A visionary plan, but only in theory
Alas, that structure is now almost as widely despised in Ireland as banks — which is not to say that individual health personnel are in the same vilified bracket as bankers.
However, the public perception of the HSE is by now so tarnished, that the Government has decided the best approach is total dismantlement. Hand in hand with this reform is a proposed overhaul of acute hospitals, described by James Reilly, the health minister as “as the most fundamental reform of Irish hospitals in decades”.
Whether or not the latest aspirations amount to a hill of beans remains to be seen, but for now, Dr Reilly is adamant that what is proposed in the report, The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts, will eventually give rise to his long-term objective as per the Programme for Government — the introduction in 2016 of universal health insurance (UHI).
The report published yesterday sets out what is seen as the roadmap to achieving this, beginning with the establishment of hospital groups, on an administrative basis initially, and then, following enactment of legislation, the transition to competing, independent, not-for-profit trusts by 2015.
Once the groups are up and running, they’ll be expected to largely manage their own affairs under a chief executive. As the report outlines, the ultimate aim of the Government through these trusts is to deliver a single-tier health system, supported by UHI.
The system will be underpinned by the principle of social solidarity, with access based on need and not on ability to pay. Under UHI, everybody will be insured for a standard package of curative services. A new insurance fund will subsidise or pay insurance premiums for those who qualify for a subsidy.
All of this sounds fine in theory. In fairness to those who produced the report under the stewardship of Prof John Higgins, chairman of the hospital groups’ strategic board, the work involved was monumental. Scores of meetings took place with various stakeholders — including with 54 groups representing HSE and HSE-funded hospitals; with 21 groups representing the Independent Hospitals Association of Ireland; with 26 groups representing the Association of Voluntary Hospitals CEOs; and six medical schools.
In terms of patient advocacy, just one group was represented, and that was Margaret Murphy, a patient safety advocate with the World Health Organisation. Prof Higgins’s approach is consensus politics and he has a proven track record, having successfully overseen the amalgamation of three maternity hospitals and much of the hospital reconfiguration process in the HSE South.
However the recommendations of his latest report, extending to 49 acute hospitals, represent something more of a challenge for those tasked with changing the health service.
An immediate problem is the state of our primary care services. Dr Reilly, in his policy document Future Health: A Strategic Framework for Reform of the Health Service 2012-2015, said an integrated system of primary and hospital care would be key features under the new system.
It says “the first point of contact for a person needing healthcare will be primary care which should meet 90%-95% of people’s health needs”.
But talk to any GP and they will tell you primary care is yet to come of age and that general practice has suffered from under-investment for years. Any GP will tell you they could be treating far more people in the community, but the resources are simply not there. Added to this is the very slow rate of formation of primary care multi-disciplinary teams (a key reform of the sector) with vacant posts in many, and little linkage between GP IT systems and those in the acute hospitals to facilitate a seamless patient journey.
Similarly, nursing numbers in the community have been decimated by a combination of retirements and the moratorium on staff recruitment, according to reports at last week’s annual delegate conference of the Irish Nurses and Midwives Organisation.
But perhaps the most basic threat to the introduction of UHI is the Government’s failure to agree how to reach even the first step in offering extended free GP care.
Under the Programme for Government, those with long-term illness should have had free GP care by Mar 2012. As I write, junior health minister Alex White is scrabbling for a means in which to do this without hitting a multitude of legislative hurdles. If the first step along the road towards UHI is so complex, how is 2016 a realistic timeframe?
To add to the challenges, a report this week by economist Colm McCarthy, on behalf of health insurer Aviva, says the principle of everyone paying the same for health insurance is under threat because of the number of young people dropping out of the market.
Our market is underpinned by the principle of community rating, where everyone pays the same premium per package, regardless of age.
Although thorough and visionary, this report will have to survive a multitude of pressures — from likely political opposition, to possible challenges to proposals, and, when it comes to UHI, the unpredictable nature of market forces.
Q: Why the need for the groups?
A: The experts say our hospitals are in need of substantial reform if we are to cope with the pressures of an ageing population, increased public expectations, and to address health inequity (disparities that exist between different parts of the country in terms of quality of care available and access to that care). They argue that experience has shown the traditional practice of providing as many services as possible in every hospital — and Ireland has 49 acute hospitals — is neither sustainable nor safe. By grouping the hospitals, reform — supposedly leading in 2016 to the introduction of universal health insurance — should be easier rather than trying to bring about change in isolation.
Q: Why six groups and how was it decided?
A: As few as four and as many as eight groups were considered. Ultimately, the hospital groups’ strategic board recommended a six-group model, building, they say, on established relationships between a number of hospitals and therefore allowing faster implementation. Some critics say the changes aren’t radical enough, especially in the Dublin area, but the report’s authors argue that “building on willing partnerships offers the best promise of effective reform”. The strategic board sought to align hospitals in neighbouring geographical areas into groups that could meet the acute hospital care needs of the population. It combined varying model, size, and speciality hospitals to maximise the range of services available. Each group must have at least one major university teaching hospital, a National Cancer Control Programme (NCCP) centre, and a maternity service. A helipad per group will be considered down the line.
Q: Will the new model affect existing hospital networks?
A: Yes and no. The Midwest was already formed into a hospital group and no change was applied. Similarly, the West has the “Galway/Roscommon Hospital Group” in situ and this has been used as the basis for the formation of the West/North West group. In the South/South West group, advanced reconfiguration of hospital services in the Cork and Kerry region means much of the legwork is done. In Dublin, groups were built around existing alliances with other new alliances formed. Probably the most controversial aspect of the new groupings is that it copperfastens the break-up of the South-East hospital network, the subject of major protest marches.
Q: So what happens to the hospitals in the southeast?
A: Under the new groupings, Wexford General and St Luke’s Hospital, Kilkenny, are aligned with Dublin East. The report says patients of these hospitals are already strong users of services in Dublin. Waterford Regional will be part of the South/South West group. However, cognisant of resistance to change in the region, Waterford looks set to retain its services, including its hard-won specialist cancer care services. It will continue as a hub for South-East regional services and as a regional trauma centre across the groups. Lourdes Orthopaedic Hospital, Kilcreene, currently managed by St Lukes, will be managed from WRH within the new South/South West group structure.
Q: Where to from here?
A: Pending Cabinet approval of the report’s recommendations, each hospital group will be established on an administrative basis for an interim period during which legislation will be enacted allowing the hospitals to move from group status to competing, independent not-for-profit hospital trusts. This is expected to happen by 2015, but not without a rigorous evaluation in 2014 to ensure all groups are meeting benchmarks in progressing greater co-ordinations of services within the groups as they move towards trust status. Revision of group composition will be considered if the evaluation indicates this is needed. Each hospital group will establish an interim group board to which the management team reports. In a hospital group where there are pre-existing voluntary boards with statutory authority, they will be asked to fully support the decisions of the interim board. The chair of the interim group board will be appointed by the minister. The chair will nominate the interim group board membership for ministerial approval. Hospital groups will be led by a group chief executive officer who will be the accounting officer for the group and will be responsible to the interim group board for management of the group. The requirement for individual hospital management teams will be determined by the size of the hospital and the rangeof services provided at each site. The management team of transitional hospital groups must comprise at least the following key posts: Chief executive officer, chief clinical director, chief academic officer, chief director of nursing, chief finance officer, and chief operations officer.
Q: Are any exceptions made for more remote populations in terms of services available to them within hospital groups?
A: It’s recommended Kerry, Letterkenny, and Wexford General Hospitals, because of their locations, should retain their full range of emergency department, medical, surgical, maternity, and paediatric services.
Catherine Shanahan
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