The Government's plans for radical reform have finally been laid bare in detailed plans, writes MARTIN WALL
THE GOVERNMENT believes that all the preparatory work for its radical transformation of the health service into a system operated on the basis of a universal health insurance, will be completed by 2016.
In briefing material for the new group appointed by the Government to draw up detailed plans for the implementation of universal health insurance, the Department of Health sets out the steps its plans to take in the years ahead and how the new system will work.
The document says that under universal health insurance every person will be insured for a standard package of curative services.
The department says that although it will be mandatory for people to have insurance, they will have the ability to choose their insurer.
However, queue-jumping will be banned under the new system.
“Neither insurers nor providers operating within the universal health insurance system will be allowed to sell faster access to services covered by the universal health insurance standard of care.”
Presumably this means the choice on offer will be for different standards of accommodation in hospitals or for particular areas of care not covered by the standard package.
The briefing document says the universal health insurance system will involve “multiple insurance funds and will be based on community rating and risk equalisation”.
Community rating is the principle that has existed in the health insurance market for decades. This mandates that all persons insured pay the same amount for similar products regardless of their age or risk status.
Risk equalisation is a system under which insurance companies with larger numbers of older subscribers – who are considered to be a greater risk of making claims – receive money to compensate them from rival companies with younger subscriber profiles.
The view of the Government for years has been that risk equalisation is essential to underpin the concept of community rating. The last risk equalisation scheme put in place was struck down by the Supreme Court several years ago.
There is currently an interim risk equalisation scheme in place but the Minister for Health James Reilly has said he intends to put in place a permanent scheme in 2013.
The briefing document also reveals that the Government is to replace the current health insurance regulator, the Health Insurance Authority, with a new body, the Insurance Fund.
The document says the Department of Health expects that all the legislative and operational groundwork for the introduction of universal health insurance will be completed by 2016.
“In order to prepare the system for universal health insurance, a number of key initiatives must be progressed including:
The strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients;
The work of the special delivery unit in tackling waiting times for hospitals;
The introduction of a more transparent and efficient “money follows the patient” funding mechanism for hospitals;
The introduction of a purchaser/provider split, whereby hospitals will be established as independent, not-for-profit trusts;
The creation of a Patient Safety Authority to oversee the transformation of publicly funded hospitals to independent trust status and to safeguard the quality of the entire health system;
Various initiatives in relation to the private health insurance market.
The document says changes to the governance and organisational structures of the HSE are currently under way as part of a sequential process to abolish it over time. It says these are viewed as a first step in the transition to universal health insurance.
Under these transitional governance arrangements the current HSE board and chief executive concepts will be replaced by a new system involving services being run by six directors and a director general. Legislation to allow for these changes will be introduced by the Minister later this year.
The document says that separately the Minster’s new special delivery unit will continue to build capacity and capability within the health system “in order to create and sustain improvements. This will be achieved by working in partnership with the HSE’s national clinical programmes.”
The 30 clinical care programmes aim to improve quality of care delivered, to improve access to services and to improve cost effectiveness.
Separately the special delivery unit will continue to set performance targets. For this year the target will be that no patient will have to wait longer than nine months for elective or non-urgent treatment in hospitals and that no patient should have to wait longer than nine hours on a trolley (with 95 per cent waiting no longer than six hours). The special delivery unit will also set targets for out-patient and diagnostic services later this year.
Recent figures showed, however, that while most hospitals met a one-year maximum waiting target for elective treatment last year, the position deteriorated in the early part of 2012. A new system of fining hospitals which breached these targets was put in place in February.
At the same time no hospital has met the targets for waiting time on trolleys, according to figures released by the HSE last week.
The document says a key element of the Government’s health reforms will be the provision of free primary care services. It has already been announced that from this year free access to GP care will be extended to people covered by the long-term illness scheme.
“Over the subsequent three years, the aim will be for a phased expansion to the remainder of the population until universal coverage is achieved. This staged implementation approach will allow for the recruitment of additional healthcare professionals.
“The Government also intends to establish a primary care fund which will pay providers of primary care on a transitional basis.”
The document says that under other initiatives the HSE is seeking to increase the number of primary care teams – involving GPs and other healthcare professionals – to 489. To date 425 primary care teams are currently in place, holding clinical meetings.
It also points out that new legislation provides for the removal of restrictions on GPs wishing to obtain a contract to work under the general medical services scheme while a new contract for doctors providing services for those covered by medical cards or GP visit cards will also be introduced.
The document also says every acute hospital in the State will be organised into hospital groups.
New group chief executives will be appointed who will be able to plan and organise services across a number of different hospitals. The new chief executives will have responsibility for the performance and outcomes of the hospital group and will operate within a clearly defined budget and employment levels.
The document says it is intended that nine smaller hospitals around the State will be developed over time to provide day surgery, ambulatory care and a range of medical and diagnostic services which will free up larger centres to carry out more complex work.
It says a new Government framework for smaller hospitals “will be an initial blueprint, setting out the main type of service change that will happen over the coming years. It is not intended as a central plan to be delivered locally, rather it will set out key criteria and principles which will then be subject to local consultation and local implementation.”
The document also says that the system of providing block grants to hospitals will be replaced by a “money follows the patient” funding mechanism. However, it says in devising proposals in this area, “it is necessary to take account of financing arrangements for private patients”.
It says recent recommendations in a value-for-money report to replace the existing system of per diem charges for private patients in public hospitals with a regime of case-base charges “appears consistent with the move towards a single-tier system set out by the Government”.