I congratulate Dr Ann Hogan on the completion of her successful term as President; I also want to congratulate the incoming President, Dr Peadar Gilligan. I look forward to working with you in the coming year.
I want to begin by noting the theme of your conference. Maybe I’m reading too much into it but I can’t help but feel there’s a subtle message to me in it...
Seriously though, I want to say that I come here in the spirit of partnership and I know that partnership is built on trust and mutual respect. I believe we are united in wishing to build a better health service and, to realise that ambition, you are important partners. Valued partners. I need you and I to work together to put the building blocks in place so that we can deliver the kind of Irish health service you will want to work in for the years ahead.
I have been clear about what I think the building blocks are:
Building capacity
Progress on recruitment and retention
Significant capital investment, the likes of which we have not seen for years
And supporting the long-talked about shift to primary care with an (admittedly also long-talked about) new GP contract
Overarching all of this is one of the most important developments in the past 12 months – the publication of the Sláintecare Report.
Sláintecare – Capacity + Reform
Although I couldn’t be here for the earlier parts of this conference, I did follow as much as I could on Twitter. Some of you might be aware I’m on Twitter I think. I’m certainly aware some of you are!
Anyway, as a result, I know you had a debate on Sláintecare already so I will try not to spend too long covering the same ground but I do need to say a few things about it and my commitment to it.
I’m sure the phrase ‘healthy scepticism’ has layers of additional meaning in rooms like this but, genuinely, Sláintecare is different. And we need to see it that way and to insist it is seen that way. It has attracted unprecedented cross-party political support.
I would like to acknowledge the Committee members, who have worked so hard on building this consensus system to create a shared vision for the future of our health service, including Deputy Michael Harty, who I know contributed to your debate.
I am determined to harness this consensus to drive change in our system and I ask for your support in making this change. This is a chance we cannot afford to squander.
Capacity
The recently published Health Service Capacity Review highlighted the scale of reform needed to meet the healthcare demands of our growing and ageing population.
We know that investment in additional capacity is necessary and we now have firm commitments in the National Development Plan for a coherent and substantial programme of capital investment in our hospital system and in the community. In fact, the capital spend in the next 10 years will increase by 165% compared to the last 10 years – that’s almost €11 billion, compared to just €4 billion. We have a real commitment and a real opportunity here for a health service that has been starved of capacity.
Reform
However, this cannot be the only answer. We must make real changes to healthcare delivery in order to have a sustainable healthcare system in the future. Put simply, we have no option but to reform.
The recommendations in the Sláintecare report are grounded in eight overarching principles which I fully endorse.
I believe that they provide a solid foundation on which to build a fair, modern and responsive health service that inspires long-term public and political confidence.
Fundamentally, the Sláintecare report envisages a re-orientation of the health service towards a high quality integrated system providing care on the basis of need.
This places the patient at the centre of a system which delivers care that is timely, free at the point of delivery, and provided at the most appropriate, cost effective service level with an emphasis on public health and illness prevention. This system places primary and community care at the heart of health care delivery.
Peadar, I understand why it can be construed as pitting hospital medicine against primary care, and why an organisation representing doctors in both would be very concerned by that. The reality is that those who say we just need more primary care are only telling half the story. Those who say we just need more beds are only telling the other half. When we put them together we begin to see the full picture – adequate hospital beds to meet our demographic needs now and for the future, coupled with primary and community care that is resourced and developed to its full potential.
And the reality is, because of the nature of your membership, perhaps no one is better placed to understand the challenges facing us in making this shift to primary care a reality but also the benefits of getting a better balance between primary and secondary care. Undoubtedly we will need more resources in the community and will need to make better use of the resources we already have.
Sláintecare recognises the need to re-orient the focus of healthcare delivery towards the community, but it also recognises that reform is needed in our acute sector. I accept that occupancy levels above 95% and unacceptably long waiting lists have become the norm in our hospitals and it can’t go on.
I share your ambition for us to do better and the building blocks as I see them are about finding a way to get there.
We must, as a system, utilise our hospitals better, while also investing in new capacity strategically in order to meet demand.
The report, I should say, recognises the need to create an enabling environment for reform. This is an environment where the workforce is appropriate, accountable, flexible, well-resourced, supported and valued, with accountability, value for money and good governance at the heart of the system. I believe that this describes a health care system that will gain the support of the people of Ireland and will meet their needs. I hope it is an aim that you would also support.
Sláintecare – Implementation
For our part, the Government is committed to delivering on the Sláintecare vision. We want to make real improvements in our health services – for patients, but also importantly for everyone who works within the system.
I have already set in train the establishment of a dedicated office to lead on implementation. The recruitment process for an Executive Director to lead the office is nearing completion.
We have set up an independent review group, chaired by Dr. Donal de Buitléir to examine the impact of private practice in public hospitals and I expect this Group to report to me by the end of the year.
Additionally, a public consultation has opened on the geo-alignment of Hospital Groups and Community Healthcare Organisations. While I believe that finding the right structures is not a panacea, I believe that the alignment of our delivery structures can be a key enabler of delivering integrated care.
National Development Plan 2018 – 2027
I wish to return to the very significant increase in capital funding in the health service as a result of the National Development Plan.
The €10.9 billion over the next ten years provides a real, long-term opportunity to improve our health services, drive down waiting lists, increase bed capacity, reform pathways of care and modernise how we deliver health services.
Capital investments in the Health services, over the coming decade, will support existing Government priority projects and commitments and will enable the roll-out of new additional capacity guided by the Sláintecare report and the Health Service Capacity Review.
Health Service Capacity Review 2018
As you know, the Capacity Review concluded that acute hospital bed capacity will need to increase by 2,600. I am pleased to say the National Development Plan provides for these acute hospital beds.
I realise you may contend that this is not enough but I go back to my point about finding the right balance between primary and secondary care, and I hope you will acknowlege that there is momentum now to reverse the frankly crazy decisions in the past to reduce beds. Other Ministers may have addressed your conferences and then left and cut bed numbers. I will do the opposite and increase bed numbers year on year. We will deliver in full on the recommendations of the internationally peer-reviewed bed capacity report.
New elective-only facilities will also be introduced in Dublin, Cork and Galway.
I don’t want people to think that a 10 year plan is all delivered in year 10. The work starts now and we need to see progress each and every year. Progress on more beds, on the elective only facilities, on more diagnostic facilities in primary care.
Listen, I recognise that we are playing catch-up here, but this unprecedented capital investment has to be acknowledged as a potential game changer.
GP Contract
I say ‘potential’ because I know – and, believe me, I know you know – it does not and cannot stand alone.
The Capacity Review also recognised the need for significant increases across primary and social care. For instance, that GP numbers would need to increase by 1,000, practice nurses by 1,200, plus increases in physios and OTs; and that expansion of homecare services and nursing home beds will also be needed.
I want to acknowledge here the hard work and dedication of general practitioners across the country, the important role you play in the lives of your patients and communities, and the trusted and respected service you provide.
But I know you want more than my acknowledgment. You want action and I can assure you so do I.
Reform of the GMS contract has long been promised yet provenfrustratingly difficult to achieve. I feel that frustration. I share it.
It is not a criticism but instead reflects the complex nature of thecontractual framework that has developed over the last three decadesand the scale of the challenge to reform it.
I think we all agree that the contract needs to be modernised to meet the needs of patients, general practitioners and the State while providing for better health promotion, structured care and disease prevention.
I also recognise that GPs need more staff supports from other healthcare professionals like practice nurses and your need to be supported to recruit more nurses to assist you with your work. I see this as an area in which we should work together to seek progress.
The discussions with IMO GP representatives throughout 2017 were constructive and covered a wide range of issues. We must now work to build upon that progress and reach agreement on a package of measures and reforms.
It is essential that the engagement on the GMS contract we will shortly embark on is aimed squarely at meeting the substantial challenges, current and future, faced by the health service and general practice.
I don’t deny this is going to challenge everyone involved but I am ambitious. I am optimistic.
I believe we share a commitment to building the health service that patients deserve and I hope we share a commitment to do so by working together.
Officials in my Department are working with the Department of Public Expenditure and the HSE to prepare for the next stage of engagement.
I have been in discussion with Government colleagues as we develop our approach to this crucial agenda and I briefed the Cabinet at the Government meeting at the end of March. I would like you to know of, and to express my appreciation for, the support my colleagueshave shown for this vital initiative.
Let me be very clear - there is now the potential for general practice to secure significant additional investment in the coming years. This is much needed and I hope that we set out sharing the ambition to see the process that will begin in the coming weeks through to a successful conclusion.
FEMPI
And I hear you loudly and clearly on the issue of FEMPI. I want to acknowledge that doctors were severely impacted by the cuts to fees introduced by successive governments as part of the then financial emergency. Like for so many others, the recession really hurt and remains painful even as we are recovering.
I know this has put many of you under stress and strain and you have raised important concerns about its impact on your ability to do your job and to meet the needs of our citizens.
Following the publication of the Public Service Pay and Pensions Act late last year, along with my colleague the Minister for Public Expenditure and Reform, I made it clear that we are committed to engaging with health contractors on the revision of fees as allowed under the new legislation.
Engagement with the IMO will start on this in the coming weeks and I hope this results in us moving into a post-FEMPI era. I believe we can work together to ensure general practice is a sustainable and rewarding career choice, while also better meeting the needs of patients.
Because the leadership of health professionals and political leadership can be a very effective combination.
I appreciated the support received at this conference for the Trauma System. That’s one example. I was very pleased to see a motion passed on the great work being done to recover the uptake in the HPV vaccine. That’s another example. And another is the support this organisation and others have provided to the Public Health Alcohol Bill.
Healthy Ireland
And there are more. The implementation of Healthy Ireland is an absolute priority. The cross-sectoral implementation of a suite of national policies and strategies is continuing, including the Obesity Policy and Action Plan, the National Physical Activity Plan, Tobacco Free Ireland and the National Sexual Health Strategy.
You know more than most the significant challenge we are facing in the Irish health service in managing the increasing incidence of chronic disease. Healthy Ireland is an essential element in reducing the burden of chronic disease. The Making Every Contact Count Programme will, over the coming months and years, receive a great deal of emphasis.
The Programme will support the prevention of chronic disease, through promoting and supporting lifestyle behaviour change for the four main lifestyle risk factors for chronic disease; tobacco use, physical inactivity, harmful alcohol consumption and unhealthy eating. I hope these efforts will have your continued support.
Mental Health
In the last six years, around €200 million, or 28%, has been added to the HSE Mental Health Budget which now totals over €910 million. This extra funding has permitted us to approve around 1,800 new Mental Health posts over this period.
Mental health care has the clear commitment of Government and we want to build now on the work commenced in 2017 on the enhancement of Community Teams for Children, Adults, Later Life and Mental Health Intellectual Disability services.
As we continue our move towards the delivery of a full 24/7 service, there is an initial focus on increasing the provision of services on a 7-day-a-week basis. A number of key projects are underway, including a refresh of the national mental health policy ‘A Vision for Change’, and the review and updating of the Mental Health Act 2001.
Patient Safety
I know that there is one goal we all certainly share – to create a health service where the patient comes first and patient safety is paramount.
The National Patient Safety Office is just over a year old but is anintegral part of my Department.
It has begun to drive new developments in patient safety policy and legislation; establish a patient safety surveillance system, and promote the clinical effectiveness agenda.
Through the work of this office we are already seeing a number of new patient safety initiatives that are starting to bear fruit, for example with the publication of monthly Maternity Patient Safety Statements since December 2015 by all maternity hospitals and units now being followed by similar monthly reports from all hospitals.
Patient Safety Legislation
The National Patient Safety Office is also bringing forward an ambitious programme of legislation. Provisions for the open disclosure of patient safety incidents were included in Part 4 of the Civil Liability (Amendment) Act 2017 which was signed into law by the President last November. The Act is part of a broader package of reforms aimed at improving the experience of those who are affected by adverse events. Work is currently underway on the drafting of Regulations to accompany Part 4 of the Act and consultation is taking place with the relevant stakeholders. I hope to be in a position to commence Part 4 shortly.
Recruitment & Retention
I know it’s not possible to talk about increasing capacity or wishing to improve our health service without talking about recruitment and retention.
We all know that working conditions, and learning and training opportunities, are a significant factor in our ability to recruit and retain medical staff.
A number of initiatives have been taken on foot of the MacCraithGroup's recommendations, including: the launch of a careers and training website; greater predictability concerning the location of training rotations; agreement on a set of flexible training principles; the introduction of the National Employment Record - now used by over 6,000 NCHDs; and the successful NCHD Lead initiative, which has been expanded to include parts of the mental health and general practice areas.
However, more needs to be done including making progress other key recommendations, such as protected training time, task transfer, better coverage of training costs incurred by NCHDs, and the situation of doctors employed in service posts. I want to now see progress in these areas.
The Public Service Pay Commission is looking at the levels of pay for certain health workforce personnel, including consultants, where it has already identified there are recruitment and retention issues. Their report is expected in June this year. In addition the Government is committed, under section 4 of the Public Service Stability Agreement, 2018 to 2020, to consideration of salary scale issues for new entrants, compared with those recruited before the reduced new entrant rates were introduced, with talks to commence on 27th April.
We also need to build further on initiatives to recognise the contribution of public health doctors.
I am very pleased to be able to say here today that the Review of Public Health Medicine has now been completed and was delivered to my Department this week. The implementation process will now be led from the Office of the Chief Medical Officer in my Department.
One of the most significant changes in the makeup of the medical workforce in the past 25 years has been the increasing number of women. In that time, the percentage of female consultants has increased from 19% in 1992 to 40% at the end of 2017. While this is a positive change, it must be considered against the facts that more than 50% of graduates have been female since 1992 and currently 52% of NCHDs are female.
We must adapt to ensure that our health service is more responsive to the changing needs of its workforce including more flexible training opportunities, predictable of training rotations and supports to retain doctors who wish to continue on a less than full-time basis rather them losing them to the public health service. Some initiatives have begun in this area and I’d like to see them continued and expanded.
I heard much discussion at your conference about supporting doctors. We have to make sure we care for our doctors and their health and wellbeing as well as their patients.
In this regard, I am also pleased that a strategy for doctors health and wellbeing is to be launched on 18th April, with the implementation group to be chaired by Professor Frank Murray and to include IMO representation.
Referendum on Article 40.3.3
Before I conclude, I would like to take the opportunity to refer briefly to the forthcoming referendum – not the substance of the issue, but a word on process.
I don’t think I can say enough that any future legislation to regulate termination of pregnancy is hypothetical at this point – it would only be considered in the event of the proposed referendum on Article 40.3.3 being passed by the People.
I wish to emphasise here that, in such circumstances, the Department of Health would of course consult with representative bodies of all relevant medical practitioners on the details of the legislative proposals, as is usually the case in developing legislation. Let there be no doubt or misunderstanding about that.
Concluding Remarks
I came here this evening to ask for your help and to offer you my support, to acknowledge the very difficult years you have been through and to outline how I believe we can work together to reach higher terrain. I believe we have the potential to be an effective combination of professional and political leadership to realise a once in a generation opportunity for our health service.
I thank you for giving me your attention this evening. I appreciate your commitment on behalf of the patients you care for on a daily basis. I am committed to providing the framework and resources to ensure that as we move forward the health services will have the capacity to deliver better care to the Irish people.
Together we can build a better health service. We know what we need to do. Let’s get on and do it.
Enjoy the evening.