7.2 Future developments
Many of these challenges were to be expected during the implementation of wide-scale change. Perhaps what is most interesting about the health service programme and strategy statements for future development are the changes that have not been proposed. Without taking anything away from the importance of the overriding principles and objectives and many of the proposals, it is important to recognize that Quality and fairness did not propose fundamental changes to the funding of the health care system, that is, it remains tax funded and regionally administered (at the time of writing through four HSE offices), with those on low income having universal coverage, GPs being paid through a mix of capitation and private fees, and hospital consultants paid on a salaried basis, retaining the opportunity to earn supplementary income from private practice.
This system is unlikely to change substantially by the time the next strategy dawns, towards the end of the 2000s. Nevertheless, there are signs that some of the long-standing, perverse economic incentives that exist within the system are being addressed; but careful evaluation of these steps will be required. Other serious challenges to the progress of reforms are likely to arise. The unprecedented rate of growth in health expenditure levels in recent years may be difficult to sustain if there is a period of economic slowdown. Rapid inward migration and increasing population diversity also present new challenges. The OECD has indicated that the Irish economy, being heavily dependent on foreign inward investment, is greatly exposed to external world economic events. The Organisation has also indicated that significant structural reform of all public services is required in order to keep pace with the rapid economic growth the country has been experiencing.
As living standards rise and funding for the health system increases, so does the need to ensure accountability for the effective deployment of public funds on behalf of the public health system. Resource issues become particularly problematic in the context of an adequate supply of medical, nursing and related personnel to support the increase in acute hospital bed capacity as well as the changes to the organization of the primary care system. This may prove to be very difficult given the problems being experienced at the time of writing in terms of attempts to sustain existing capacity. The role of HIQA in assessing the effectiveness and cost–effectiveness of interventions and organizational structures may be vital in promoting efficiency.
The issue of resource allocation across the system also needs to be addressed. The methodology used at the time of writing is still largely based on historical precedent – with some adjustments for the demographic characteristics of the population – rather than on an assessment of population needs. Nor does it reflect actual costs within the health care system. The move towards a greater use of DRG case-mix funding, coupled with further investment in information systems such as the HIPE, may go some way towards improving system efficiency.
The challenges of promoting equity in the system are likely to remain critical to public confidence in the performance of the health service. The persistence of inefficiencies within the health system is the focus of reform but will need to go further still. Given the continuing commitment of successive Irish governments to support a “mixed” health care system, whereby the same personnel may deliver public and private services within the same facilities, a clarification of the “boundaries” of each sector must be addressed if the rights and entitlements of public patients, in particular, are to be protected. More generally, this may yet prove to be a particularly challenging undertaking in an environment where half the population has private health insurance and the capacity of the private – as well as public – systems to deliver against rising consumer expectations may be open to question.
In December 2019, the Government approved the provision of state funded infertility services in the public health system. The proposed model of infertility care includes developing primary, secondary and tertiary services, with general practitioners as the first point of contact in the community, regional fertility hubs as the secondary services, and establishing 2-3 national centres for tertiary care to provide IVF.
€2 million is to be allocated in 2020 to improve access to public consultations for people with infertility issues. Two new regional fertility hubs are planned in 2020, with one in each maternity care networks.
Currently IVF treatment is not regulated by the state and only available privately. Some fertility medication is currently covered under publicly funded schemes and people undergoing IVF can claim tax relief under the medical expenses scheme. In October 2017, the General Scheme of the Assisted Human Reproduction Bill 2017, provided a legal framework for AHR services. In July 2019, an Oireachtas review of the scheme was published. Although the timeframe for legislation is yet uncertain, public infertility services are expected to be fully operational by 2021.
On 31 October 2019 Minister for Health Simon Harris launched the Climate Change Adaptation Plan 2019-2024 [https://assets.gov.ie/38322/fd5750277357421cb2472687e9b33d8f.pdf]. The plan sets out the Irish Government’s approach to mitigating health effects of climate change. The plan is part of the bigger strategy on climate change and one of twelve sectoral adaptation plans developed under the National Climate Change Adaptation Framework (2018) and the Climate Action and Low Carbon Development Act (2015).
The plan explores six scenarios which are likely to result from climate change and offers strategies and actions to mitigate these and/or adapt to them:
• UV/Sun exposure
• Air pollution
• High Precipitation/Flooding
• Extreme cold snaps
The goal of the plan is to reduce the vulnerability of the health sector to climate change through protecting people’s health and wellbeing to prevent avoidable illness and through increasing the resilience of health and social care services as well as protecting infrastructure from severe weather events.
Agencies involved are the Department of Health, the HSE, all relevant external organisations including General Practice, private hospitals and nursing homes.
The Sláintecare Action Plan was published on 13 March 2019. It outlines the approach for delivery of Sláintecare and key milestones to be achieved by the end of 2019. The Action Plan was developed by the Slaintecare Programme Implementation Office and is described as ‘a fundamental enabler in the delivery of the Sláintecare vision for reformed health and social care services in Ireland’.
The Action Plan states that ‘Sláintecare is about delivering a health and social care service that meets the needs of our population and attracts and retains the very best healthcare professionals, managers and staff. Over a ten-year period, we will deliver a universal health service that offers the right care, in the right place, at the right time, with a priority focus on developing primary and community services within a national policy context. With appropriate, well-governed investment, we will deliver a service that is given by the right team at low or no charge. Crucially, it will be essential to engage with staff, staff representative bodies, and the wider stakeholder network, to find new ways of working to deliver expanded services and optimise the wealth of skills and knowledge inherent in our workforce’.
The plan is centred on a Citizen Care Masterplan, whereby citizens and staff will be central to redesigning the health system as well as empowering everyone to look after their own health. The Action Plan specifies a framework for the implementation of the Citizens Care Masterplan which is supported by a continuous and cross cutting programme delivery approach. There are 10 components underpinning this master plan and four overarching work streams. The components are 1) Citizen and Staff Engagement and Empowerment; 2) Clinical and Corporate Governance; 3) Population Health Planning; 4) Service Redesign; 5) Infrastructure and eHealth; 6) Public and Private Delivery Partners; 7) Workforce Planning and Capacity Building; 8) Entitlement and Eligibility; 9) Accountability and Value for Money; 10) Programme delivery.
The four work streams through which the work will be achieved are:
Workstream 1; Service ReDesign and supporting infrastructure
Workstream 2: Safe care, co-ordinated governance and value for money
Workstream 3: Teams of the Future
Workstream 4: Sharing Progress.
There are 20 specific work programmes for 2019 with key deliverables and timelines. This Action Plan is the first tangible result of the work of the Slaintecare Implementation Office. The plan acknowledges that 2019 is the first full year of Sláintecare’s implementation. While some of the plan is a rehash of existing health strategies, it is necessary to weave these into the Sláintecare implementation process and it does this well.
The 2017 Oireachtas report contained a transition fund – €3 billion to make up for historic underspending in health and much-needed investment – and costed the entitlements expansion at €20 billion over a 10-year period. The plan specifies “it will prepare detailed budgets for a transition fund to support Sláintecare reform” but there is no quantum or specific timelines for this fund in the Action Plan.
The plan is weaker on universalism than the 2017 Oireachtas report, committing to develop “an approach to modeling [sic] various entitlement and eligibility scenarios and examine costs and benefits . . . We will plan how, when and in what order of priority this could be done and make proposals to government for consideration”. It specifies that “everyone will have entitlement to a comprehensive range of primary, acute and social care services . . . providing universal services at no or low cost to the patient/service user” but has no detail as to how and by when. There is a strong emphasis on getting the right workforce in place, rightly so as they are the essence of delivering accessible, high-quality care. But more staff are needed and this is notably absent in the action plan.
When a new government was established in May 2016, the Programme for Partnership Government 2016 committed to set up a parliamentary committee to agree cross party consensus on the future of health reform. The Oireachtas (the Irish Houses of Parliament) Committee on the Future of Healthcare was established in July 2016. As the Senate was not yet elected, only members of the Daíl (the House of Parliament) became Committee members.
The terms of reference of the Oireachtas Committee on the Future of Healthcare included the need for political consensus on a ten year plan for health reform which was to establish a universal, single-tier health services where patients are treated on the basis of health need not ability to pay’, as well as ‘reorienting the health service on a phased basis towards integrated primary and community care, consistent with the highest quality of patient safety’.
The Committee met between June 2016 and May 2017. They invited written submissions from interested representative bodies, individuals and groups. Guidelines for structuring responses and recommendations were given under the themes of 1) strategy; 2) integrated and primary care; 3) funding model. 167 submissions were received from public and private healthcare providers, managers, frontline staff, unions, academics, advocacy and voluntary agencies, industry and interested individuals.
They committee held 22 public hearings between July 2016 and January 2017. Through its months-long consultation process, the Committee examined submissions from 167 of stakeholders which gave broad support for the approach taken by the Committee and the recommendations made in its final report.
A secretariat from the Houses of the Oireachtas provided administrative and health policy support to the Committee, while a small team from the Centre for Health Policy and Management in the School of Medicine in Trinity College Dublin facilitated three expert-led workshops with the Committee in November and December 2016 and provided technical support until April 2017.
The Committee drafted their report in closed sessions between February and May, all the time seeking to achieve consensus on matters. When they did not they voted on the wording and recommendations in the report.
The Committee framed their report on five key areas:
- Population health profile
- Entitlements and access to healthcare
- Integrated care
The Oireachtas Committee on the Future of Healthcare Sláintecare report, published on 30 May 2017 and debated in the Daíl on 21 June 2017, sets out a ten year strategy for health care reform in Ireland. It is the first time that cross party political consensus on health reform and agreement on a new model for healthcare has been reached in Ireland. The Committee’s remit was to ‘adopt a ten year plan’, providing ‘a single long-term vision for health’, establishing ‘a universal single tier where patients are treated on the basis of health need not ability to pay’.
Under Sláintecare, universal care will be an entitlement, charges will be reduced and abolished as appropriate, a health card (Carta Sláinte) will entitle all citizens to access to a comprehensive range of services over a five year period. There will be no charge to access GP, primary and hospital care The Committee’s report is underpinned by a stronger policy focus on public health and health promotion and that shifting care out of hospitals into the primary and community setting will assist in tackling some of the major challenges in the Irish public hospital system. These include long waits for access to Emergency Departments, for outpatient appointments with a hospital specialist and planned elective hospital care. In response the report recommends waiting time guarantees of 12 weeks for an inpatient procedure, 10 weeks for an outpatient appointment, ten days for a diagnostic test and 4 hours in an emergency department.
The phased elimination of private care in public hospitals is recommended over the first six years of the plan. The Committee recommends an independent impact analysis of the separation of private practice from the public system to identify any adverse or unintended consequences on the public system as an aide to implementation of the separation.
Expansion of capacity is required including the provision of diagnostics in the community, earlier and better access to mental health services, and an expanded workforce (such as additional allied health professionals, public health nurses, practice nurses and specialist nurses, GPs and consultants). The importance of addressing recruitment and retention issues of all healthcare staff and the development of integrated workforce planning is emphasised in the report.
The report sets out specific costings for the expansion of entitlements and system development and timelines for implementation, recommending the establishment of an Implementation Office in the Department of An Taoiseach (Prime minister) to drive the reform.
It is envisaged that it will cost an additional €2.8 billion by year ten, with a one-off transitional fund of €3 billion required over six years for infrastructure investment, expansion of training capacity and the timely implementation of the eHealth strategy.
Additionally, a new government was formed in Ireland on 14 June 2017 when the Taoiseach (prime minister) Enda Kenny resigned and a new one (Leo Varadkar) took over. Simon Harris remained the health minister in the cabinet reshuffle on 14 June 2017 and has been tasked with ‘preparing a detailed response to the report including proposed measures and timelines responding to the report’.
Click here for the report
And here and here for more on the Committee
The Oireachtas Committee on the Future of Healthcare sought an extension for its work to develop cross political party consensus on a ten year plan for health reform including the delivery of a universal health system.
The Committee has held extensive public hearings with key witnesses, has received over 150 submissions from the public and will publish its work by the end of April 2017.
Key themes emerging from their work include broad support for delivering services on the basis of medical need; the critical importance of health promotion and public health; the fundamental role of primary care in managing the vast majority of care needs; the importance of integrated care; how eHealth developments are a critical enabler for integrated care; the necessity in retaining and recruiting quality staff; a desire to have clinical and managerial accountability and governance.
The Second Interim report of the Committee is here http://www.oireachtas.ie/parliament/media/committees/futureofhealthcare/Second-Interim-Report-of-the-Committee-on-the-Future-of-Healthcare-200117.pdf
Programme for Partnership Government 2016 sets up parliamentary committee to agree cross-party consensus on the future of the health services
The Programme for Partnership Government 2016 was published in May 2016 after two months of negotiations to form a minority government. Fine Gael who were in power from 2011 to March 2016 formed a government with the support of a group of independents.
The programme demonstrates a shift in policy from Universal Health Insurance (which was the priority to goal of the 2011 Programme for Government) to Universal Healthcare.
There are seven priorities identified:
- A Decisive shift of the Health Service to Primary Care with the delivery of enhanced Primary Care in every Community.
This commits to enhanced and more primary care, increased numbers of GP training places, increased numbers of primary care professionals, a new GP contract as well as greater integration of primary and secondary care, reducing the cost of medicines, expanding the role of community pharmacists as well as increased funding for homecare packages and home help;
- Guaranteeing the Future Sustainability of Rural Practice and in Disadvantaged Urban Areas;
- Creating a Healthy Ireland;
- Building Capacity for our Emergency and Acute Services;
- Improving Waiting Times for Hospital Procedures;
- Reforming HSE into a more Efficient, Transparent Health Service for Patients and Staff;
- Funding of the Health Service.
Under priority seven, the Programme for Government committed to establish a specific Oireachtas (parliamentary) Committee on the Future of Health Reform. This was established in July 2016 to ‘develop cross-party consensus on the future of the health service… recognising … the need to establish a universal single-tier service where patients are treated on the basis of health need rather than on ability to pay’.
The Daíl motion that established the committee specified that ‘the Committee shall examine and recommend how to progress a changed model of healthcare that advocates the principles of prevention and early intervention, self-management and primary care services as well as integrated care… and how best to re-orientate the health service on a phased basis towards integrated, primary and community care, consistent with highest quality of patient safety, in as short a time-frame as possible’. It is due to report in January 2017.
This demonstrates a commitment to universal healthcare and to extending primary care. However, there is no detail on how or when such universalism or extended primary care will be achieved.
More on Programme for Government here http://www.merrionstreet.ie/merrionstreet/en/imagelibrary/programme_for_partnership_government.pdf
More on work of the committee here
In July 2014, Leo Varadkar was appointed as the new Irish health minister after a cabinet reshuffle. The reshuffle was a response to very poor results for the government coalition parties in the local and European elections in March 2014. When people were polled leaving the voting stations, they gave the loss of medical cards as their main reason for anger with the government.
Varadkar as health minister indicated new priorities for the government contrary to commitments made in the Programme for Government, including a decision to continue (not abolish) the HSE, increased numbers of discretionary medical cards, and a shift in emphasis from universal health insurance to universal health care.
In January 2015, a new set of Government ‘priority areas, actions and deliverables for the period 2015-2017’ were published. There are seven main priority areas:
- Drive the Healthy Ireland agenda
- Deliver improved patient outcomes health and well-being
- Reform operation systems to drive high performance
- Introduce innovative funding models
- Modernise health facilities and ICT infrastructure
- Implement agreed steps towards universal healthcare
- Develop the Department of Health’s workforce and capability.
Even though, there has to be a general election by Spring 2016, which may result in a change of government, the priority areas are dated 2015 to 2017 and are a good indicator of the intent of departmental health policy in the years ahead.
The priorities include new legislation to reduced alcohol consumption, the expanded remit of the health regulator – HIQA and the first national health survey since 2007. The extension of primary care services is committed to including ‘make the first concrete steps to universal healthcare by extending GP services without fees to the under 6s and over 70s’ and the ‘extension of GP care without fees to other cohorts of the population’. It also prioritises to ‘implement a package of measures to increase the number of people with health insurance’.
New targets are set for waiting times for the public hospital treatment – ‘nobody will wait longer than 18 months for in patient and day case treatment or an outpatient appointment, with a further reduction thereafter to no greater than 15 months by end year’. Previously the government committed to a maximum eight and 12 month wait time targets which have not been achieved.
The priorities include three new major infrastructure projects – a new children’s hospital, a new maternity hospital and a new forensic mental health service, as well as primary care centres, investment in eHealth including the introduction of the first individual health identifiers and an integrated financial management system for the HSE.
The 2011 Programme for Government committed to the introduction of a single tiered health system supported by universal health insurance where access is based in need, not ability to pay.
On 1 April 2014, the government published The Path to Universal Healthcare - White Paper on Universal Health Insurance (UHI).
Under UHI, everyone will be required to have insurance, with a choice of insurers. Insurers will not be allowed to discriminate on the basis of age, gender or health status and will compete on the basis of price. A Health Pricing Office has been set up in the health service (HSE) to set prices and keep costs down. Central to achieving UHI by 2019 is bringing down the costs of care in Ireland by incentivising treatment in lower cost settings.
Everyone will have access to care, with no differences in speed of access between public and private providers.
The publication of the UHI white paper also saw the launch of a public consultation process on the proposed plan. A UHI Commission is being established which will recommend to government what is to be included in the ‘future basket of services’. People will only be allowed to have supplementary insurance for services not included in the basket such as more luxurious accommodation.
It is proposed in the White Paper that the following services will be included
- Universal Primary Care
- Chronic Disease and Case Management
- Acute Hospital Care (including all inpatient, daycase and outpatient care)
- Acute Mental Health Care
- Rehabilitative Care (for up to 12 months)
- Step-down Care.
It is expected that some services such as public health, emergency care and social care will be outside of the basket of services. It is not decided whether prescription drugs, which currently have high charges in Ireland, will be included or not.
The 40% of the population who currently have medical cards (free access to GP and hospital care) will have their insurance paid for by the government. Those who currently pay privately will continue to pay, while those who currently have neither coverage will contribute towards their insurance, although it is not known how much they will have to pay.
There is a lot of opposition to the proposed UHI model for competing private insurers to be responsible for spending significant amounts of public money. Due to multiple delays in the government’s programme of health reform, it is possible that the UHI plan as currently envisaged may not be delivered by 2019.
In March 2011, a Programme for Government was published which included a radical plan to reform the Irish health system detailing 87 commitments on health. These included the pledge for the first time in the history of the state to develop ‘a universal, single-tier health service, which guarantees access to medical care based on need, not income’.
The blueprint of the new government promised to ‘end the unfair, unequal and inefficient two-tier health system’, through ‘the introduction of Universal Health Insurance with equal access to care for all’. It guaranteed citizens that ‘under this system, there will be no discrimination between patients on the grounds of income or insurance status. The two-tier system of unequal access to hospital care will end.’
The Programme for Government set out steps to deliver Universal Health Insurance including staged free GP care at the point of access by 2016. It specified that ‘Universal Primary Care will be introduced in phases so that additional doctors, nurses and other primary care professionals can be recruited’ as well as detailing the increase in training places, deferring retirement, increased numbers of practice nurses and recruitment from abroad so that staffing in primary care would be sufficient to deliver universal primary care.
Under the programme, the Universal Health Insurance system ‘will be designed according to the European principle of social solidarity: access will be according to need and payment will be according to ability to pay. The principle of social solidarity will underpin all relevant legislation’. It committed to introducing ‘a system of risk equalisation for the current insurance market’. A White Paper on Financing UHI was to be published early in the Government’s first term.
The Programme for Government also specified the establishment of a Special Delivery Unit in the Department of Health with a focus on reducing waiting lists for public patients and introducing a major upgrade of Information Technology in the health system.
It outlined a shift in control of the health budget from the Health Service Executive (HSE) to the Department of Health stating that ‘the Minister for Health will be responsible for health policy and for implementing this ambitious programme of reform and cost control’ and that ‘the Health Service Executive will cease to exist over time... its functions will return to the Minister for Health and the Department of Health and Children’. Cost reduction strategies detailed include cutting the salaries of medical consultants, fees paid to GPs, reducing the cost of drugs, procurement for medical equipments and construction of facilities.
2011 Programme for Government: http://www.merrionstreet.ie/wp-content/uploads/2010/05/Programme_for_Government_2011.pdf