There are a lot of good ideas in the Sláinte Care report, published yesterday, less than a year after the committee on the future of healthcare started that thankless job.
Trouble is, a lot of the ideas are well worn — Fine Gael’s 2011 Programme for Government, and New Direction, the government primary care strategy of 2001.
An almost verbatim version of the vision for a universal single-tier health and social care system — where everyone has equitable access to services based on need and not ability to pay — is contained in the 2011 programme. And although it remains no less worthy now than what it was then, the only notable achievement in the interim has been the extension of free GP care to under sixes and over 70s — and that took years.
Likewise, Sláinte Care’s proposals vis-à-vis primary care tie in with Micheál Martin’s vision for same in 2001. Had that strategy been properly pursued at the time, primary care could by now have the greatly expanded role envisaged in this latest report. Instead, hospitals continue to be packed to the rafters; services easily provided in the community — such as chronic disease management — remain in secondary care and the cost of healthcare delivery continues to soar.
Reasons for slow progress are multifarious but inevitably involve budgetary pressures, a lack of political will and resistance to change among members of the medical profession who have no intention of assuming additional responsibilities or agreeing to changes to work practices without some kind of quid pro quo.
Predictably, doctors’ representative bodies have tempered their welcome for Sláinte Care.
The general gist is “laudable, but impossible to deliver without a significant increase in staffing, capacity and funding”.
They raise a host of issues in relation to the proposal to extend free primary care to all. The Irish College of General Practitioners (ICGP) argues it could create waiting lists to see the family doctor at a time when the GP rate per head of population is approximately 64 per 100,000, about half the rate in Canada.
The Irish Medical Organisation (IMO) says making free GP care universal is not achievable “given current problems of capacity and funding in general practice” and that while the report has “many useful proposals” its credibility was “seriously undermined by a failure to recommend realistic funding”.
The IMO was also critical of the report’s failure to recommend significant increases in bed numbers and to prioritise recruitment of consultants at a time when there are approximately 400 vacant consultant posts.
And it said the proposal to cease providing private care in public hospitals was flawed in the absence of an evidence-backed assessment “of how this measure would increase capacity in our hospitals”. Nor had there been any analysis of how it might impact on the budget of public hospitals — previously predicted to result in a €621m drop in income from insurers — although the report does recommend “an independent impact analysis of the separation of private practice from the public system”.
The Private Hospitals Association (PHA) described this impact study as “a fudge”.
The PHA also makes the point that the public wants action on waiting lists and this will “only happen if politicians take a wide-angle view on the health assets of the state”.
In relation to waiting lists, Sláinte Care proposes waiting time guarantees of 12 weeks for an inpatient procedure, 10 weeks for an outpatient appointment and 10 days for a diagnostic test. It proposes enshrining these waiting times in legislation, with full implementation by 2023. It proposes that hospitals breaching these guarantees be held accountable through a range of measures, including sanctions of senior staff.
If we’ve learned anything in the last few years, it’s that sanctioning anyone for anything in the health system where almost all mistakes are held up as “systemic” is well nigh impossible.
A key question, and perhaps the one the general public will have the most interest in, is how will this free care for all be funded? The committee estimates an investment of €2.8bn is needed over the next 10 years, as well as a “once-off transitional funding” estimated at €3bn. It says developing multi-annual budget cycles will help preserve funding stability. It proposes a single-tier system be funded “through a combination of general taxation revenues (currently 69% of funding comes from general taxation) “and earmarking of some taxes, levies or charges into a single National Health Fund”.
In terms of healthcare delivery, the report recommends that the HSE remain to carry out “national level functions”, while, in a nod to the health board era, it says “regional bodies will be established to ensure timely access to integrated care, with regional health resource allocation”.
There’s a lot in the report to digest. And while it’s clear many of the ideas are not original, it has a clear advantage over its legion of predecessors because of support from a broad political base. That, perhaps, is its greatest strength. It’s in no politician’s interest to pick this one apart. As the Irish Nurses and Midwives Organisation (INMO) points out, the key question now is whether future governments will commit to implementing the recommendations of Sláinte Care over the next 10 years.