There comes a time in the tenure of most Ministers for Health when the ambitious reform plans with which they usually start off in office have to overcome difficult economic or political realities if they are ever to be implemented.
Mary Harney’s plans to co-locate private hospitals on the grounds of public facilities came a cropper in the face of the great recession.
James Reilly’s aim to put in place a radically different health system based on universal health insurance collapsed in the teeth of opposition from within his own government, notably the Department of Public Expenditure.
By this time next year it should be possible to make a reasonable estimate about the prospects for Sláintecare, the latest blueprint for healthcare reform.
Sláintecare enjoys the benefit of having general cross-party support in the Oireachtas. However, shifting the focus from hospitals to primary care and divorcing private practice from the operation of public hospitals will be challenging. Already there has been criticism from politicians about a slow pace of progress, and from some doctors about the overall direction of travel envisaged.
By next year it should also be apparent the extent to which the Government is prepared to tackle the capacity issues – both in terms of beds and key personnel – which most observers agree is a root cause of many of the problems in the system.
Minister for Health Simon Harris is firmly of the view that there are insufficient beds in the Irish health system. He says he is "puzzled" as to why beds were cut from the system even during the boom years when there was no economic necessity to do so.
He says that even if the health system is reformed, and a proposed shift to primary care does take place, more beds will still be needed.
The Minister says a new bed-capacity review which is under way will look at requirements out to 2031, based on assumptions of a 12 per cent growth in population overall and, particularly, a surge in the number over 65 and over 85 years.
Pent up demand
He says while there are obvious pent up demands for additional critical care and intensive care facilities, the new review will not just look at the needs of acute hospitals but also those in the community.
He declines to predict the exact numbers involved, but says “you can take it with a degree of certainty that it is going to require thousands of more beds” across the acute and community sectors.
Harris also says it would be "silly and ludicrous" to suggest that there were not recruitment and retention difficulties in relation to frontline medical and nursing posts in the health service. He says the Public Service Pay Commission will examine these issues in the months ahead.
However, he says this is not just an Irish phenomenon. "The World Health Organisation estimates there will be a shortfall of about 18 million in the terms of healthcare professionals in the coming years."
He says while he accepts absolutely that there is a recruitment/retention challenge, he argues the number of nurses, GPs and consultants is continuing to increase.
“The numbers are going up rather than down, but so is the population, the complexity of illness and the demographics. The real challenge is that owing to demographics more people are going to need healthcare, and that means more staff.”
The Minster says he is concerned at revelations that more than 80 doctors employed as consultants in public hospitals do not have specific specialist qualifications and are not on the specialist register of the Medical Council. Organisations such as the Irish Hospital Consultants' Association contend that such practices pose risks for patients.
Harris says he has been assured that the HSE is taking steps to address this issue.
“People are trying to run the health service as best they can with recruitment challenges, but patient safety has to come first. It is a reality in this country that some vacancies have been filled by people not on the specialist register and that does concern me, but the HSE assures me that they are taking measures .”
However, he says patients should be told by the HSE or hospitals in cases where a consultant in charge of their care is not on the specialist register.
The Minister is still hopeful that progress can be made in 2018 to extend free GP care to more children, but hints there could be some restrictions to such arrangements whether that be co-payments by parents or limits to the number of visits.
Contract reforms
In parallel with talks on contract reforms with GPs, there will be negotiations on rolling back cuts imposed under financial emergency legislation over recent years – a major issue for doctors.
He says while he wanted to broaden the conversation with GPs to issues they wished to raise, including chronic disease management, practice sustainability, practice nurses and medicine monitoring programmes, he is unapologetic for highlighting the Government’s view that it costs too much for children to go to the family doctor.
“Let no one be under any illusion – in broadening the conversation with GPs the Government’s view is that €55 or €60 to bring your child to see the doctor is too expensive.”
He says he received criticism for stating publicly that there are parents who go to bed at night worrying about finding the €55 or €60 to bring their child to the doctor, let alone two or three children. However, he says he believes this to be the case.
He says he has heard GPs asking should “free” GP care be completely without cost or should there be a co-payment or a cap on visits .
“In a negotiations you have to be willing to negotiate. I am not negotiating on the principle. It is my absolute view that GP care for children in this country is too expensive, and should be made more affordable. I am willing to engage and negotiate on it on how you go about it.”
An outlier
He is a strong supporter of Sláintecare, and fully supports its proposals to separate public and private medicine in State-owned hospitals. He describes the Irish system as an outlier across Europe.
“It is not a normal way of running a health service. It is not right that someone can walk into a public health service where all the fixtures and fittings and most of the things in it are paid for by the taxpayer, and yet you can jump the queue if you are lucky enough to be able to afford.”
He says he has appointed an expert group to advise on how this separation can be brought about.
He acknowledges, however, that such a divorce of public and private medicine will involve a new contract with consultants which will involve addressing pay.
“It is going to require remunerating our consultants appropriately if they are going to be working exclusively in the public sector.”
However, he says while he is talking about de-coupling public and private medicine in public hospitals, he is not ruling out allowing senior doctors to see fee-paying patients in private facilities.
