Health Identifiers Bill

[Speaking in the Seanad during Second Stage of the Health Identifiers Bill 2013]

I am broadly in support of the idea of enhanced patient identification as a means of improving safety. There is no doubt that when one has as internally discordant set of health services as we have in this country that it is essential that we think of better ways of managing medical records and facilitating appropriate transferral of sensitive information. However, it is important to put this in a context. There is a colossal problem with medical records in general in Irish hospitals. I believe that about 95% of the total dysfunction that occurs in Irish hospitals as a result of poor record systems will not be fixed by this initiative. The problem is internal in the hospitals. We have systems that cannot talk to each other, so to speak, within the same hospital. We have a reliance on paper charts. We have charts that disappear going from one clinic to another. These are issues which on a daily basis cause potential risks to the care of patients. This is the key priority in patient informatics which needs to be addressed. It needs to be addressed at a systems level, by mandate, with what, I believe, would be a relatively modest degree of infrastructure, and with what would be a colossal cultural change in the work practices of health professionals.

From a very simple point of view, in some rudimentary situations there are occasions where some aspects of medical information are displayed primarily electronically rather than on paper. Are there enough terminals? If one has three or four doctors and nurses working in one ward trying to deal with the problems of 15 or 20 patients, there is only one terminal and an orderly queue is forming, that is not a recipe for efficiency or safety. It is an incentive to cut corners and say “maybe that piece of information is not so important after all”. I would not want to disrespect the notion of having the unique patient identifier and the provider identifier but nor would I want to overstate the impact it will have. By and large the great majority of patient interactions occur along relatively well-established referral pathways with relatively decent lines of communication. They will get better with this initiative but the fundamental problems will not be fixed.

I am addressing my remarks to the Minister today which, coincidentally, is the day that we found out that Her Majesty’s House of Lords will debate an amendment to the Child Protection Act, which will in one swoop make it illegal to smoke a cigarette in a car where a child is present, and this is happening nearly two years after we introduced our legislation in this area.

I speak as somebody who is a little concerned about the prioritisation of reform within the health service at present. For the benefit of folks who perhaps have been lucky enough not to hear me say this before, all of us and pretty much everybody in this country agrees with the principle of socialised health care, of cross-community solidarity, of the rich subsidising the poor and of care determined by need, not by ability to pay. We all believe that but there are different models of delivering it. One model, which is used in a small number of developed countries, is the general taxation or NHS model, where the government takes money at the beginning of the year, centrally runs, controls, co-ordinates, mandates and budgets the entire system on an annual basis prospectively. Budgets are predetermined. This is a system which is incredibly good for containing costs and that is the reason the NHS has one of the lowest cost outputs of any of the health systems in the developed world. It is also a system which incentivises waiting lists, inactivity and also an extreme degree of inefficiency. It is for that reason that many of us over the years who have studied health policy have examined other models such as the German model in particular. At the time of the last election, I believe the Minister, his Cabinet colleagues and two parties in government were given a thumping mandate from the electorate to introduce this kind of reformed health system. It is one which is based on universal insurance, competition, a level playing field for all patients, and all patients having a freely transferable insurance instrument, which they could take to a hospital of their choice, one which might be public, one which might be private, one which – my own preferred model – might be run by not-for-profit companies, by universities, by academic organisations or perhaps by charities. Most of all the truly great leading, international medical centres in the world would follow that model. They are led by people who have a board of governance who act with the mission of the institution in mind.

Let me parenthetically state at this stage that I was troubled over the last several weeks to hear the board of a large institution, which gets €206 million in direct Exchequer funding annually, say that they now would concede the point that it was necessary to set up a public interest committee. If the board is not acting in the public interest, in whose interest is it acting? This is a question that needs to asked by the Minister of the governing boards of several of our largest hospitals.

On the tempo of the reforms we are seeing at present, I am prepared to concede the point the Minister has always stated that the goal of universal insurance-based reform is the ultimate goal and that it is not a short-term goal. I believe it could be a shorter-term goal than is being currently suggested. I believe it is essential we do it now because until we do it we are copperfastening the inefficiencies, the waste and the poor quality which I am afraid exists throughout our system. Looking at this from the outside, I see a huge amount of effort being put into reforming the current system in the direction of – I ask the Minister not to not take this as too harsh a criticism – making it look like the NHS. In terms of elements such as having national contracts for doctors, in the kind of model we are talking about, doctors who are employed in different circumstances would have widely different kinds of contracts, depending on their working conditions, their employment and even their specialty. We talk of a model of money following the patient as if this is somehow the implementation of an insurance-based model. It must be remembered that in the Thatcher era with the reforms of the internal market in the National Health Service there was also an attempt at money following the patient and what we are doing in the short term, something which parenthetically will be facilitated by this unique identifier, appears to be introducing that type of health care instead. There is an increasing tendency for the HSE to refer to itself as “the health service”. In the reforms that we are talking about and the kinds of models we will have there will be many people who will have nothing to do with the HSE. They may well have occupationally, socially, or privately-based insurance, they may well deal, I would hope, with the university College Dublin medical centre or the Eccles Street medical centre or some other hospital which is not owned by the HSE. They may have nothing to do with the HSE which should become a management organisation for a smaller number of State services.

The introduction of the groups, while rational in some ways, will also have the effect of decreasing competition and bringing in more of a directed referral model, which has been something long espoused by the HSE.

I look forward to having more opportunities to look into some of the more complicated details of the Bill. I ask the Minister to clarify one issue for me, which perhaps reflects on my lack of comprehension. How much of the medical record of a patient will be available to anybody who has legitimate access to the unique identifier number? Will someone have complete access to records nationally? If not, what is the point of the system?

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