Opening Address at ESRI Policy Conference 24 September 2019 by Jim Breslin, Secretary General, Department of Health

Check against delivery

Good morning.

It’s a great pleasure for me to welcome the research undertaken by the ESRI and funded by the Health Research Board which is being presented at today’s conference. This is really excellent, timely and policy relevant research.

I agree with Alan on the transformation in health research at the ESRI and the crucial role this research is playing in health decision making.

I say timely because there is immediate opportunity to use this research to inform the implementation of health policy and specifically Sláintecare reforms. Key features of those reforms include:

• a shift in favour of home care and community care and away from unnecessary admissions or stays in hospitals or other healthcare facilities
• a move to six integrated Regional Health Areas
• a commitment to the development of data infrastructure and research to inform policy development, needs assessment, health planning and resource allocation.

The research we are discussing today has something very valuable to say in each of these areas.

The finding that an expansion in the supply of home care can contribute to shorter acute hospital stays goes to the heart of the shift we are seeking to bring about towards a more sustainable model of care. We are not unique in this. Almost all developed healthcare systems are seeking to promote a more anticipatory and ambulatory model of care that supports people – particularly those at risk of chronic disease - to achieve healthier and more independent lives.

To take one example, the US healthcare system has long prided itself on specialist, highly interventionist and hospital based management of acute illness. But Mount Sinai Hospital in New York today advertises its commitment to community based population health management, rather than traditional fee for service hospital medicine, with the slogan:

The Sláintecare programme includes a range of measures to bring about this shift in our own model of care - from the new agreement with GPs for roll out chronic disease management under the GMS from next year to the development of a statutory home care scheme.

Turning to the six new integrated Regional Health Areas it would be a mistake to see the government's recent decision as primarily about structural change. Instead the fundamental driver is the imperative to have clear and defined regional geographies that facilitate:

• population-based needs assessment
• detailed demand and supply analysis at a regional level
• integrated care planning centred on the needs of the patient or service user
• the development of a resource allocation framework that will - for the first time - be based on population needs

The research we will discuss this morning clearly demonstrates how currently healthcare supply is not allocated according to population need. Rather it is a product of legacy decisions, provider influence and a failure to align resources with population change and ageing.

Those of us who have been around this debate long enough risk veering into anecdote, even in an august research setting such as this.

I recall the honesty of a former health board CEO who told me how he introduced an impressive range of community services by continually exceeding the employment creation targets which public bodies were given by Government in the late 1970s. Public sector employment creation targets seem like an age ago now, but the research we are discussing today shows that particular geographic area to have sustained its head start up to the present day.

I also recall in the early 2000s researching what looked at first sight to be an imbalance between the East and the rest of the country in acute hospital services. However, adjusted for patient flows the position was reversed and patients in the East actually had poorer access and longer waiting times for routine secondary care.

This was not the only issue of equity at play. The Department of Health had up until 2000 funded the major voluntary hospitals in Dublin directly. There was little or no relationship between these hospitals and the major statutory health body in the region. The Eastern Health Board was one of eight nationally but its population was far in excess of all others and growing rapidly. The inequity of its resourcing was obscured by the fact that, to a much greater degree that other health boards, it was not responsible for some of the largest healthcare providers in its region.

So simultaneously there existed a widespread and increasingly outdated view that Dublin was advantaged in relation to hospital services while the resourcing of community services in the East was at a growing disadvantage compared to the East’s share of the national population.

These are some of the historical factors that continue to influence the position emerging from even the most recent research.

To bring my diversion into history more up to date it is arguable that the creation of the HSE has had a less profound influence on geographic equity in resource allocation and shifting the balance in service provision than might have been expected. It is worth exploring this as it illustrates, I think, that achieving such change requires more than technical know-how, even if such expertise and the availability of the necessary data are certainly prerequisites.

The choice to construct the HSE based upon the national pillars of acute and primary, community and continuing care, rather than regional delivery systems, may have contributed.

In fairness there are some examples within the HSE of the use of population based resource allocation in particular care areas – notably in mental health in respect of the allocation of development funds.

But it is also the case that the HSE not long after its establishment had to cope with the severe retrenchment in budgets heralded by the financial crisis. This would have made the task of rebalancing, had it been embraced, one requiring the redistribution of falling budgets – a task not for the faint hearted.

As you will recognise I’m not much of a historian, but there is some comfort in playing the role as it is much easier to critique the past than it is to successfully direct the future. So let me look forward.

We can predict that this future will be one of major population growth and ageing. At the same time the National Planning Framework seeks to provide a counter weight to the concentration of such growth in Dublin and Leinster counties. So joining population based needs assessment to resource allocation between and within the six regions will be essential in this evolving situation.

Furthermore the ESRI’s own demographic projections indicate that one in every six people will be aged 80 years and older by 2030 - an increase of approximately 90% on today.

We will simply not be equipped to manage this demand without a shift in our model of care and our resourcing, including towards better chronic disease management and homecare.

In committing to implement Sláintecare this is what all of the major political parties, the government, the department, the HSE and many stakeholders have committed to do.

If the broad findings of the ESRI’s research are not unexpected, they do contribute to a much richer evidence base upon which to both plot and evaluate the required shift in care and the associated implementation arrangements which are set out at a high level in Sláintecare.

But as we know, an evidence base – however powerful - is not sufficient. Nor indeed are words in a strategy document. History teaches us that less reliable than the evidence or the printed word is our readiness to acknowledge and undertake the profound change required to our established and sometimes ad hoc way of doing things.

The way we do things as politicians, civil servants, health service leaders, clinicians, patients, carers and citizens.

There are issues in how we have approached health care as a country – including, but not limited to, the use of resources - which we can no longer avoid. We have a unique but finite opportunity to do something about this through building upon the consensus that has been secured through Sláintecare.

I congratulate the researchers and thank them for supplying us with further evidence on the need for this change.

And I look forward to teasing out, by way of detailed discussion over the course of the morning, the new approaches that we will - individually and collectively - need to adopt in place of our established way of doing things.

Thank you.