A NEW YEAR challenge facing our society is to ensure that, as we shape post-troika Ireland, we guarantee decent and equitable public services in health and social care, writes RÓISÍN SHORTALL
When resources are reduced and choices constrained, those choices we do control become critically important. Reform becomes a must and may also become more doable.
The National Health Service was established in Britain in 1948 after the destruction of the second World War. Roosevelt’s New Deal emerged from the Great Depression of the 1930s. Ireland’s inequitable and chaotic healthcare system is an anomaly in modern Europe. I believe we can achieve its reform even at this time when so little seems within our control. With economic uncertainty threatening every family, the individualism of the boom years is exposed as hollow and the case for social solidarity is compelling. But our health and social care system has individualism at its heart. Access is largely determined by a person’s ability to pay. Most of the population pay fees to visit their family doctor. Those who can manage to pay rapidly increasing private insurance premiums get faster access to treatment, even in public hospitals.
We have lived through a private medicine boom, which was as deluded as our property boom. Both government-sponsored, they were often bizarrely interlinked: property developers have chosen the sites of primary care centres, private hospitals cohabit with hotels. Generating profit has driven up insurance costs. Unplanned private hospitals mushroomed while public hospitals struggled and the most important part of the healthcare system – primary care – was neglected.
Mapping family doctor locations against areas of deprivation shows many blackspots across the country where local care is unavailable. Among the many dedicated GPs, pharmacists and primary care professionals whom I have met since becoming Minister of State, there is a very discernible yearning to get back to healthcare basics.
At a time of cutbacks in public spending, we cannot continue with business as usual in Irish healthcare. Unless there is fundamental reform, there will be substantial cuts in services and the poorest will be hardest hit.
Reform means driving down the cost of care and changing the model of care. It means an aggressive pursuit of savings in the drugs budget with the introduction this year of legislation which reforms our pricing system. This is a priority for me. It means bringing payments for hospital doctors into line with the rest of Europe, so that Ireland can afford consultant-delivered care in public hospitals; and can employ the talented medical graduates who emigrate to countries where they achieve professional satisfaction for much lower remuneration.
Reform means above all changing the model of care so that it is delivered in the best setting by the most appropriate person. Most care should be delivered close to home by primary care professionals such as GPs, practice nurses, public health nurses, occupational therapists and pharmacists.
Development of a modern primary care system, with professionals working in teams, an aim to which governments have paid lip service for a decade, has been impeded by our system of private fee payments for GP services. Private patient fee payments to GPs contribute less than 2 per cent of total health spending. Yet their existence maintains primary care as a free market in which GPs locate their services where there are more high earners who can afford fee payments. Fees incentivise GPs to deliver care personally, even when it would make better sense for care to be delivered by a nurse.
Increasingly, people put off visiting their GP because of cost and often end up requiring more expensive hospital care. The programme for government commits to removing fees for GP care within this Government’s term. The phased ending of GP fees begins this year with the extension of free GP care to people who receive free drugs under the long-term illness scheme for conditions such as epilepsy or diabetes.
Crucially, removal of fees will unlock a key barrier in our health service. It will allow the overdue development of intensive treatment in primary care of chronic conditions such as diabetes, where regular monitoring can prevent life-altering and life-threatening conditions such as blindness, leg amputation or heart attack. This year will see the first phase of the diabetes chronic care programme in primary care, with much care delivered by diabetes clinical nurse specialists. This programme will be extended in coming years throughout the country, along with programmes for other chronic conditions such as heart failure and asthma.
This is fundamental healthcare reform. It makes medical sense and economic sense. Removing financial barriers to accessing GP care; developing team-working so that care is delivered by the appropriate professional at the lowest level of complexity (and cost); and implementing primary care programmes for chronic diseases are overdue reforms that will deliver significant health gains and savings on expensive hospital care.
The primary care reforms will be facilitated by interim structures within the Health Service Executive to make healthcare funding more transparent and its administration more accountable on the path to universal health insurance. For the first time this year there will be a national director for primary care and a ring-fenced primary care fund, which will enable the shift of resources from hospitals to primary care, reversing a bias which left primary care teams with 350 staff vacancies last year.
Social care too must move to this new model in which care is delivered at the lowest level of complexity. The Fair Deal incentivises residential over community care. Reform is needed to ensure that older people needing long-term care are assisted in remaining in their own homes. Resourcing primary care – filling all public health nurse vacancies, for instance – will enhance care in the community for older people and for children.
Although this is a challenging new year on many fronts, I believe it is possible to emerge from this crisis with a reformed health and social care system.
Róisín Shortall is Minister of State at the Department of Health with responsibility for primary care