(Thursday, 2nd Oct, 2014)
Death-Row, Angola, the Poisoned chalice – it has many names – but the Department of Health is not a place for the faint–hearted. The current Minister, Micheal Martin has been in the portfolio now for over four years and bears some of the scars of his time there.
The daily diet in health includes crowded A&E units, long waiting lists, serious medical errors, vested interest groups resistant to change, strikes and attacks from all sides, and in Martin’s case even from Cabinet colleagues.
His last major interview with irishhealth.com was in 2001 and much has happened since then. In a major interview with us this week, Minister Martin revealed: plans for a new Statutory Patient Complaints System, a concession to allow local public representatives an input into the health service after the scrapping of health boards this year, has warned consultants they can not block change, he revealed a Government decision to make the VHI a semi-State company with independence to set its own subscription rates from 2005, ruled out a Tribunal of Inquiry into the Dr Neary affair and insisted that he was ‘not unhappy’ in health. But he did not say he wanted to stay there either after the expected Cabinet reshuffle in the summer.
There is currently no legal framework for patients to complain about how they were treated in hospital. An ad hoc voluntary complaints system was put in place in the early 90s but it is not working.
The Department of Health was going to produce a new Patient Complaints Bill (legislation) but because of the health reform programme, this will now be incorporated into the new health legislation for the Health Service Executive, which takes over running the service in January 2005, when the health boards are axed.
Mr Martin told irishhealth.com that the new complaints legislation will require hospitals and other health agencies funded by the taxpayer to establish local complaints handling procedures. Guidelines will be issued and approved by the Minister. Complaint officers will be appointed by each health service provider, who will be independent in the exercise of their functions. Significantly, there will also be an outside appeals system if someone is dissatisfied with the outcome of an investigation.
“The complaints officer will report to the head of the hospital or health body. It will be a statutory system”, the Minister added. Complaints will have to be investigated in a set manner and within a set time frame. One flaw in the plan some may see is that there will be no penalties for hospitals that fail to meet their requirements under the new patient complaints law. However, the Minister is willing to look at this if it becomes an issue.
The new Health Service Executive will have to produce an annual report on the handling of complaints by hospitals. The Medical Council, not by the new Patient Complaints System, will deal with clinical issues that arise.
The Minister also revealed that the Department of Finance has secured Government approval to amend the Ombudsman’s Act to include voluntary hospitals (hospitals funded but not owned or run by the State). This will end an anomaly whereby the Ombudsman could examine issues arising in health board hospitals, but not all public hospitals. “This means that the public will in future have a statutory right to an independent examination of any complaint be it in a health board or a public voluntary hospital”, the Minister said.
Most observers, even the Minister to a large degree, accept that the problems in the health service have been overanalysed and now it is time for major change, not more reports. A key part of that change is the Government’s Health Reform Plan. It will see the country’s 11 health boards replaced by a Health Service Executive (HSE) (served by four Regional Health Offices) as well as the controversial reorganisation of hospital services.
The chairman of the HSE, Kevin Kelly has drawn people from the existing health service to set up a transition team. But the critical appointment will be the Chief Executive of the HSE. The post was recently advertised. “A lot hangs on that appointment and his or her team”, Micheal Martin admitted. While the appointment is a decision for the HSE, the pay level will have to be agreed between Health and Finance.
Sweeping pieces of legislation are needed for the massive reform plan.
“There are two sets of legislation involved. The first is enabling legislation which went to Cabinet this year and is currently being drafted by the Attorney General’s office and is close to finalisation”, Minister Martin said. “It will basically enable the Minister from the local elections onwards, or at some future date prior to the establishment of the Health Service Executive, to abolish health boards”.
The existing Chief Executives of the health boards would continue to run the service for a time after the abolition of the health boards, which may happen around June. The Minister ‘hopes’ to have the legislation for the HSE ready by the end of the year so that it can take over the running of the service in January 2005. It is an ambitious timescale, after decades of inactivity in health in terms of structural reform.
The decision to end professional representation (by doctors and dentists) and public representation by local councillors on the health boards when they are axed has been very controversial. Since it was made known, local politicians have been lobbying hard to retain some input into local health services, as a democratic right.
The Minister has revealed to irishhealth.com details of a compromise that will apply to councillors, under the new system.
Groups are to be set up to facilitate the voice of public representatives at regional level. “They will meet 4-6 times a year and be serviced by the Regional Health Office executive. The groups will be made up of local councillors from the constituent county councils and corporations in a given region”, the Minister said. At the meetings of these bodies, Regional Health Office executives will have to explain the annual health plan for the region. Public representatives will also have the right to correspond with the executive of the Regional Health Office on local issues.
While local authorities will have representatives on the new bodies the Minister is anxious to point out: “It will not be a health board - we need to be clear about that. But it will facilitate public representatives to articulate their views on their regional health services”.
For doctors, nurses, dentists and other professionals, they will have to voice their concerns through local hospitals and the internal structures of the HSE as they will no longer be on health boards.
The exact regional boundaries for the new health system (there will be four regional areas covered in the country with Regional Health Offices in each of these) have still to be decided. Also, the locations for some of the new health agencies being set up under the reform programme have also to be decided. The HSE (which is operating on an interim basis pending legislation) will shortly make a recommendation to Government on its preferred location.
In terms of accountability, the new Health Service Executive will report to the Health Minister (not the Department of Health) and will also appear from time to time before the Oireachtas Committee on Health and Children. It remains unclear whether HSE meetings will be held in public, which was the way under the health board system and it allowed public accountability with the media in attendance.
Since the publication of the Hanly Report on hospital reform, the Minister has clashed bitterly with local groups over concerns that accident and emergency units will close and fears that the plan amounts to centralisation of acute services.
There is much confusion about the Government’s intentions. While Mr Martin insists it will mean decentralisation of a range of services to local hospitals (planned medical and surgical work, out-patients, day case procedures, diagnostic work, elderly care) opponents see it very differently – the centralisation of major acute services including full-scale emergency services in a small number of major hospitals and the downgrading of local hospitals.
“I don’t think Hanly will get a fair reading until after the local elections. A proper debate is hampered by the fact that we are in a political campaign now and people are wrapping every local hospital around them and are trying to get to the head of the queue to say they are the saviour of their local hospital. There is hysteria and hype”, he said.
The public wants to know if, under Hanly, A&E units or hospitals will close? “No A&E is going to close”, the Minister promised. However, some may in future provide services only for minor injuries and illnesses and they may not be open 24 hours to provide a full service, as is currently the case. Indeed, the Hanly Report was clear about this – it said that in order to provide a full-scale emergency service, a hospital must have 24-hour surgery, anaesthesia and medicine on the site. This is not sustainable in smaller hospitals where a minimum of around 50 consultants would be needed to provide the comprehensive service, it argued.
Mr Martin insists that the plan is to move consultant services out to the regions, especially services that have been starved in many areas such as neurology and dermatology. “Hanly is about stopping the traffic of patients from the regions to Dublin in a whole range of specialties and that has to mean expansion of services to the regions”.
His Progressive Democrat partners in Government put it clearly at their recent annual conference – the health service will be developed to have top-quality teams of consultants, 24 hours a day on a regional basis, “but it can not be done for every town or even county”, Tanaiste Mary Harney insisted.
“The big picture of Hanly is having a consultant provided service whereby we will have more senior doctors available to see patients. We are too dependent on junior doctors in training to provide the service and this message is being lost in the debate about issues to do with A&E and overnight cover. I actually don’t think people have a full understanding of what happens in local hospitals in the middle of the night. There is a sense that there are all of these consultants floating around the place, not wishing to cast aspersions on anyone, but that is not the case”, Mr Martin said.
But he pointed out that, having had discussions in January with David Hanly, who chaired the Hanly Group, “it should be possible to organise 24 hour medical cover overnight” for local hospitals. This is something that is being examined in the two health boards (the Mid Western Health Board and the East Coast Area Health Board) where the Hanly plans are currently being piloted. A national plan for hospital reorganisation seems some years away, in reality, given the politics involved and a General Election due in 2007.
Because of a separate dispute between consultants and the Minister, consultants have halted any talks on a new contract, which will delay progress on the reform programme. The question is, do consultants have such power that they can derail or kill reform completely?
“We have a sense that we can resolve the problem (the row with consultants over the Government’s decision to introduce a new medical lawsuit insurance system) but we would not stand around forever. If people are not going to cooperate with the reform programme, we would have to go ahead and do it ourselves”, Mr Martin warns.
Even if consultants agree to come to the table for new contract talks, history shows that these talks could take years. “The talks could be extremely long, or they could be short if there is a meeting of minds.” Indeed, the Government has largely indicated what it wants – consultants working longer hours, more on the front line with patients, shift systems and a bigger commitment to public work. Mr Martin also pointed out that some of the representatives of consultant organisations were on the reform groups such as Hanly and so the proposed changes “did not emerge from politicians but from medical experts”.
But while the Minister said he would like consultants to be involved locally in the reconfiguration of hospital services, he insisted that they could not stand in the way of reform.
Long-promised legislation on the regulation and monitoring of doctors (by the Medical Council) is now promised for 2005. It has been delayed by pressure of work in other areas, such as the Health Strategy and the Health Reform Programme, and ensuring that it fits into the new structures. While the detailed legislation will not be available until 2005, the Heads of Bill (outline of main proposals) for the new Medical Practitioners Act have now been circulated to all Government Departments. “We should be going to Cabinet with the Heads of Bill after Easter and we will publish it to generate a public debate about the issues”, the Minister said.
The proposed legislation will provide for a mandatory system to ensure that doctors regularly prove themselves to be competent, a bigger Medical Council and with a greater public membership. A speedier process to deal with complaints by members of the public about doctors will also be provided for, as well as the facility for the Council to use outside experts to assist its work.
The public will also be able to appeal to an outside body, probably the Ombudsman, if they are unhappy with the way their complaint was handled by the Medical Council.
“We are maintaining the self-regulation model for doctors but significantly changed in the interests of the consumer”.
On the issue of medical errors, Mr Martin said it was unsatisfactory that we were extrapolating from studies in the US and Britain to gage the level of medical mistakes here. “It’s not ideal because these countries have different services. However, we are the first country in Europe to put in place recently the adverse incident reporting system and that is a plus. It gives us a good picture of the level of mistakes”. But he made the point that while around 25,000 errors have been reported under the system to date, it would be wrong to take from this that we have a major level of serious medical errors as “these errors can involve a slip or a handwriting error”.
Mr Martin said there had been Government discussion on the future of the VHI. “We are going to go-ahead and give semi-State status to the VHI, probably in 2005. No decision had been given to the privatisation of the VHI – the first priority is semi-State status”, the Minister said. This will allow the VHI to set its own rates for subscriptions each year, without having to seek Ministerial approval, as well as more commercial freedom generally. “I think it is wrong that the Minister should have the existing role with regard to the VHI”, he said. The move will deflect public criticism away from the Health Minister, as he will have no future role in relation to controversial subscription rises. “I think it is ludicrous that every September the Minister is asked to endorse the VHI’s latest big increase! What you are doing is second-guessing the work of the company who are at this all-year long”.
Other legislative plans include a new Nursing Bill, regulation for Health Care Professionals (not currently covered by existing legislation) and regulating the Pharmacy Sector.
The recently published Mortell Report on regulating the pharmacy sector recommended that no firm should be allow own more than 8% of pharmacies in a health board region. The Irish Pharmaceutical Union is concerned that existing deregulation in the marketplace (and even the 8% rule) will still allow large chains to kill off the small single-owner pharmacy sector here.
The Minister’s latest comments will not ease their concern. He referred the Mortell Report to the Attorney General for a legal opinion on it and obtained a detailed view. “The Mortell Report was not legally proofed”, said the Minister adding that he has now, through the Attorney General, sought a second legal opinion from an expert in commercial law.
“I want to know whether the Minister can regulate the market to 8% in each health board area. It’s a fundamental question, under the Constitution and under European Law. If it’s not legally tenable, that’s it”.
The experience of the whole pharmacy area is that it has been bedevilled with problems, he said, as previous regulations were found to be against the law and had to be changed. All this may mean that pharmacies will have to face a virtually complete open market.
Asked how he would describe the high and low points of his tenure to date in health, Mr Martin quipped “I’d describe them as peaks and valleys”. He says there is a constant struggle in planning strategy for the medium and long term, ‘putting out the fires’ as they arise and the annual battle for funding.
He said that most people agree with 90% of the National Health Strategy and it is the blueprint along with other key reports. “Some people get tired of strategies but you do need to work within a framework. But don’t worry, no more strategies in this area, it’s action now.”
Asked if he would be happy to remain in health after the expected reshuffle, he replied: “I don’t know whether there will be a change or not in the summer. It’s a matter for the Taoiseach. I am not unhappy in health if that’s the question.”
The smoking ban is one highlight for him but “we have also, with the Department of Health, set the scene for the most fundamental change in structures since the beginning of the State.” But will he be around to see the big promises through?
Whatever about the Minister getting out of health, a recent survey of staff at his Department found that three quarters (mostly lower ranks) were keen to decentralise. Is morale that bad? The Minister does not agree that is the issue.
“Most decentralisation moves have been oversubscribed to date. Remember a lot of civil servants are originally from the country.”
In relation to staffing, the question arises as to whether Ireland should follow the direction of UK Finance Minister, Gordon Brown and axe staff (in his case 40,000 civil servants to free up money for health and other areas). Mr Martin urged caution. “It’s one thing to announce it, it’s another to achieve it. Wait and see if Gordon Brown meets his target. Charlie McCreevy did announce some staff curtailment in the last Budget. Health and Education employ the most. I don’t get the impression we are overstaffed. If you cut staff you impact on services.”
On the smoking ban introduced this week, the Minister said he did not believe he would take a personal political hit at the next election over the issue, or that a future Minister might water down the regulations if publicans claim a significant loss of business. “What sustained me through this was the ordinary person in the street and the wide support for it. Don’t let them get you down was the common refrain.
I would have as good a political sense for it as anyone else. Perhaps we were naïve but I did not anticipate the degree to which this grasped the imagination of the people. It sparked a great public health debate.
I went out last night for a few pints and some people at the bar came up to thank me. Of course there are some chronic smokers who are not happy with me and some publicans too and you have to take that on the chin.”
Ironically, the first political casualty of the smoking ban came just hours after this interview, when Fine Gael’s justice spokesperson, John Deasy was sacked for smoking in the Dail bar.
In relation to cancer care, Mr Martin argues that the public and private sector have to work together and in line with the recent Radiotherapy Report – a clear signal that he is unhappy with the private sector trying to establish its own network of radiotherapy services in an ad hoc way.
Under EU law, for health and safety reasons, junior doctor’s hours must be cut to 58 hours a week by August 1. The Minister said that while it was not impossible, it would be difficult. Talks have started again with the Irish Medical Organisation on the issue. “I am informed that in 60% of specialties in hospitals, we are already there. There are legal implications if we do not meet the target. We would be in breach of European Commission directives. If we don’t obey the law, the Commission or doctors can take action against us.”
A big problem in the health service is a lack of capacity - the shortage of beds.
A recent EuroStat report found that we had one of the lowest ratios of beds per capita in the EU.
The first 700 of 3,000 promised beds have still not been put in place. Just over 500 have, but while the Minister insisted that the money was there for the other 200 or so beds, some hospitals are not ready because of refurbishment work, he claimed. More will come on stream this year but he made no promises that they will all be provided. As regards the other 2,300 beds promised, work is continuing on which specialties should get those beds and where they should be.
The Department of Health is facing a number if inquiries into the actions of doctors, failures in the blood service and the retention of children’s organs. The Terms of Reference for the inquiry into issues concerning consultant obstetrician, Dr Michael Neary and his performing unnecessary hysterectomies are being finalised. But despite the campaign by those affected, the Minister told irishhealth.com that it would not be a statutory inquiry.
He expects the first report from the Dunne Inquiry (also a non-statutory probe) into the organ retention controversy around June but accepts that the delay has been difficult for the families affected. Two other issues relating to the Blood Bank – involving blood donors in the early 90s not being told they were infected with the Hepatitis C virus, and the role of US drug companies in the infection of haemophiliacs with HIV and Hepatitis C – are likely to be dealt with after the planned legislation allowing for Committees of Inquiry is passed, rather than through Tribunals of Inquiry.
Last week, as reported by irishhealth.com, the Medical Council gave the green light to couples involved in fertility treatment to donate unused frozen embryos to other couples with infertility problems. Mr Martin said he was awaiting the report from the Commission on Assisted Human Reproduction on this and related matters.
“The Commission will recommend to me whether the legislative route is the way to go or not. I would envisage once the Commission’s report is finalised, there would be a need for political debate on it. We are probably looking at an all-party committee in the same way the abortion issue was examined, to achieve a consensus.”
Following our interview the Minister was due to fly to Prague to debate, among other issues, the question of patient mobility in the EU. It sounds dull but it is about the right of patients, in Ireland for example, to travel to other countries and obtain health care there, if there has been an undue delay here in providing treatment. Ireland would have to pick up the tab for such care.
Agreeing the rules on this are a key part of Ireland’s EU health presidency, and have been forced by recent European Court of Justice judgments. “It could mean the creation of certain centres in Europe for the treatment of rare diseases or an expansion of the E112 form”, Mr Martin said. Some countries have spare capacity and would welcome the influx of patients, others are already stretched and very concerned at how it might affect their health systems. There is also the anomaly whereby certain procedures cost very little in some of the new accession States but are very expensive in others.
What Micheal Martin’s legacy in health will be is hard to say at this stage. The smoking ban will be remembered, but some may view it as a smokescreen which has hidden any real reform in the service. The day-to-day problems remain. Given his knowledge now of the sector, there is a strong argument that he should remain in health to see the changes through to the end. However, politically, for the Taoiseach, a change of Minister might allow for compromise on hospital reform and dare one say it, the smoking ban? In any event, the big tasks in health have still to be achieved.
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Last Reviewed: 1st April 2004
|Anonymous Posted: 01/04/2004 13:49|
|I am a victim of a medical error and I have had no recompence or expect any as the system "as it is and as it always will be" covers the medic not the victim. Why because it can and will never change We have Garda investigating Garda We have Medics investigating Medics well if not Why not. I have been trying to get a surgeon inot court for over ten years now and with his luck I will die of his mistake before I do.|
|Fiona(FiBar) Posted: 01/04/2004 15:50|
|Is there anything Michael Martin can do about the amount doctors are charging for a consultation. It seems to vary considerably, from about €25 in kerry to €50 in Dublin! It is so expensive to see a doctor that I'm sure more people aren't bothering to go with health problems unless they feel they are serious.|
|Anonymous Posted: 01/04/2004 16:45|
|well lets see, Mr Martin promised 200,000 extra medical cards before the last general election. That would have helped a lot of people who cant afford the doctor. but he didn't go through with it once voted in - oh what a shock.|
|Fiona(FiBar) Posted: 01/04/2004 16:53|
|this country is disgraceful. In the UK, you can go to the doctor under the NHS and not pay a huge fee just for them to write a prescription. I lived in the uk as a student for a while and also worked there and it was such a relief to not have to pay to get medical care. I find I put off going to the doctor here as its so expensive, and that's before they even prescribe you anything. I paid over €80 in 20 mins in Jan between seeing the doctor and getting a prescription, for a chest infection!! My sister has a 2 year old child, and she was refused the medical card because she works and pays a mortgage...how does that make her rich???|
|Deirdre(doconnell) Posted: 02/04/2004 11:41|
|It is a great pity that patients only surface in the interview in connection with complaints. It is very disappointing that there is no reference to patient and patient organisation involvement in the new health structures, as should be the case in a modern democratic system.|
|Anonymous Posted: 05/04/2004 12:01|
|When is Mr Martin going to develop the Neurology Unit for the South East as outlined in the Comhairle Na nOspideal report published last year.|
|Anonymous Posted: 06/04/2004 14:44|
|The fact is that many people can't afford €50 for the doctor and another €30 or €40 for the chemist and thus wait until they are seriously ill.|
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