public health service, which is a fundamental social good in any society. As an indication of our support for the report, the health committee of the Irish Congress of Trade Unions is currently meeting with the health spokespersons of all political parties. We are satisfied that, to date, these engagements have been positive and all political parties have reaffirmed their commitment while recognising the challenges and scale of change involved.

Primary care expansion, as detailed within the report, is undoubtedly a cornerstone of the reform programme. ICTU fully supports, and will actively work towards achieving, the delivery of health care in the community as near as possible to the home of the patient or client. In that regard, we note that the report identifies all critical areas to be reformed and expanded, including universal access to primary care; universal GP care; expansion of diagnostics; expansion of home care and palliative care; and additional services for citizens with disabilities.

In working towards implementing all of the report’s recommendations, we remind the committee of the recent report, from the Economic and Social Research Institute, ESRI, which measured the increasing demand upon the health service between now and 2030.

In a further confirmation of the scale of the challenge facing our health system, the report states that demand for home help hours will increase by between 38% and 54%, demand for practice nurse visits is to increase by between 26% and 32% and demand for GP visits to increase by between 20% and 27%. It should be noted that, in addition to these very significant increases in primary care based services, the report also states that the demand for inpatient bed days will increase by between 32% and 37% for the same period. We believe this highlights two critical facts in relation to our public health service. First, the expansion of our primary care services, faced with this level of measured increased demand, is absolutely critical and cannot be ignored. Second, even with major expansion of our primary care services, the nature of our demographics will still result in a significant increase in demand for inpatient bed days; in other words, the demand for acute care will continue, even while we are expanding primary care services, and this has resource implications which must be accepted by all political parties.

Turning to the issue of universal GP and primary care access, it is self-evident that any expansion of primary care, as recommended in the report, requires a seismic shift in the eligibility of citizens to access all services outside the hospital setting. In that regard, the Sláintecare report correctly identifies the need for the expansion of, and universal access to, GP services and primary care services. From the Irish Congress of Trade Unions, ICTU, perspective we believe the expansion of these services should, in the context of universal access, be integrated. In other words, universal access to GP and primary care services should be seamless and delivered by a primary care team of health professionals who can directly receive self-referred patients, refer patients and clients to other health professionals within the team and refer on to other specialist or sub-specialist services as required. In that context, the GP is an integral member of this team but so, equally, are all other health professionals. This seamless approach, by fully utilising the skills of all, is the most effective way of dealing with growing demand including the management of chronic disease in a quality assured way.

It remains the view of ICTU that the most efficient and effective way of delivering universal access to all primary care services, including GP services, is that they should be provided by directly employed health professionals. The ongoing discussions, with regard to a revision of the GP contract, should be wholly informed by, and against the background of, a requirement that in future all new GPs should be directly employed by the public service. They should be rostered, particularly in urban areas, on a seven over seven basis, as should other key health professionals, and all members of the team paid a competitive salary reflecting their role and experience. This would ensure recruitment and retention.

With regard to the steps to implementation and ensuring delivery of the reform programme, ICTU believes that a critical first step is the establishment of an implementation office in the Department of the Taoiseach. This will ensure a whole of Government approach to implementation. In the absence of this initial oversight step, ICTU is already very concerned at the failure in budget 2018 to provide earmarked funding to prepare for the reform programme including the absence of a dedicated capital building programme, with regard to primary care centres with comprehensive diagnostic services to deliver the required community based infrastructure. There has also been no engagement on the necessary funded workforce plan required to deliver universal access, which the report states are 900 general nurses to expand the child health and well-being programmes; 1,917 health care assistants to expand home care and other services; 1,296 allied health professionals to delivery universal access to primary care; and 2,021 nurses of various grades to also deliver universal access.

In the context of the current recruitment and retention difficulties, facing grades within the health system, no expansion can take place without these additional staff. The reality is these additional staff will not be recruited without a properly structured and funded workforce plan covering the numbers of training places, clarity on the autonomy of roles within each team fully utilising all available skills and improved pay and conditions of employment. The report also recommends expansion of such critical services as the child and family health, community based child, adolescent and adult mental health services, expansion of palliative care services, and expansion of home care and disability services.

The report states that in the transition period, lasting up to ten years with many developments delivered within five years, expansion of these services should begin in year one. The report is correct when its states that all of these service expansions, while taking place on a phased basis, should be developed through an integrated model of care. This means that we must have simultaneous developments within all these strands of services so that the user, who will often have more than one need, can enjoy the benefits of a seamless expanding service. Against the background of the foregoing, we are already required to ask when the implementation will start. Is this year one or ten? Why was there not greater clarity about the funding in budget 2018?

A very broad overview of the additional funding requirement, arising from the expansion of services listed under primary care, identifies a cost of some €1.297 billion. This is separate from the capital build, essential to develop primary care centres, which will be the hub of the provision of seven over seven services required as part of the reform programme. Recognising the additional funding required, it is necessary for all political parties in the context of their support for Sláintecare to be forthright in saying in their policy statements that reducing overall taxation levels is not compatible with delivering a single tiered, equitable and universally accessible public health service capable of meeting future demand.

Regarding health care and social economic good, in 2001 the then Government defined primary care in its primary care strategy as:

...an approach to care that includes a range of services designed to keep people well, from promotion of health and screening for disease to assessment, diagnosis, treatment and rehabilitation as well as personal social services. The services provide first-level contact that is fully accessible by self-referral and have a strong emphasis on working with communities and individuals to improve their health and social well-being.

Almost two decades later, despite the excellence of effort by health service staff and significant expenditure by the Government, it has to be said we have not achieved this goal in the interest of all citizens. There are many reasons for this, with some related to funding and others related to ideology and an acceptance that a two tiered health system was somehow acceptable. The Sláintecare report provides the opportunity and solid platform for this State as a society to address the glaring inequality that is inevitable when money can ensure faster access to senior clinicians, diagnostics and, ultimately, treatment. We now have the opportunity by working together at political, organisational and societal level to address this inequality informed by this report and the expansion of primary care services is a cornerstone of this transitional journey. ICTU fully supports this report and the recommendations detailing how we expand our primary care services. We commit, on behalf of all of our members and their families, to work with all parties in delivering the transformational change now available to us.

I thank the members for their time and attention and we look forward to discussing this submission and the relevant elements of the report with the committee.