Thursday, 22 June 2017
Committee on the Future of Healthcare Report: Motion
That Dáil Éireann shall consider the Report of the Committee on the Future of Healthcare, entitled ‘Sláintecare Report’, copies of which were laid before Dáil Éireann on 30th May, 2017.
In last year’s general election, health care was the No. 1 issue of concern for the public. This was hardly surprising when one considers the huge level of unmet need, with over 600,000 people on waiting lists for hospital services, hundreds of thousands on waiting lists for community services such as speech and language therapy and physiotherapy, and great difficulties for many in accessing mental health services, home care and disability services. There is no doubt that the political system has failed the people in one of the most basic and essential public services, namely, health care.
Unlike most other developed countries, we in Ireland have never sought to identify the most appropriate model of health care for the Irish people. A very disjointed, inefficient and inequitable system has evolved over the years which fails to adequately meet the needs of the people. Ireland is an outlier in terms of our two-tier health system. In no other European country are so many people denied access to services or forced into private health insurance. On the one hand, almost 40% have eligibility for free health care. This is eligibility rather than entitlement and is merely theoretical as many of the services either do not exist or are hopelessly inadequate. On the other hand, some 45% of the population feel they have no choice but to take out expensive private health insurance that rises every year, yet the level of cover provided fails to meet the cost of many essential services.
All service users are faced with significant out-of-pocket expenses that have risen significantly in recent years, often to a catastrophic level at which many are denied access to care. In the Irish context, the inverse care law clearly applies. Those most in need of care are least likely to receive it. This point was very strongly emphasised and graphically displayed to the committee by a group of GPs working in disadvantaged areas known as "Doctors at the Deep End".
Our health service is very much dominated by vested interests. Going back as far as the mother and child scheme of the 1950s, proper public health services have been blocked by those who see health care as a commodity from which to gain profits. The reality is that the weaker the public system, the more the private system benefits. The reverse also applies. The better the public health system, the less opportunity there is for profiteering. As a result, too often attempts to reform our dysfunctional system have been stymied by those who care little about equity and put private interests ahead of the public interest. When we hear public commentary on the health service, including some of the negative responses to this report, it is always wise to ask cui bono- who benefits? Are these people more concerned with their own commercial interests rather than the public good? At a political level and often at official level, vested interests have held too much sway. Too often, the ministerial approach has been to juggle these vested interests and thereby maintain the status quo. This has happened at the expense of the patient.
The interregnum last year provided an opportunity for the Dáil to take a new approach. Some 89 members signed up to a Dáil motion calling for an all-party consensus. Shortly afterwards, the Minister and Government came on board and the result was a unanimous decision of the Dáil to establish the Committee on the Future of Healthcare. The Dáil motion set the terms of reference for the committee. These had three key aims. They were to seek political consensus on a ten-year strategy for the health service, to plan for the introduction of a universal single-tier health service based on need rather than ability to pay and to re-orientate the health service away from our hospital-centric model so the vast bulk of care is provided at primary and social care level. Fundamental to these objectives was an acceptance that we need to stop making a political football out of health and reach a consensus on how our health service should be designed and structured in order to put the needs of patients first.
From the outset, we decided that our approach would have a number of elements. We were determined that our work would be evidence-based. We said it was a priority to listen to service users and staff. We took expert advice, most notably from the Centre for Health Policy and Management at Trinity College Dublin, which worked very closely with us and guided us in developing our report. We learned from best practice in other countries and took advice from people like Allyson Pollock and Dr. Josep Figueras of the OECD. We held expert-led workshops and agreed on a set of values and eight principles which would underpin our work. They are creating a modern, responsive and integrated public health system comparable to other European countries through building long-term public and political confidence in the delivery and implementation of this plan; all care planned and provided so that the patient is paramount ensuring appropriate care pathways and seamless transition backed up by full patient record and information; timely access to all health and social care according to medical need; care provided free at point of delivery based entirely on clinical need; patients accessing care at most appropriate and cost-effective service level with a strong emphasis on prevention and public health; a health service workforce that is appropriate, accountable, flexible, well-resourced, supported and valued; only spending public money in the public interest or for the public good ensuring value for money, integration, oversight, accountability and correct incentives; and the centrality of accountability, effective organisational alignment and good governance to the organisation and functioning of the health system.
The areas which we prioritised became the key chapters of our report. They are population health profile, entitlements and access, integrated care, funding and implementation. We have called our proposals Sláintecare. The key elements are a new general health card, cárta sláinte, entitling everyone to a broad range of treatments and medicines at low cost or for free, which will reduce out-of-pocket expenses for all; waiting time guarantees of 12 weeks for an inpatient procedure, ten weeks for an outpatient appointment and ten days for a diagnostic test, all of which are to be underpinned by legislation; delivery of at least 70% of peoples' health care services locally in their community, including chronic illness management, diagnostic services and minor injury care; more investment in preventative public health and the promotion of healthy lifestyles, mental well-being and early detection and management of chronic illness; and the phased elimination of private care from public hospitals. Everyone will be entitled to access public care in public hospitals. Those who have private health insurance will still be able to purchase care from private health care providers but there will be no subsidisation of that. Other key elements of the plan include significant up-front and ongoing year-on-year investment rising to €2.8 billion over a ten-year period and a transitional fund of €3 billion to support investment across the health system in areas such as infrastructure, e-health and expansion of training capacity and the settling up of a Sláinte implementation office under the auspices of An Taoiseach to develop a detailed implementation plan for the reform programme.
On the question of funding, we very much recognise that Ireland already spends a lot on health relative to other countries but it is clear that the manner in which that money is being spent means we get very poor value for money and unsatisfactory health outcomes. Our approach has been to recommend spending in order to save where there will be significant saving for individuals and families in terms of out-of-pocket expenses, where the need for private health insurance will decrease, where we move to a much lower cost model of care and where this is facilitated by a full e-health programme.
We urge the Government to endorse the detailed and costed approach set out by the committee in Sláintecare. This is not a menu of options from which to pick and choose. It is a comprehensive strategy whose elements are inter-related and interdependent.
As a result, I am concerned about the mixed messages coming from the Government in respect of its response. While the Minister is sounding positive, the Government Press Office seems to be briefing negatively. A report in The Irish Timeson Monday went as far as to say that the Minister has signalled his intention to implement the future of health care report only partially and that he will tell the Dáil that he welcomes those elements which are consistent with Government policy. I also know that there was similar negative briefing of journalists after Tuesday's Cabinet meeting. I sincerely hope this is not what the Minister is going to say and I hope it does not represent his views because to do so would be to fly in the face of the hard-won political consensus on which Sláintecare is built.
I take this opportunity to thank all members of the committee for their engagement in this process over the past 11 months. It was demanding and time consuming and involved a lot of meetings and much reading between meetings. We were all challenged to find workable solutions. I believe all members approached the task with an earnest desire to fulfill the remit which they had been given by the Dáil and to draft a strategy to ensure that their constituents and all people in Ireland would be provided with a modern, equitable and efficient public health care system.
I also thank the secretariat here in the Oireachtas, which provided important support and backup and worked to challenging and tight deadlines. The committee was particularly fortunate in being able to engage the expertise of the team from the Trinity College Dublin centre for health policy and management, under the leadership of Dr. Stephen Thomas. Its wide-ranging expertise and guidance was invaluable to the work of the committee. I also thank the Minister for Health, the Department of Health and the HSE for their support during the process, and for the data and responses which they were able to provide for the many queries which we raised.
The Sláintecare plan will deliver for Ireland the sort of fair, affordable and effective public health system that we desperately need and deserve, and which most of our European neighbours enjoy. This is the first time there has ever been cross-party consensus on how to deliver a modern universal health care system that meets the needs of all people based on their medical needs, not on their economic status. Sláintecare is a realistic and achievable plan. It is about investing now in those key elements of the health care system in order to bring about better results and to save on funding later. It has been costed by health experts and has strong support among many patient groups and medical practitioners.
What we now need is a Government commitment to implement this plan in its entirety. We cannot continue with our broken health system where patients are dying on waiting lists, where many people's lives are limited by the lack of availability of much-needed services, and where families are impoverished because they have had to bear the costs of services that should be available free of charge in a modern, fully-developed country.
This is an historic opportunity to introduce a high-quality public health service for everyone in Ireland. We will not be forgiven if we allow this opportunity to pass.