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Public consensus needed on investment

06 Dec 2016

Gary Culliton reports from the latest Oireachtas Committee on the Future of Healthcare meeting, which saw HSE Director General Tony O’Brien spell out his vision of the future of the Irish health service, which was in dire need of long-term investment

There is a need to build a general public consensus concerning the maximum appropriate and feasible investment in health and social care for the next 15-to-20 years, the HSE Director General (DG) has suggested.

“In other words, how much is the taxpayer willing to hand over for the health service it wants?” Tony O’Brien elaborated, at last week’s (November 30) meeting of the Oireachtas Committee on the Future of Healthcare.

To achieve a “decisive” shift away from the acute hospital setting to primary care and social care, a very significant additional resource would be required. However, such a resource — based on how the health service was currently funded — would take time to develop.

“To overcome this, a considerable rethink is needed of some of our existing policies, particularly in relation to how we can sustainably fund the type of supports that we need as we grow older (whether that be long-term care, home care packages, home help hours, aids and appliances). It will also require a rethink of our capital funding investment. A change to multi-annual service planning and budgeting would also assist in supporting longer-term planning for the demands on our resources,” he told TDs.

He stressed that the “change cycle” in health was longer than 12 months. “An annual budget/service plan cycle hampers rather than facilitates improvement and reform. Instead, we need a capacity to plan that allows and supports longer-term decision-making, and which promotes an environment of strategic thought based on evidence.”

The Nursing Home Support Scheme, or Fair Deal, gave a good degree of assurance for the older population around their long-term care, O’Brien added. “Why we do not have such a scheme or level of assurance for the elderly around care that is not long-term? One of the policy issues should be considered as we examine the future of healthcare is whether we are going to put in place a ‘demand-led’ funded environment that guarantees the supports for people moving on from the acute phase of their care to live their lives where they would wish to — which by and large is in their own homes,” he told the Oireachtas Committee. “Such a scheme would allow the likes of expensive home care packages to be funded into the future. We need to reach a settled view on that, otherwise our system will become increasingly unsustainable.”

He explained how the HSE’s Programme for Health Services Improvement had 12 major programmes currently under way, which constituted in the order of 500 sub-programmes. For the most part, these were patient-centred projects that would happen over three-to-five years and were designed to enhance service delivery to patients and service-users.

At the meeting, O’Brien cited a major American health service reform called the Delivery System Reform Incentive Payment programme (DSRIP) in the State of New York. The aim of DSRIP was to significantly improve the way Medicaid beneficiaries receives their healthcare in order to reduce that cost, and deal with the issue of chronic disease through integration and the avoidance of hospitals. Over the five-year implementation period, the authorities hope to cut costs by US$17 billion (€15.9bn). “They recognise that in order to make that saving they have first to invest,” said the DG.

In his view, an overstretched system could not easily move resources from one part of its service to another in order to effect that change. “We know we have to move resources out of the acute sector and into primary care, but if we were simply to do that now, we would probably collapse our system overall.”

In the State of New York, part of that saving was invested upfront, against a “very clear roadmap and very clear deliverables”. Thus service providers in New York State had been given US$8.5 billion (€8bn) over five years to fund the cost of transformation. DSRIP would promote community-level collaborations and focus on system reform, specifically a goal to achieve a 25 per cent reduction in avoidable hospital use over five years, O’Brien explained. “All DSRIP funds will be based on performance linked to achievement of project milestones — paying for value.”

In the UK, the King’s Fund reached similar conclusions about what was necessary to effect transformation in the NHS, he added, and a recently published expert panel report in Northern Ireland titled ‘Systems not Structures’ had recommended a ring-fenced transformation fund.

“If ongoing and future transformation is not funded in this jurisdiction, particularly in an overstretched and growing healthcare economy, you will not achieve the transformation you expect or desire. It’s as simple as that,” said the Director General.

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