President, Vice-President, members of the executive, staff of the IMO, ladies and gentlemen.
Thank you for inviting me to address you at your AGM today. I’m delighted to be here. I hope you have had productive meetings and that you have also had time to catch up with colleagues and friends.
And thank you for your contribution and dedication to the Irish health service. As I travel the country and meet with people, it is clear many challenges exist in our health service and I want to discuss some of them today and the solutions needed – but people always remark to me about the dedication and professionalism of those who work in our healthcare service. So today gives me an opportunity to publicly acknowledge that at the IMO Conference.
I’d like to start by congratulating Dr John Duddy, on the completion of his successful term in office. John has been and, no doubt, will continue to be a strong advocate for our public health service. I’d like to welcome your incoming IMO President Dr Ann Hogan. I wish you Ann every success in the year ahead and I look forward to working with you as you, me and everybody in this room strives to achieve the same aim - to give the people of this country the kind of healthcare service they need and deserve and one that we can all be extremely proud of.
I believe we all want to arrive at the same destination – a health service that cares for patients on the basis of medical need, that promotes positive healthy lifestyles and that values healthcare professionals, their skills and their views. We may not agree on every step along the way – and that’s ok – disagreement at times can even be healthy! But I know that at the end of the day, we all want to do right by patients. That’s the big prize and it is what keeps me going on the tough days – the belief that it cannot be beyond us as a country to get this right and to get this done and to once and for all deliver a world class health service. We have done it in so many other areas of policy and society. Surely, we can do it for health care. One vision. One goal – a country full of healthier, happier people. A country where we have successfully broken the vicious and ongoing cycle of overcrowding and waiting lists. A country where we don’t just fight fires in the health service and deal with the challenge of today, but instead one where we put in place a plan and a roadmap for health care. A country that doesn’t just want to be the best small country in the world in which to do business in – but one which strives to be the best country in the world in which to grow old with dignity, to give birth safely, to have your children’s medical needs meet quickly and to reward innovation and best practice amongst health care professionals.
It’s easy to say all that, I know and I genuinely believe it with every fibre of my being - but I don’t have to tell anyone in this room that we have a huge amount of work to do to arrive at that point.
And I know you’re up for it – and, let me assure you – so am I.
Our health care service is a complicated tapestry. It involves public and private, voluntary and NGOs, charities and advocacy groups. It was not created by you or by me and it goes back years. But it is the reality of the environment we are working in. Together we can harness what works well and together we can change and improve what doesn't work as well.
In case I was under any illusion – which I’m not but, let me tell you - this week is a very good example of this complicated tapestry in action.
After years of failing to progress the building of a new National Maternity Hospital and failing women and infants by leaving them in out of date, inadequate and not fit for purpose hospital facilities, late last year the two voluntary hospitals, Holles St and St Vincent’s reached an agreement on how they would work together to deliver this new state of the art hospital, and in line with international best practice, co-located with an acute adult hospital. A new National Maternity Hospital that women and infants in this country desperately need.
I know reaching that agreement wasn’t easy and I am very grateful to both hospitals for having achieved that. Central to that agreement is the decision by St Vincent’s Healthcare Group to give the State, free of charge, a site in the middle of their campus in Elm Park, co-located with their public adult acute hospital. Now I, as Minister for Health have to make that agreement and the hospital to be built on that site,work for public health policy, the taxpayer and the State.
We have all heard the concerns and opinions that very many people have expressed over recent days. This has been difficult for all stakeholders and I know that St Vincent’s want time to reflect on this and indeed to reflect on some of the things I have said. I respect that. But here’s the thing. We need to build this new hospital. It is not good enough for women have to ‘put up with’ delivering their babies in Holles St, which the Master, Dr Rhona Mahony, very clearly says is a hospital facility which is not fit for purpose.
The international norm is to co-locate maternity hospitals with acute adult hospitals. And whilst much commentary this week has been about bricks and mortar – it is about so much more than that. It’s about access to theatres, to intensive care facilities, to high dependency units, to consultants. It’s about two hospitals working together to meet the full spectrum of needs of women and infants. It’s about empowering doctors to make clinical decisions. It’s about making sure that no doctor finds themselves at three in the morning in the National Maternity Hospital with a woman needing emergency care and waiting and wondering how and when they will get to an acute adult hospital.
I am very committed to this project and I will work with all stakeholders to ensure that we do build this hospital. Yes, it's complicated, and we must work together to address concerns that some people have expressed.
And you can be absolutely sure that, for my part, I will discharge my duties by putting in place appropriate legal mechanisms including arrangements to secure the State’s interest, which apply in all capital projects in voluntary hospitals to protect the State’s investment. My formal sanction will be required before any investment is made.
This will be the same safeguard that applied in the €266m public investment in the Mater over a number of years and the €29m investment in the Nutley Wing in St. Vincent’s University Hospital.
In addition the clinical, operational and financial independence of the new hospital, as provided for in the agreement, will be copper-fastened in new legal arrangements, which I will put in place.
And lest there be any doubt – in this country, doctors and healthcare professionals make clinical decisions – nobody else.
It is time for cool heads – we can do this – we can deliver the hospital and we can and will ensure all the protections necessary for the State – the patient, the doctor and the taxpayer.
It’s almost a year now since I became Minister for Health and it’s the tough days that strengthen my resolve to keep focussed on the big picture. And when we deliver for people and patients – improving their lives in different ways – it makes it all worthwhile.
Looking back over the past year or so, I can cite some examples of that:
- Making things a little bit easier for parents of children with a disability, by providing children in receipt of DCA with full medical cards and stopping the bureaucratic reviews and paper-filling exercises for these parents who already have more than enough to do and I want to thank the IMO sincerely for your support of this initiative.
- Making sure that prescription charges for 390,000 people over 70 and their dependants were reduced, so that no such charge is prohibitive for patients but we can keep a charge in place to ensure proper use of medicines.
- Negotiating a very good deal with IPHA on the cost of medicines, leading to savings of hundreds of millions of euro which will be reinvested in health and specifically in new and innovative drugs.
- Publishing the National Standards for Bereavement Care following pregnancy loss and perinatal death and the first ever HIQA Standards for maternity services.
- Planning for a statutory scheme for home help so we can turn the important wish of enabling people to grow old in their own home into a reality.
- Making Orkambi and Kalydeco available for adults and children with Cystic Fibrosis from next month.
- Extending the vaccine immunisation programme and again thank you for your support with this initiative
- Publishing and implementing our first ever National Obesity Strategy.
- Introducing plain packaging for tobacco products in Ireland effective from September.
- Advancing the Public Health Alcohol Bill in recognition of the health issues arising from alcohol.
- Announcing plans to legislate for an opt-out register for organ donation.
- Developing our new National Cancer Strategy for the next decade.
But we have so much more to do and in many ways, the discussions here in Galway have hit the nail on the head – we need investment and we need increased capacity.
No matter who the Minister is, which parties are in Government or how well the economy grows, there are always many competing and important demands on the public purse.
However, I have worked hard to increase the health budget this year to almost €14.2 billion.
But increased investment comes after almost a lost decade in terms of investment in public services due to a deep and painful economic reality.
And increased investment comes at a time when health care demand continues to rise due to our growing and ageing population; the increasing incidence of chronic conditions; and advances in treatments.
So, there is clearly pent up demand in terms of investment – particularly capital investment in health – our infrastructure is ageing, some hospitals built to treat 15,000 patients a year, now treat 40,000. The population has grown and so too must the bed numbers and the numbers working in our health service.
Overall reform agenda / Committee on the Future of Healthcare
But plans to invest, plans to improve and develop our public health service cannot just exist in accordance with political or electoral cycles or the political life-span of any one Health Minister.
This is going to require a plan that survives Ministerial and electoral changes; a long-term, 10 year plan for the health service.
That is why one of my first acts as Health Minister was to work with the Opposition to establish a cross-party Oireachtas Committee on the Future of Health Care.
This Committee is due to report in the coming weeks and I must say, I fully agree with what I read of the IMO discussion on this yesterday. The plan must be realistic, conscious of cost and timelines and I know the Committee will be working hard on this.
For my part, in my own submission to the Committee last month, I outlined 8 keys areas which must underpin any 10 year plan if we are to make progress on challenges, improve access and create a universal health care system:
1. Shift our model of care towards more comprehensive and accessible primary care.
2. Increase health service capacity, in the form of physical infrastructure and staffing, to address unmet need and future demographic requirements.
3. Exploit the full potential of integrated care programmes and eHealth to achieve service integration around the needs of patients across primary, community and acute care.
4. Strengthen incentives for providers to effectively respond to unmet health care needs by ramping up Activity Based Funding.
5. Empower the voice of the clinician and provide them with opportunities to contribute to the management of our health services.
6. Further develop Hospital Groups and Community Health Organisations, align them geographically and as they develop, devolve greater decision-making and accountability.
7. Follow this with the provision of a statutory basis for Hospital and Community Health Organisations, operating as integrated delivery systems within defined geographic areas.
8. Once statutory responsibilities and accountabilities are devolved from the centre to these Hospital and Community Health Organisations, dismantle the HSE and replace it with a much leaner national health agency. In the interim, reform the existing legislation within which the HSE operates to improve governance and accountability.
Structures
As part of a new vision and strategic plan for our health services, I am of the view that we need to revisit the structural arrangements we have in place. While structural reform is by no means a panacea for improvement in our health services, I do not believe the current structures are best serving our patients, or indeed staff, within ourhealth services.
But I also firmly believe that we can achieve a very different and much more effective structure in the next 5 years, building up to a radically new structure in 10 years.
Hospital Groups and Community Healthcare Organisations can provide the framework for a re-constituted health system. Strong regional entities can provide for decision making closer to the point of delivery and can provide a counter weight to the over centralisation of decision making and accountability which impedes service responsiveness.
I believe that the current hospital groups and CHOs should be geographically aligned and brought together into regional integrated entities. To complement these, we need to retain a national health agency, to ensure the continuation of initiatives and reforms that need to take place at a national level. This entity is likely to be a much-slimmed down body than the current HSE arrangements.
While there is much to be considered around the detailed plans and implementation path for any reforms in this area, I hope that this can be the broad direction of travel.
New GP Contract
The development of primary care is central to the objective to deliver a high-quality, integrated and cost effective health service. As doctorsthough, you can probably plaster the walls of this conference room with speeches and statements from Ministers about the importance of primary care going back decades. We need to move beyond the talking and get on with the doing - the “making this a reality” piece.
The development of a new, modernised contract for the provision of general practitioner services will be a key element in facilitating this process. The current contract is out of date and does not enable our GPs to do all that they want to and that we need them to do.
The challenge for us is to develop models of care that enable patients’ conditions to be better managed and which place the emphasis on prevention as well as reduction of exacerbations.
I acknowledge also that GPs working in rural and socially deprived areas play a particularly important role. That is why I am committed to ensuring that general practice in such areas remains a sustainable option for doctors. This includes discussing the possibility of an option of salaried GPs as part of the new GP contract negotiations.
I think it is important to acknowledge that these negotiations will take some time - it is a huge body of work. No doubt it will present many challenges to all of us involved in the process, but I would hope that everyone will remain focused on the goal of putting in place more suitable arrangements that will work better for patients, for GPs, for the healthcare service and for the country generally.
From my perspective, I want to see a new contract which has a population health focus, providing in particular for health promotion and disease prevention and for the structured on-going care of chronic conditions. A new modern contract should be flexible and be able to respond to the changing nature of the GP workforce.
It should also include provisions in relation to service quality and standards and transparency. I look forward to significant progress being made in these discussions over the months ahead.
I am pleased that the next phase of negotiation of a new contract for GPs is under way and I look forward to constructive and positive engagements. I understand that there are a wide range of topics being covered, and that these talks are ambitious in their scope. Let 2017 be the year we make real progress on this.
Health Service (Bed) Capacity Review
I have repeatedly made clear that increasing capacity within our health services is a priority. Put simply we need more beds – and we can only open more beds if there are more staff. That is why increasing bed capacity and addressing recruitment and retention are priorities for 2017.
My Department commenced a capacity review earlier this year in line with the commitment in the Programme for Government. Unlike previous work in this area, this will examine key elements of primary and community care infrastructure in addition to hospital facilities. It will look at all bed capacity needs across the health service – in the hospital, in the community, long term beds, short term beds, specialist beds and so on.
It will look at demographic needs now and into the future – in a way that perhaps the health service has not adequately done to date – and it will examine the impact of models of care including primary care on capacity needs.
The review will be supported by international expertise and will provide us with a clear understanding of the need within this year and in time to allow me make progress through the capital plan and budgetary process.
Recruitment
Central to addressing the capacity deficit is the recruitment and retention of front line staff. I am pleased to say that there has been an increase of 7,000 staffing levels n the public health services over the past three years, albeit coming from a low base.
Consultant recruitment must continue to be prioritised and efforts continue to fill consultant vacancies. The HSE has changed its consultant recruitment process and has developed more streamlined application processes.
Work is also underway to introduce a system of work planning and an individualised induction programme for consultants on appointment. Iam confident that all of these efforts will assist in the recruitment of more consultants.
Healthy Ireland - Prevention
Of course, health policy in Ireland is not just about treating patients when they get sick. Public health policy is and must be about trying to keep people well. That is at the core of the Healthy Ireland agenda.
There is no doubt that the clinical voice is so important in our collective effort to effect sustainable improvements in health and wellbeing for everybody living in Ireland. We all have a role in creating a supportive environment where we can all make healthier choices whether by being more active or by making better food choices.
Like many countries in the world today, in Ireland obesity is a major area of concern to people, society and Government. 60% of all adults are either overweight or obese. One in four children is either overweight or obese.
The World Health Organisation is predicting that current levels will continue to increase and if we continue on this path Ireland wouldbecome the most obese European nation.
In September of last year, I published Ireland’s policy on obesity: A Healthy Weight for Ireland – Obesity Policy and Action Plan 2016-2025.
This Policy is based on a whole of Government and a whole of society approach where every single sector has a contribution to make. As everyone here knows, obesity is multifactorial and no single programme, agency or service, on its own, is able to resolve this issue. Therefore, a concerted and sustainable effort is necessary.
Another vital tool in the prevention of disease and illness is the continued investment in immunisation programmes to protect children.
The introduction of Men B and Rotavirus immunisation to the Primary Childhood Immunisation Programme in December 2016, will further protect children against life threatening meningitis, and will significantly reduce the numbers of children requiring medical care due to rotavirus.
I would like to acknowledge the cooperation and commitment of GPs and the IMO for your contribution to the high uptake rates achieved in the Primary Childhood Immunisation Programme.
Uptake rates at 24 months for many of the recommended vaccines have reached the WHO target rate of 95%. But we know we have a problem with those who wish to scaremonger and misinform when it comes to vaccination. As doctors, you have an extremely important role in reassuring parents by providing clear and accurate information on the benefits of vaccination.
Let’s come out fighting. Let’s take on the scaremongers. Let’s tell people - in no uncertain terms - that it is you, the doctors, who are the experts and the people who are most trusted, to know what is best for our people’s health and wellbeing, young and old.
I take my advice on vaccinations from the Chief Medical Officer, from the European Medicines Agency, from the World Health Organisation and the medical community – not from random social media accounts.
If you want to give medical advice on vaccinations, become a doctor. If not, get out of the way and stay away from our public health policy. We have vaccines in this country that can prevent death. We have a vaccine that can prevent girls from dying of cancer. And yet we have uninformed nonsense interfering with medical efforts to save lives. Shame on them.
Pay Issues and Contracts
I note there has been debate at this conference about a range of pay issues. We do of course have public sector pay talks looming and your organisation will be pursuing pay claims for all members beyond the restoration of the FEMPI cuts imposed in 2013 that are now in the process of being restored on a phased basis as resources allow.
I look forward to that process and the work of the Pay Commission in terms of identifying the staffing needs of our health service now and into the future and dealing with pay issues in a structured way. No doubt, the IMO will play an important role in such discussions and negotiations.
Public Health Doctors
I recognise the importance of the public health specialty, particularly in the context of the wider demographic and health challenges we face. There is an ongoing imperative for public health expertise in the areas of health protection and environmental protection and in evaluating and advising on healthcare service delivery and reform.
It is important therefore that the concerns expressed by the MacCraith Group about the many challenges facing the specialty are addressed. While the number of public health specialists has increased in the past 3 years from 53 in February 2014 to 60 in February 2017, and the number of Medical Officers has increased marginally, it is simply not enough and we continue to have recruitment and retention challenges.
Following on from the MacCraith recommendation, my Department has engaged consultants to examine and report on the current and future role of the public health specialist in Ireland; the attractiveness of public health medicine as a career option; and the curriculum and content of the specialist training scheme.
The report will be due during the summer and I look forward to receiving it and acting upon it.
NCHDs
The numbers of Non Consultant Hospital Doctors employed by the HSE has increased in recent years. This is primarily a result of measures being implemented to achieve the requirement to be compliant with the European Working Time Directive and supporting care delivery.
There have been a number of positive developments arising from the recommendations of the Strategic Review Working Group chaired by Brian McCraith in 2013, though work remains to be done.
I regard the implementation of the Lead NCHD Initiative at national level as a very important step. I recently met with a number of Lead NCHDs and I recognise that they are at the forefront of the service and have practical ideas to improve service delivery.
We have seen some really good progress in terms of working hours. Having achieved over 95% compliance with the IMO requirement in relation to 24 hour shifts, we have made progress in reducing the numbers of NCHDs working over 48 hours per week to 17% of the cohort and we are committed to continuing with this progress.
Another positive development which will also address issues around recruitment and retention for NCHDs is the restoration of the Living Out Allowance for NCHDs appointed since 2012, which will be incorporated in to the basic salary of these doctors from 1 July 2017.
This of course arises from the campaign pursued by the IMO and I welcome the agreement that was reached.
The agreement will also enable us address more comprehensively your training needs in the months ahead, needs that have been highlighted in dialogue between your representatives and the MacCraith Implementation Monitoring Group.
Conclusion
In concluding, I wish to return to the pivotal issue of the future of our health services. I believe that we all recognise that the way forward is integrated care with a focus on preventative and primary care, with the capacity in the acute sector to meet the ever-growing demands.
The IMO is an organisation that works across these key areas. I wish to acknowledge the work of the IMO and its constructive contribution to the development of health care services.
I particularly welcome your campaign to highlight and tackle bullying in the workplace. There can be no place for bullies to hide in our society or in our health service. In particular people who prey on and bully younger people who are vulnerable and who can be damaged for life as a result of experiencing this kind of behaviour, need to be exposed and rooted out.
Thank you again for giving me the opportunity to address you today. I look forward to ongoing cooperation with you as together we work to achieve the same aim - to give the people of this country the kind of healthcare service they need and deserve.