Three documents published on the Department of Health website in the past six months sketch out the plans for the future delivery of healthcare in Ireland. The documents, Future health, The path to universal health insurance and Money follows the patient, describe a vision for a completely different health system to the one in which we currently work. Essentially the Government will no longer be responsible for the provision of healthcare – that will be the responsibility of a variety of healthcare providers, funded by commercial health insurers. But the Government will have a strong role in regulation of healthcare. This will be achieved through a number of regulatory agencies and also because a large chunk, if not the majority, of the premiums paid to the commercial health insurers will come from government funding. 

The goal is to develop an “efficient and effective health service… which provides equitable access to high quality care on the basis of need”. The steps to achieve this state of affairs are described in sufficient detail to be credible, and with a stated intention that reform and learning about the effects of the process will go hand in hand. 

The four pillars

The four pillars of the proposed change are:

• Health and wellbeing

• Service reform

• Structural reform

• Financial reform. 

Health and wellbeing is a whole-government approach to keeping healthy. It is planned to have a Health and Wellbeing Agency by 2015 which will work with all government departments, for example Social Protection, Education, to consider health determinants according to models such as that by Grant and Barton.¹

Service reform intends to treat people “at the lowest level of complexity that is safe, timely and as close to home as possible”. Structural reform is the journey from the current structures to those that support universal health insurance. It is summarised as comprising a change in the governance of the state health structures, in particular the HSE, the development of a formal provider/purchaser split and the movement of resources to primary care with development of integrated care. Financial reform is the journey from current financing arrangements to the financing of universal health insurance. It is summarised as the formation of hospital groups, later to become hospital trusts, the development of the ‘money follows the patient’ (MFTP) model with detailed performance contracts, and the setting up of a statuary system of health insurance. 

Phased development of the four pillars

These four pillars will be developed in three phases.

Phase 1

The Health Service Executive Governance Bill was published in July 2012 and allows for rearrangement of the HSE along the lines depicted in Figure 2. 

Simultaneously, acute Irish hospitals are being encouraged to form administrative hospital groups, and this has already begun to happen in various regions throughout the country. It is envisaged these groups will have a single administrative executive and will progress to form hospital trusts.

Alongside this process, reform of the outpatient services is described, such as validation of waiting lists throughout the country, standardisation and systems improvement in the handling of GP referrals and a policy to discharge patients from OPD once this is appropriate. Ambitious targets have been set that the maximum waiting time for a public OPD will be 12 months by December 2013, 26 weeks by December 2014 and 12 weeks by December 2015. 

Another parallel process is the development of clinical care programmes, such as is being built for asthma, COPD and diabetes mellitus. It is noted in the Future health document that while these will be separate pathways in the hospital specialist setting, they will be handled differently in primary care: “The critical chronic disease requirements (in terms of promotion, prevention, early detection, patient education and empowerment, registration and recall and quality assurance) are all progressed in a holistic and patient-centred manner that recognises the difference between managing patients and people, and managing diseases.” 

A number of interim agencies to drive change are being set up (see Figure 3). The advisory Implementation Group on Universal Health Insurance will be temporary, leading to a longer term Health Insurance Consultative Forum. Critical enablers to drive change are recognised to be performance contracts, a skilled, motivated flexible workforce, and systematic improvement of clinical and operational processes. Also vital to the process are common electronic datasets and the development of unique patient identifiers, which allows the tracking of a patient through a number of systems. The idea of a national electronic health record has been dropped in favour of systems that can communicate with each other. Also, legislation is currently being prepared to provide the legal framework for individual identifiers and for identifiers of healthcare providers. This, the Health Information Bill, will also legislate for population registries and for national standards of health information management.

Phase 2

In the second planned phase, the hospital trusts will be formed and their budgets will be allocated on a money follows the patient model, in contrast to the current block grants. During this phase the HSE will be disbanded and its directors will be moved to a new Healthcare Commissioning Agency. This agency will have a central role in determining performance contracts and target driven payments. Payments will be according to Diagnosis Related Groups (DRGs), an Australian model, in which 698 individual DRGs have been categorised. In the early years, emergency department charges, bad debts and pensions will be excluded, so a hospital payment will remain. The annual performance contract will pay a sum calculated by the DRG activity, plus a smaller budget, plus a quality performance payment.

During the second phase, the national regulation of healthcare providers will be set up. There will be a mandatory system of licensing for healthcare providers, both public and private. To this end a licensing bill is being prepared. It is envisaged that general practices will require a licence. 

It is planned to establish a Patient Safety Agency, along the lines of the Canadian model, which will be answerable to HIQA. A National Clinical Effectiveness Committee has already been set up, which presumably advises along the lines of the NICE guidelines.

Another parallel process in this phase is the development of the Consultative Forum on Health Insurance. So far it is stated that the representation on this group will be from each of the health insurers and the Department of Health and Children. 

Phase 3

In the third phase, it is envisaged that the Health Commissioning Agency will shift the funding responsibility for acute hospital care (including mental health) and general practice to the insurance companies. The Healthcare Commissioning Agency (see Table 3) formed after the phasing out of the HSE, will continue to funnel the general taxation funding of social care, disability and longterm care. 

There will be four commercial health insurance agencies, of which the VHI will be the state health insurance agency. The Health Insurance Legislation Act, which was passed in December 2012, has given the legal basis for health risk equalisation. It is planned that the Consultative Forum on Health Insurance will safeguard continuing affordability of health insurance. This will pay for a basic basket of services, yet to be decided. It is stated that limitations to that basic basket will occur and that co-payments, where appropriate, will apply. It appears that medications will generally be covered by health insurance, again with limitations and co-payments. 

Also described is the concept of integrated care contracts. This is where networks of primary care and hospital providers agree to provide a defined population with care that meets specified quality targets. Bundled payments are used to make a single payment to the group which is then divided among the care providers.

The longer term structures which are described are shown in Table 3. The legislation which is being planned to drive change is summarised in Table 4.

Plans for primary care

The Universal Primary Care (UPC) Project Team has been set up in the Department of Health, reporting to the Minister for Primary Care. It is responsible for planning, costing and legislative preparation for free-at-point-of-care general practice. Preparations are underway for a new GP contract, the anticipated content of which is given below. Attention will also be paid to: 

• A primary care ICT record with role-based access to professionals on the basis of patient consent

• The traditional primary care reporting relationships with an eye to new governance structures

• Alignment of GP services and HSE-provided services according to population need. 

What is planned for the new GP contract includes compulsory cooperation with the primary care team, and universal patient registration with a team. For chronic disease management there will be structured reviews, individual care plans, and call and recall systems, along with mechanisms to audit and reports on outcomes. The new contract will focus on prevention and development of physical and IT infrastructure in general practice. 

The intention is to plan recruitment in primary care in advance, so that allocation of posts will be governed by a consistent transparent method, to supply staff where most needed and in the most deprived areas. 

Questions and clarifications

The most fundamental question about the planned changes is how efficient the structures will be to maximise health spending on quality care centred on the patient rather than administrative spending or increased profits for insurance companies. Getting the representation right to minimise vested interests on the Consultative Forum for Health Insurance will be vital to the process.

The next important question is how will the levels of insurance beyond the basic basket of services be managed to maintain a single tier system? Has there been sufficient consideration of deprivation indices?

Much of the proposed changes rest on the development of IT infrastructure and I take issue with a statement in the document Future Health: “Improvement is urgently needed across non-acute areas such as primary and community care, where ICT remains poorly developed.” Certainly, Irish general practice has not been behind in developing clinical software systems. What alterations in our clinical software will be required to allow role based access for all the members of the primary care teams? How will patient consent issues be managed? Will the health service be able to overcome the complexities of IT development in all the other areas which are needed?

Lastly, where does professional training fit into the proposed model?

But change is coming. The planned changes are to be rolled out on a reform, measure and learn, and alter reform basis. This article gives a very condensed indication of what is in the published plans, told from a general practice perspective. General practice will be in a better standing through these changes if we all inform ourselves of what is planned and seek clarification from the Department of Health. 

Reference

1. Barton H, Grant M. A health map for the local human habitat. J Royal Soc Promotion of Health 2006; 126(6): 252-253. ISSN 1466-4240