Ladies and Gentlemen,
One of the things I’ve found fascinating and helpful, since I became Minister, is the free advice.
Any of us in medicine know that if we’re at a party, and if people hear we’re a nurse or a doctor, sooner or later, they’re going to ask for free medical advice. Not for themselves, of course. They just have this “very good friend who’s having a bit of a problem…”
One of the things that has surprised me, since I became Minister, is that – for Ministers – it works the other way around.
People give you free advice.
Well, they’ve been giving me lots of advice over the past few weeks.
Advice like “Don’t choke yourself when there’s a camera around.”
Advice like “Always expect the worst, in the Department of Health.”
Oh, and that key bit of advice: “Never fight with the nurses.”
As if I would…
When you’ve worked in hospitals and as a GP, when you’ve worked in Ireland and overseas, with every passing year you get a better appreciation of the importance of the work of nurses.
Some of the best lessons I was ever taught came, not from lecturers, but from nurses who bluntly said either “You’re doing that wrong…” or, if they had the time to be more gentle about it, would say “Let me show you a more effective way…”
If there’s one thing I learned early in healthcare and had reinforced down the years, it was that you listen to nurses.
You listen to nurses.
When a solicitor listened to two nurses, it led to the uncovering of one of the biggest medical scandals in recent years – the Neary tragedy. But that’s an example of late-on listening. Because I’m trying to radically improve the health service – for patients and for the professionals who work within it – I have been listening and I will continue to listen to you, as a professional group and as individuals.
The reality is that without your insight, experience, expertise and commitment, the health service wouldn’t have got as far as it has got, and without that insight, experience, expertise and commitment, the changes we so desperately need simply won’t happen.
Because of your numbers and because you serve within so many areas within the Health service,
From Intensive Care to Community Care,
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From Midwifery to Mental Health,
Yours is the catalyst profession. You have it within your power to spark the changes we need and lead towards the new model of healthcare we so obviously need.
That model of healthcare says services should be delivered at the most appropriate level and setting. Where possible thorough primary care, community care and smaller hospitals. As close as possible to where people live.
That requires us to turn the system around from a view of the acute hospital as the first stop to a view of the acute hospital as a largely preventable last stop.
It may be the right way to go, but it’s fraught with challenges.
The most obvious challenge is, of course, our economic situation.
By nature, I’m an optimist, and by conviction, I’m positive.
So I hate the fact that I simply can’t offer any immediate “get out of jail” card on the economy.
But I can’t.
Nor can Michael Noonan.
We are where we are (please excuse the cliché) and where we are is not a place any of us would want to be.
Particularly those of us committed to healthcare.
And then, of course, we’ve the other challenges.
An ageing population. The Greying of Ireland.
Unhealthy lifestyles.
Those two, added together, mean we have a steadily increasing level of chronic diseases in this country.
First of all, the number of people over 65 is projected to increase from over 500,000 now to over 1,300,000 in the next 30 years. And the greatest proportional increases will be in 85+ age group. By 2021, three out of every ten people over 65 years of age are going to be living alone.
As a result of all of those factors coming together, the demand on the health service is going to increase by 60% by 2020 in the next nine years. Sixty percent. Not a happy figure. While I’m at it, let me give you another 60%. 60% of the disease burden is accounted for by seven risk factors:
High blood pressure
Tobacco
Alcohol
High cholesterol
Obesity and being overweight
Poor diet
Physical inactivity
That 60% wouldn’t be so bad if it was static or decreasing, but it isn’t.
If you look at the Obesity issue, for example, 36% of adults are overweight and 15% are obese. And the trend is getting worse.
If we look at smoking, recent EU data shows that Ireland is one of the few countries in the EU with a rising prevalence of smoking.
We know that roughly 80% of cardiovascular disease and Type 2 diabetes as well as 40% of cancer could be avoided if major risk factors – like obesity, smoking and alcohol misuse were eliminated.
But we also know that, anecdotally at least, in a downturn, people “pop more pills, drink more beer and eat more junk.”
Nurses know, better than anybody else, the see-saw of priorities on this one: we must try to prevent these seven risk factors on the one hand, and cope with the chronic diseases they cause and complicate on the other.
And we must – at one and the same time – meet the challenge posed by a health service that is either fair nor efficient.
By the way, I don’t mean it’s unfair and inefficient for patients. It’s just as unfair and inefficient for the people working inside the health service.
I hold strongly to the principle that,
When people feel valued by a system,
when their normal contribution is registered and their above-and-beyond contribution is noticed,
when they take pride in their place of work, then they produce the very best that they can.
In setting out to reform Ireland’s healthcare system, a constant theme must be ensuring that every aspect of that system is a magnet employer of professionals who wake up in the morning glad to be going to work.
I think that’s worth a big, long term effort and I’m pretty sure you do, too.
The primary goal is to radically reform the health system so as to guarantee equal access to healthcare for everyone in our country. This can be achieved only through a single-tier system. Access must be based on need. Not on ability to pay.
The Core commitment within the Programme for Government is to introduce Universal Health Insurance for the whole population of Ireland.
One of the key strands of the Reform process involves enhancing our capacity in the primary care sector to deliver universal primary care with the removal of cost as a barrier to access for patients.
This policy, supported by the appointment of Minister Shortall with special responsibility for Primary Care, will be phased in while at the same time, we’re reforming the acute hospital sector.
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The Special Delivery Unit will tackle the issue of waiting times and waiting lists.
I’m sure you’ve heard of our "Money Follows the Patient" funding system for hospitals. It’s quite simply a more efficient financing mechanism than the current block grant funding allocations.
We will also introduce a purchaser/provider split in the hospital sector by establishing hospitals as independent not for profit trusts.
Now, a quick word about A&E.
Waiting times for patients attending Emergency Departments in many hospitals during last winter and in particular the first week of January of this year were unacceptable.
If they were unacceptable for patients, then they also presented a real problem for the committed professionals who dealt with those patients.
I’m determined that this should not happen again.
I am, however, clear that difficulties in Emergency Departments cannot be resolved solely within the EDs themselves and must, as you appreciate, be addressed on the basis of a hospital-wide and health-system wide approach.
Primary care can safely deal with a lot of the types of case that present at hospitals EDs – and there’s a significant difference in approach between urban and rural GPs in this regard. We need to look at that.
There has been an ongoing difference of opinion on the measurement of trolleys between the INMO and HSE. It is clearly not helpful to be arguing about how we measure trolleys when our focus should be on how to significantly reduce the trolleys. I have made a commitment to be open and transparent about how we manage the health service.
With this in mind I have had discussions with the HSE and in particular the emergency medicine programme and we are of the view that the basis on
which the INMO has been producing the figures is the one we should use from now on. However it should be noted that international and national expert opinion on this matter is firmly of the view that we need to move as quickly as possibly to the 6 hour target meaning patients are either in a bed on a ward or appropriately discharged within 6 hours. With this in mind the trolley number count will now be published by the HSE based on the methodology currently being used in each hospital to collect the INMO data. This will be validated by Nurse Mangers in Emergency Departments and bed managers within each hospital. Furthermore the six hour target will become the primary measure for admission delays.
I’ve indicated to the HSE that we must have a clear plan of action to address the problems in Emergency Departments – not just for the coming year but for the long term.
In order to make sure that happens, I intend to establish a Special Delivery Unit to tackle the problem of waiting lists and difficulties in Emergency Departments.
Intensive work is now underway to allow the Unit's establishment as soon as possible.
Now, no matter what the challenges, along with all of these plans, we must built a culture of patient safety – and the nursing and midwifery professions have a central contribution to make to this.
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The Government is committed to the establishment of a Patient Safety Authority to incorporate HIQA.
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I want to have an Authority which provides a robust and effective patient safety and quality system in a streamlined and cost-effective manner. My Department is currently preparing a detailed policy proposal in this regard, having regard to international good practice and consultation with major stakeholders.
I’ve referred a number of times to how essential it is that the patient can have access to an extensive range of services in their own community. Right now, more than 1,700 nurses work in the Primary Care Teams already developed. These teams will allow many patients have their necessary treatment close to home and will help to reduce unnecessary acute hospital admissions – and inappropriate reliance on hospital OPD services.
In addition, this primary care model will create an environment allowing:
A structured approach to chronic disease management
Enhanced multidisciplinary team working
Improved diagnostic capabilities in Primary Care
and
Integration of services between primary and secondary care.
Patients will benefit, but those caring for them will also have a much fuller picture of what’s going on, when a range of health care professionals work together in the same building.
The fact is that – whether you work in primary care or as a midwife, whether you’re a clinical nurse or a nurse practitioner, your role is going to expand in the next few years, and I hope in a way that enhances nursing as a dynamic and fulfilling profession.
Earlier this week I launched the Strategic Framework for Role Expansion of Nurses and Midwives: Promoting Quality Patient Care.
The foundation for the role expansion it addresses lies in the achievements of the last 10 years in Irish nursing and midwifery.
The framework document sets nursing and midwifery role expansion in line with service needs and national policy direction
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Nurses have taken on expanded roles in relation to comprehensive physical and psychosocial assessments, prescribing of medications and ionising radiation, caseload management, nurse and midwife-led clinics and nurse-led admission and discharge practice.
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Nurses, similarly, play a most impressive lead role in the Community Intervention Teams.
We have, in effect, a series of pilots that demonstrate just how capable are nurses when given wider opportunities, and just how improved the resultant service to patients is.
When I talk of pilots, for example, I mean examples like the model of Community Oncology Services developed in Donegal which has resulted in an integrated care pathway and person centred care, spanning hospital and community settings for oncology patients in Donegal.
We need to see these innovative approaches adopted as the standard models of care delivery where this is appropriate to people’s needs.
Or, to put it another way, we need to catch ourselves doing things right – and spread the word and the methodology.
Part of that is the HSE’s Quality and Clinical Care Directorate which is trying to find ways to improve patient care, address waiting lists and save money.
They’re using a multidisciplinary approach. So nurses are involved with their medical and allied health professional colleagues in defining the most appropriate models of care and service organisation. Nurses and midwives will be vital to the successful implementation of the programmes.
At the same time, the HSE clinical programme for Obstetrics and Gynaecology is working to develop and implement a maternity and gynaecology programme that will provide for the most appropriate and sustainable models of care. They’re doing so, keeping in mind the preferences of patients – who want early release and local services.
I would like to acknowledge the central role being played by nurses and the Irish Association of Directors of nursing and Midwifery in clinical programmes.
I want to make a couple of very brief comments about human resource issues.
First of all, I very much welcome the engagement through the Labour Relations Commissions between the unions and the HSE on issues linked to the use of agency staff.�
Secondly, the INMO has raised with me the November 2010 Labour Court recommendation that the Government reconsider the application of the moratorium to Senior Staff Nurse Posts. I can assure you the views expressed by the Labour Court are receiving careful consideration and I hope that it will be possible to resolve this issue in a satisfactory way.
Thirdly, the Government is committed to undertaking a review of the decision to abolish pay for student nurses.
I’m told there was a misunderstanding on the part of the INMO about whether this review had my authority. It very definitely does. We’ve invited the INMO to contribute to this process and I hope the INMO will.
My Department is also initiating a broader review of the degree programme itself, including possible changes to the clinical placement arrangements, curriculum content and five specialised points of entry.
Ten years after the degree programme started, now’s the right time to do a comprehensive review, because we must ensure nurse training matches developments of the service delivery model and future workforce needs.
I mentioned at the beginning that I’ve been given a lot of advice – some of it welcome, some of it less welcome – since I took on this new job.
The unwelcome advice was all about abandonment of possibility: “You’ll have to long-finger this or that because there’s no money.”
I don’t accept that advice. We can’t postpone life or careers or improvements in how we deal with sick people. We have to find a way. Ideally a way that doesn’t start with money - simply increasing the funding or staffing levels does not necessarily lead to better services or improved outcomes. We know that from experience. One of the things we can do is redeploy.
The Employment Control Framework for the Health sector is designed to reduce numbers of management, administrative and non-frontline staff and to redeploy staff, where appropriate, to the Primary and Community settings.
Whenever committed people within a profession are faced with an unprecedented challenge – as we all now face in re-shaping healthcare in incredibly difficult times – they find ways around apparently insuperable problems.
Nurses and midwives want a strong leadership role in the process of radical change.
Nurses and midwives should be centre stage in re-shaping the health service for the better – because they have insight and experience in every key area – and ideas to match. I hope I can create a context in which you can use that expertise and those ideas to help us radically improve our health. A health service in which patients feel safe and in which we are all proud to work.
Thank you.