Shifting care out of hospitals and into the primary care, community setting is at the heart of a plan to radically transform Irish healthcare.
A key measure is the introduction of a Cárta Sláinte within five years that will entitle holders to access a comprehensive range of GP and hospital services based on need, at no or reduced cost.
The report on the future of healthcare, published yesterday, outlines a new model of healthcare with cross-party support requiring an additional €2.86bn over 10 years, with the expansion of entitlements phased in over the period.
Legislation will be introduced giving people a clear entitlement to care, rather than the current eligibility system.
The chairwoman of the Oireachtas committee on the future of healthcare, Roisín Shortall, said the Sláinte Care report represents a new vision for the future of healthcare and she pointed out that it features “a very careful and conservative approach” to the cost. They have not factored in the savings that would be made.
“We hope that today will prove to be a historic day because we hope that from today on, health and issues in health will cease to be a political football,” she said.
The committee was set up last year to get cross-party political agreement on health service reforms. It heard evidence from experts, medics and patient groups over the past year.
An expansion of capacity in primary care and social care includes investment in community diagnostics, primary care teams and mental health teams, services for people with disabilities, home care services and free GP care.
Over time, everyone will have an entitlement to a comprehensive range of primary, acute and social care services at no cost or reduced cost.
Shifting care out of hospitals and into the primary and community setting will in turn help address the challenge of access to the hospital system.
However, other measures are needed — including waiting-time guarantees for hospital care, expanded hospital capacity and the phased eliminating of private care in public hospitals.
Public hospitals earn around €650m in income each year from private insurers, so this income will have to be replaced.
The report acknowledges that removing private care from public hospitals will be “complex” and recommends an independent impact analysis be conducted to identify any adverse and unintended consequences.
There will be waiting time guarantees of 12 weeks for an inpatient procedure; 10 weeks for an outpatient appointment and 10 days for a diagnostic test.
Ms Shortall said they want to move to a situation where everybody will have an opportunity to avail of high-quality, timely health services, irrespective of ability to pay.
Labour spokesman on health and a member of the committee, Alan Kelly, said steps should be taken immediately to implement the report: “The Government should immediately commit to providing the €3bn transition fund so that the plan can meet its ambitious objectives to transform our health system.”
He said it is a genuine attempt to provide a path forward and suggested that the expected €3bn proceeds from the sale of the State’s 25% shareholding in AIB could be used to implement it.
Under the plan, a national health fund would be established that would include a mixture of general taxation and specifically earmarked funds to be decided by the government of the day.
- Under the committee’s plan there would be investment in hospital infrastructure and staffing in order to enhance capacity.
- “The outcome of the Capacity Review currently under way should inform the detailed planning for the infrastructural investment provided for in the proposed Transitional Fund, as well as for the staffing required.” It also sets treatment targets, stating: “No-one should wait more than 12 weeks for an inpatient procedure; 10 weeks for an outpatient appointment; and ten days for a diagnostic test. Hospitals that breach guarantees are held accountable, through a range of effective measures including, ultimately, sanctions on senior staff, but not to the detriment of healthcare delivery.”
- Providing timely access to public hospital care would be achieved by measures including the expansion of public hospital care, costing €649m from years two to six of the plan with an increase in the numbers of public hospital consultants costing €119m between years four and 10. Renovation and hospital bed capacity would cost €1.23bn.
- In acute hospitals, “the provision of private care by consultants in public hospitals will be eliminated over five years. This will mean that all patients will be treated on the same public basis in public hospitals, ensuring equity of access for all based on need rather than ability to pay”.
- It would also see the removal of inpatient charges for public hospital care. People without medical cards and those who opt not to have their care covered by private health insurance are charged €80 per night for public hospital care, capped at €800 per year.
- Under an expansion of primary care, community diagnostics would grow and treatment would be moved from the acute sector to the community sector.
- It would also affect counselling in primary care, with plans to extend counselling provided by private providers through GP/primary care referral at a cost of the order of €6.6m over three years. According to the report: “Ensure significant expansion of diagnostic services outside of hospitals to enable timely access for GPs to diagnostic tests. Primary care centres should be the hub of community diagnostic services so that all patients can access diagnostics in these centres.” It also argues that where certain conditions are “effectively managed by primary care teams and patients themselves are empowered, exacerbations or hospitalisations can be minimised”.
- It would also develop public psychology services in primary care at a cost of the order of €5m over two years to get the service up and running. This would fund 114 assistant psychologists, 20 child psychologists and allow for the development of a cognitive behavioural therapy online resource.
- Universal GP care would cost €455m over five years aligned with universal primary care to cost €265.6m over first five years of the plan.
- The proposals on integrated care are based primarily around policy changes led by “a strong, government-wide commitment to promoting health, reducing health status inequalities and supporting good health throughout the life course”.
- The report recommends that care should be delivered at the lowest level of complexity as is safe, efficient and good for patients, assisted by the significant expansion of diagnostic services outside of hospitals that would “enable timely access for GPs and other referring clinicians to diagnostic tests which do not necessarily need to be provided in hospitals”.
- According to the report, a new model of integrated care would also require the disentanglement of public and private care and the phased elimination of private care from public hospitals. “This will require a range of measures including, addressing the replacement of private income currently received by public hospitals, and careful workforce planning and strategies to recruit and retain staff.” The committee recommends an independent impact analysis of the separation of private practice from the public system with a view to identifying any adverse and unintended consequences that may arise.
- It also aims to address long waiting times, poor conditions and delayed access to essential diagnosis and treatment in emergency departments and to address long waiting list for access to elective care.
- Under the proposals a new health card called a Cárta Sláinte would ensure access to all publicly funded health and social care services including GPs, public health nurses, primary care, addiction services, diagnostics, hospital care, home care, long-term care and palliative care. It would also mean access to public health/population health services, mental health services, maternity care, services for people with disabilities, access to medication, aids and appliances, as well as dental, eye and ear services. Under the plan the Cárta Sláinte would be introduced to the whole population over a five-year period.
- According to the report, the card would entitle all those ordinarily resident to access care based on need.
- The report says the phasing-in of the card would be dependent on funding and having the staffing capacity to deliver universal care, with costings are projected at an additional €380m-€465m per year to deliver universal healthcare annually for the first six years, after which additional costs would decline.
- According to the report: “People will be incentivised to access care in primary and social care settings as their Cárta Sláinte will ensure access in these settings either free of charge or at a low cost.” It adds: “In order to guarantee access to care and not a place on a waiting list, those entitled to universal health and social care will be guaranteed access within a set period of time.”
Funding all the proposed changes to the health system is no small undertaking and the report believes it should be spearheaded by the setting up of a National Health Fund.
- According to the report: “The single-tier system will be funded through a combination of general taxation revenues and earmarking of some taxes, levies or charges into a single National Health Fund”, to be decided by the government of the day.
- It would feature guaranteed expansion of health funding by between €380-€465m per year, for expanded entitlements and capacity to delivery universal healthcare. It recommends implementation of transitional and legacy funding arrangements to a total of €3bn over six years, to boost reinvestment into one-off system changing measures, training capacity and capital expenditure.
- It also wants to earmark/ringfence funds to healthcare priorities, such as expanded primary and social care, palliative care, and mental health, and to ringfence savings that will arise from reduced tax-relief costs as people move from Private Health Insurance to avail of improved public health provision and allocate these to expansion of entitlement and transitional funding.
- It says: “For change to happen investment is needed. Significant change cannot be squeezed out of resources already allocated to already stretched regular health care activities and services.”
- It also argues that “with these costs being funded centrally, individual households will incur less direct expenditure. When the strategy is fully implemented (year 10), households overall will be paying an estimated €1.482bn less in direct personal health expenditure or between €285 and €294 per person.”
The plan proposes removing a raft of existing charges:
- Reduce prescription charge for medical card holders from €2.50 to €1.50, to 50c. “Budget 2010 introduced a prescription charge for medical card holders of 50 cent, capped at €10 per family per month. This was increased to €1.50 in January 2013 (capped at €20 per family per month) and €2.50 in December 2013 (capped at €25 per family per month). From 1 March 2017, the prescription charge for medical card holders over the age of 70 was reduced to €2 per item and the monthly maximum will be €20. These payments cause financial hardship to people on low income and can deter necessary use.”
- Reduce the drug payments scheme threshold from €144 per month to €120 and €100 at a cost of €75m in year three and €184.9m in year six (€259.9m in total).
- Halve the drugs payment scheme threshold for single-headed households in year one to €72 per month.
- Removal of emergency department charge in year eight.
- It recommends the hiring of up to 900 more general nurses to work in the community, thereby freeing up public health nurses to carry out child health work as part of the current nurture-infant health and wellbeing programme and the HSE’s National Healthy Childhood Programme.
- It also proposes universal palliative care, universal home care, adequately-staffed child and adolescent mental health teams, adequately-staffed adult mental health teams and more staff in old-age psychiatry mental health teams.