By Niall Hunter
Health Minister Leo Varadkar has hit out at GPs who claim it is unethical to give free GP care to children under six from relatively well-off families at the expense of poorer and sicker people who are still being denied this care.
The Minister, in an interview with irishhealth.com, said the only completely fair system was a universal one, where everyone was entitled to GP care, and this would be implemented in stages.
Minister Varadkar said if the current Government is re-elected, he wants all children to be covered for free GP care during its next term of office, but he declined to put a timeline on when GP care for the whole population would be rolled out as promised.
The Minister also admitted that a small number of hospitals may need to be provided with additional beds to reduce pressure on their services. However, he said the hospital system as a whole did not need more beds.
He also said while significant investment has already been made to reduce pressure on EDs, major 'cultural' changes in hospital staff working practices will now be needed to tackle the ED crisis.
Free GP care
On the under sixes free GP scheme, Leo Varadkar said when GPs object to this being done at the expense of other patients on low to moderate incomes and with special needs who currently do not have free GP care, the first question he asks is what doctors' views were on the granting of full medical cards to all over 70s, including wealthy elderly people, in 2002.
"When I ask that the eyes tend to go down and people are embarrassed to answer it because of course, some of the people who are now arguing that the under sixes scheme is unethical, immoral and unfair were enormous financial beneficiaries of that (the over 70s scheme)."
He says that there are similar logistical and ethical problems with means tests and sickness tests in deciding on eligibility for services. "When it comes to means tests, you always have people who are just a little bit over the threshold, and when you raise the threshold then you have a different group of people who are just above it."
"We had an expert group that tried to come up with a sickness test for medical cards and not only could they not decide who should get a medical card and who should not, they said to do so would be unethical and unfeasible."
"There is no perfect way to do this but I would really question why people who are such big fans of means tests and sickness tests believe they are somehow morally right."
"I am absolutely convinced that the only system that is ever going to be fair is one that provides universal coverage, but we can only do that in steps." He stresses, however, that since his appointment the number of people with discretionary medical cards has increased by 30,000.
Minister Varadkar said he cannot put a timeline on when free GP care for the whole population will be rolled out, should the current Government be re-elected.
"Firstly, that has to be done by negotiation, secondly, we need to see how the under sixes pans out; whether it really does significantly increase GP attendances, and I'm not particularly hung up on how we do the next phases. I'm open to suggestions, for example, whether we prioritise more (GP treatment programmes for) chronic diseases first or that we increase the income limits first. But what I definitely want to do is to cover all children (for GP care) in the next term of the Government, it we get one. I don't think it's right that children are means-tested on the basis of their parents' income."
He said when it comes to covering GP services for working adults, there are different options. "One option that could be explored, for example, is using the social insurance system, or existing private health insurance, or using the Universal Health Insurance system to refund GP fees. But again that's something that needs to be discussed."
Some GPs have objected that a gun is being put to their heads in signing up for the under sixes contract, as if they do not they stand to lose medical card patients.
Leo Varadkar says: "First of all the key thing to remember is patients come first in all of this and patients have the right to choose their GP within reason, so it has always been the case that the patient can move to a different GP, that's true for private as well as GMS patients. He said If GPs were not willing to provide an enhanced service he would understand why patients would want to move to a GP who is prepared to provide the service. "It's always important to see this from the point of view of patients."
"We're not going to reassign existing medical card patients to another GP during the transition period; we're going to allow the summer period to pass."
The Minister stressed that when a new scheme comes in, at a certain point the old scheme has to end. "For example, when free secondary education was brought in (in the late 1960s) schools that used to charge at a certain point had to stop doing that."
He said the June 5 signing deadline was not a 'drop dead deadline' and GPs who are a bit late in signing up will not be turned away, adding that when the HSE website resource informing patients of participating GPs goes live this week, within a week or two he believes most GPs will have signed up.
The Minister said he did not believe that the provision of free GP care to under sixes patients who previously had to pay will lead to the huge rise in attendances that some GPs have predicted, 'but we will need to see what happens'.
Universal health insurance
On Universal Health Insurance (UHI), the Minister says he cannot predict at this stage the timeline for its roll-out, or what model will be used. "There are a lot of factors in play that effect timelines."
Asked was he against the UHI model proposed by his predecessor, of private health insurance companies running such a scheme, Leo Varadkar said he was not in principle opposed to this.
"I just want to see the numbers, to see how much it would cost people in terms of premiums, and I want to see evidence that it will bring about efficiencies. I also want to see how much would actually end up going to the profits of insurers, and in transactional costs, rather than into services."
Can an argument not be made to have a State-run and funded system? "There's certainly an argument for it, but having studied different funding models in different countries, no-one system is the same. Anyone who thinks there are two or three or four models to choose from...there aren't. There are about sixty different models. We need to decide for ourselves which is the one that's best for us."
Hospital trolley crisis
Asked if the recent ED taskforce recommendations will be resourced, the Minister said many of the most expensive components had already been resourced; for example, €44 million had been provided to make the Fair Deal scheme demand-led in order to free up more nursing home places and thereby free up more hospital beds.
The Fair Deal wait is now down to four weeks from 18 weeks and that is making an impact, the Minister said.
"The next set of actions are not enormously expensive, but they are the trickiest because they involve changes in working practices, changes in culture."
But there have been recommendations in previous action plans on how hospitals should deal with ED overcrowding quite similar to many of those in the taskforce report.
He agrees that a lot of what is in the taskforce report is not very different from what was in the 2006 one, which wasn't particularly implemented at the time. "We are setting up a small implementation group, which will meet every six months to drive it forward, and that wasn't done in the past. But that's not saying that we're not going to have a surge in January - it's very likely we will."
"There will always be surges in EDs. Anyone who tells you otherwise isn't telling you the truth. Every country experiences ED surges from time to time. This is not something you can ever say will just go away. What we can do is to make sure that it isn't a year-round phenomenon, which it is in Ireland in some hospitals, and that we are better prepared for surges when they do occur."
Hospital waiting lists
On the issue of treatment waiting lists, Minister Varadkar says it is planned to deal with this through activity-based funding.
"What we do at the moment is public hospitals provide a certain amount of service and then when waiting lists arise very often they are outsourced to the private sector. If we had proper activity-based funding, we could match the demand to the funding. From day one if we know that next year we need x number of hips done we can put them out to tender and they can go to public hospitals or private hospitals."
He points out that activity-based funding is already in existence on a 'shadow basis' in the system, in areas like day case procedures. Minister Varadkar says in general he doesn't agree that more acute beds are needed.
"We certainly need more social care beds for long-term care. We need to develop primary care and community intervention teams so that fewer people end up in hospital in the first place and people get out of hospital quicker. Often people stay in hospital for days just to get investigations done, so I think if we use our beds as efficiently as we should we won't need any more."
He does, however, believe there may be a small number of hospitals that may need additional beds. "These would be those which are central hospitals to hospitals that have been reconfigured. Obvious examples would be Limerick University Hospital, which is now picking up a lot of patients who would have previously gone to Nenagh and Ennis; the Lourdes in Drogheda, which is picking up patients who would have previously gone to Dundalk; St Vincent's, which is picking up patients who previously went to St Columcille's, and then whatever happens in the midlands - I would imagine Tallaght will need additional beds to pick up patients from there. The latter is being progressed- one of the closed wards is now being opened."
"There is a tender out at the moment for the private sector to assist with very long waiters - people waiting more than 18 months at the moment or people who will be waiting 15 months by the end of the year. Where there is capacity in the public sector we are using that more."
He says there has been so much change and structural upheaval within the HSE in recent years and he would like 'things to settle down a bit' before phasing it out. "There are too many people who are relatively new in their jobs. There are too many people who are interim or acting. I'd like to have a bit of stability in the health service for a little while."
He said, however, the plan still was to dismantle the HSE, with the hospital groups and community healthcare organisations set to be a major part of the new health service structure that will be put in place.
"What you will have replacing the HSE in due course is a health commission; a health purchaser. But there will still need to be some sort of national oversight."
However, Leo Varadkar admits that we will never get to the point where health service management will be popular with the public.
"People in Britain see the NHS as the service they get, and then there are also these 'nasty managers'. People in Ireland see the service they get, and they are not always that critical of it, but they see the HSE as the management. A friend of mine who had cancer described it well. He said the doctors and nurses cured his cancer, but if anything had been misdiagnosed it would have been (the fault of) the HSE, when in truth it would have been the exact same people.
"The HSE is in many ways a mudguard that gets the blame for anything that goes wrong in the health service."
The Minister said he had confidence in the Director General of the HSE, Tony O'Brien, who came in for some criticism following the recent HIQA report on Portlaoise Hospital.
Leo Varadkar says he believes in general our health services are safe, despite recent controversies.
"If you compare mortality and morbidity statistics with those of Britain, for example, we actually perform better. We have a lower or similar perinatal mortality and maternal mortality rates, we are quite similar on c-sections, lower surgical complications, lower rates of in-hospital mortality from heart attacks and strokes."
"So if you look at the OECD stats we are as safe as anywhere else, but it's a foolish person who would ever say that every single person in the health service is safe and that every single unit within the health service is safe. That's an impossible thing to say, which is why we need to be much more vigilant in auditing our health services and licensing them, which we will do with the Health Information Bill."
The Minister revealed he is planning major changes to the current childhood vaccination programme. "Among the issues being considered are whether we need to continue to give the BCG to all children."
His Department is, he said, also examining the introduction of new vaccination schemes to protect against rotavirus and meningitis B, and is also considering the introduction of the HPV vaccine for boys and men who have sex with men (MSM).
Minister Varadkar said cost would be a key factor in terms of expanding the range of vaccination schemes available, but he hoped to be able to make some decision on this in October or November.
Discussions on this topic are now closed.