Dáil Éireann debate -
Thursday, 21 Feb 2008

Vol. 648 No. 1

Adjournment Debate.

Hospital Services.

Deputy Joe Carey

I thank the Ceann Comhairle for allowing me the opportunity to raise this serious issue on the Adjournment. I discovered yesterday that the HSE intends to change its policy in the mid-west such that all major trauma cases presenting in County Clare will be sent to Limerick Regional Hospital, thereby bypassing Ennis General Hospital. This proposed change, which is to come into effect next April, ignores the standard international maximum time limit to treat accident victims, commonly known as the golden hour. This is a high risk strategy. At the centre of this decision is cost-cutting and not patient care. It is a matter of cuts before care, theory without practice. The Government, the Minister for Health and Children and the HSE are determined to implement the Hanly report by stealth and this move is another step on the way.

This decision ignores the unique geographical nature of County Clare and, in particular, the west Clare peninsula. It ignores the fact that some patients in west and north Clare will have to travel up to 70 miles to Limerick on roads that are among the worst in the country. I refer in particular to the Kilrush and Ennistymon roads. This decision was made without any upgrading in ambulance cover in County Clare and without any upgrading of the accident and emergency facility at Limerick Regional Hospital to cater for the greater workload.

Furthermore, there was no consultation with the ambulance personnel who attend these scenes and have practical knowledge of the matter. I spoke with one of them yesterday. Frank O'Malley works at Ennis General Hospital and has 35 years' experience. He is outraged by this decision which he described as "totally ludicrous". Mr. O Malley informed me it could take patients three hours to get to Limerick Regional Hospital from areas like Kilbaha and Carrigaholt. A seriously ill person, he remarked, would not have a prayer of surviving this journey on such poor roads.

In recent weeks, there have been three separate incidents where expectant mothers in west Clare have had their babies without medical care because the ambulance service is so badly resourced and understaffed. Thankfully, all three mothers and their babies are doing well. This proposed move will stretch our faulty ambulance service even further. It is unacceptable that people's lives should be put at risk in this way. The Minister for Health and Children and her advisers must ensure an immediate review of ambulance cover in County Clare. She must ensure there is 24-hour cover in Kilrush, Ennistymon and Scariff, which only has 19 hours' daily cover.

It is an absolute disgrace that successive Fianna Fáil-led Governments have ignored the need for serious investment in Ennis General Hospital. The Government has ignored the county hospital because it wants to run it into the ground and erode people's confidence in it. It is doing a great job in that regard. We in County Clare demand and deserve a world class health service, not a system that is thrown together and with major shortcomings and repeated cuts in services. I strongly believe we need to bring hospital services closer to people, rather than moving them further away. I do not advocate that we should have every discipline in every hospital. However, a fully functioning accident and emergency unit should be available 24 hours a day, seven days a week to protect the 110,000 people who live in County Clare. The service should be supported by a properly staffed and well resourced ambulance service. Far too many promises have been made about the upgrading of Ennis General Hospital, but no work has taken place. I ask the Minister for Health and Children to get on with it. She should spend the money that is needed to upgrade Ennis General Hospital. It has been proven that longer journey distances to hospitals lead to increased mortality rates. They also affect recovery times and the type of recovery a patient can expect. In the interests of public health, I respectfully ask the Minister to intervene to ensure the plan to stop using Ennis General Hospital for major trauma cases does not proceed.

Minister of State at the Department of Health and Children (Deputy Brendan Smith)

I will respond on behalf of my colleague, the Minister for Health and Children, Deputy Harney. As Deputy Carey is aware, the provision of services at Ennis General Hospital and the mid-west in general is the responsibility of the Health Service Executive. One of the priorities of the Government and the HSE is to improve the delivery of accident and emergency services. Considerable improvements in the delivery of such services have been made over the last two years. Medical and paramedical experts consistently advise that all major trauma cases should be transported to regional trauma centres. International and national evidence has shown that trauma victims have a better chance of survival and recovery when they are treated at specialist centres. Over the years, many senior consultants in Ennis, Limerick and Nenagh have expressed their desire for best international practice in this regard to be introduced in the mid-west.

Deputy Joe Carey

What about the golden hour?

Deputy Brendan Smith

Consultants have expressed concern about the policy of taking major trauma cases to Ennis and Nenagh before transferring them to Limerick. Many years ago, the Medical Council advocated the introduction of what is known as the "trauma bypass". The HSE has informed me that from April 2008, six trained advanced paramedics will be qualified to intubate and cannulate patients in County Clare.

Deputy Joe Carey

That is not enough.

Deputy Brendan Smith

The Government is committed to the continued development of appropriate services at Ennis General Hospital. It has provided for developments at the hospital in the past. It will continue to invest in services at the hospital.

Deputy Joe Carey

The Government has done absolutely nothing.

Deputy Brendan Smith

Ennis General Hospital will continue to play a vital role in providing services for the people of County Clare.

Pharmacy Regulations.

Deputy Caoimhghín Ó Caoláin

I have sought this debate because the Health Service Executive, on the direction of the Minister for Health and Children, Deputy Harney, intends to proceed with the unilateral imposition of new scales of payment for community pharmacists from 1 March next. This will pour petrol on the flames of the prolonged dispute between the HSE and the Irish Pharmaceutical Union. Tens of thousands of patients will be adversely affected if the imposition goes ahead and the IPU withdraws from the medical card and drug payment schemes. There was no need for the Minister and the HSE to escalate the dispute in this way. The IPU has welcomed the announcement by the Minister that an independent body will be established to review the contract issues between the HSE and the pharmacists. When the IPU welcomed that announcement, it asked the Minister and the HSE to avoid making unilateral changes to existing payment arrangements pending the outcome of the agreed independent review. The Minister and the HSE carried on regardless.

There is no dispute about the need for better value for money when drugs are purchased within the health service, as prices are far too high. Given that the big multinational pharmaceutical manufacturers and wholesalers have got away with charging exorbitant prices for medicines over many years, why are pharmacists being confronted so aggressively? The Minister is trying to shirk her responsibilities, including her duty to show some accountability, in this crisis. The Joint Committee on Health and Children has asked her to attend a meeting in advance of the 1 March deadline, but she has not agreed to do so. When the committee met over three days last week, it heard thorough submissions from the HSE and the IPU, followed by detailed questions and answers. The seriousness of the situation and the concerns of pharmacists and patients are clear to all Deputies from the many representations we have received. The Minister has not treated the committee, the House and, most importantly, the issue with the seriousness and constructive engagement that is needed.

On the eve of the joint committee's meeting of 14 February last, the chairman of the committee circulated a draft motion which was set to receive all-party support at the meeting. The motion proposed:

That no changes be made to contracts between the HSE and community pharmacists in advance of the setting up, and reporting, of an independent body whose remit will be to make recommendations on the reimbursement to pharmacists for drugs supplied under the State's Community Drugs Schemes, in consultation with the interests concerned;

That the committee recognises the vital role that community-based pharmacies play in the delivery of the health service;

That the committee further recognises that the proposed changes to the contracts between the HSE and the pharmacies should be designed to allow financial sustainability; and

That no changes in the current contract or remuneration will take place until such a body reports and likewise pharmacists will refrain from any reduction in services.

The basis of a solution is in that motion. The Chairman of the joint committee withdrew the motion at the 14 February meeting. In its place, the Fianna Fáil members of the committee proposed a bland motion simply calling on the HSE and the IPU to resolve the dispute. They divided the committee so the motion would be passed. The Government spurned another opportunity to help to resolve the dispute. It seems to have decided to follow a course of confrontation with pharmacists. The Government has doggedly stuck to the position that competition legislation precludes negotiations between the HSE and the IPU on fees. It has spurned every opportunity to amend that legislation to allow such negotiations.

Patients fear that their access to vital medication will be disrupted from 1 March. Medical card patients and everyone who has signed up for the drug payments scheme, especially elderly and infirm people, are particularly concerned. The Minister for Health and Children should immediately require the HSE to defer its 1 March deadline for the imposition of new fees for pharmacists. She should facilitate direct dialogue between the HSE and the IPU on all elements of the new contract, including the cost elements. She must act now to ensure a full and uninterrupted service for all patients. I hope this further appeal does not land on deaf ears. This is a crisis waiting to happen. The Minister must act now.

Deputy Brendan Smith

I am responding on behalf of the Minister for Health and Children, Deputy Harney. I emphasise that 1 March next is not the deadline for the imposition of a new contract for pharmacists — it is the date for the introduction of the new wholesaler pricing arrangements. The Government believes the wholesale mark-up paid on the price of drugs should be reduced to a level that is fair to taxpayers and wholesalers. The existing mark-up of between 15% and 17.6% is neither reasonable nor sustainable. The HSE will proceed with its plan to pay an 8% mark-up from 1 March next and a 7% mark-up from 1 January 2009. The Minister is keen to support pharmacies which have a high proportion of medical card patients and to which a dispensing fee of €3.27 applies for most transactions. As many such pharmacies are in rural or inner city areas, they provide an important social and health service. With the support of the Minister, the HSE has indicated that it is prepared to offer a higher fee of at least €5 per item dispensed to community pharmacists, on the basis of an interim contract which would be essentially the same as the existing contract. The interim contract is being offered on a voluntary basis — community pharmacists can opt to remain on their existing contract if they wish.

When the Minister met representatives of the Irish Pharmaceutical Union last week, she was advised that an independent assessment of the fees offered should be undertaken. In an effort to resolve this situation, the Minister announced that she is establishing an independent body to begin work immediately on assessing an interim, fair community pharmacy dispensing fee of at least €5 to be paid in respect of the medical card scheme, the drug payment scheme and the other community drug schemes covered by the present pharmacy contract. This body will be chaired by Sean Dorgan, former head of IDA Ireland. It will take submissions from all sides and will carry out its own analysis. It will be asked to make its recommendations by the end of May 2008 and its recommended fee level, subject to Government approval, will be backdated to 1 March 2008.

The requested date for submission of the report is 31 May 2008. The development of the substantive new contract will get under way immediately and will be completed as soon as possible. This will be done under the auspices of an agreed facilitator and it will be priced by the independent body. The HSE, as the contracting body, and the IPU, as the representative organisation for community pharmacists, with other stakeholders will be entitled to make submissions to the independent body on issues of concern to them. The Minister believes this will provide all concerned with a reasonable way to make the transition to a fair and transparent method of payment for present services and a greatly developed pharmacy service in the near future.

Vaccination Programme.

Deputy Joan Burton

The BCG vaccine was last available in the middle of October last year. I was advised by the HSE on 3 December last that a new stock of vaccines would not become available until mid-February. I understand, however, that vaccines may not be available until the end of March, if even then, while tens of thousands of children are waiting on vaccinations and being potentially exposed to tuberculosis, TB, infection. Upwards of 50,000 newborn children could be exposed.

Eliminating the scourge of tuberculosis was one of the greatest achievements of Dr. Noel Browne as Minister for Health. At that time, approximately 60 years ago, the BCG vaccine first became widely used and it became central to the practical elimination of the disease in Ireland. As early as 29 March 2007, the Minister for Health and Children acknowledged an acute shortage of the vaccine in the House. The shortage came about as a result of problems with three vaccine shipments towards the end of 2006. The shortage was then described by the Minister as "temporary".

Until recently, the BCG vaccine was recommended for all newborn babies and it is usually administered to children during a short window between birth and the age of one month. Newborn babies have a natural immunisation up to the age of 12 weeks but after that they are exposed to infection by TB and other diseases. If there are significant vaccine shortages or delays, the possibilities for administering the vaccine during this 12-week period are greatly diminished. The first symptoms may not appear for up to 15 years, during which the infection can be passed on and this is of obvious concern to parents. The HSE has run several high profile campaigns to encourage greater immunisation. However, parents are completely confused as to what is the position and this calls into question the HSE's credibility. There is a risk of undoing all the good work undertaken on immunisation in recent years.

The incidence of TB in Ireland has been low for several decades but it has not been eradicated. There is no need to be alarmist about the possibility of a new TB pandemic, but we do not have a reason to be complacent. There have been isolated outbreaks of the disease in the recent past, for instance in Cork last year, while the incidence of TB infection has increased year on year in each of the past five years. The last dedicated TB hospital in the State, in Peamount, County Dublin, has been closed and that was a controversial decision.

Parents are understandably concerned about the lack of vaccines. The fact that the risk of infection is low is understood but they should be kept informed about what is happening. The Minister and the HSE have known about these problems for long enough. There is no good reason, a year after this came to light, the issue has not been resolved. I ask the Minister to get to grips with this as soon as possible to ensure no more children are put at risk.

It is emerging that the HSE's policy is to suspend BCG vaccinations. While there may be good reasons for that, parents and grandparents expect the vaccination for their newborn babies. They are being repeatedly informed about a continuous shortage of vaccines but they read in newspapers about cases of exposure to TB that must be addressed. Many immigrants are entering the State, some of whom come from countries with a higher incidence of TB. It is an extremely confusing scenario. The HSE needs to clarify whether there is a shortage of the BCG vaccine, which will be addressed given that the executive obtains all its supplies from one source, or whether a change in policy is under way by stealth whereby the State is moving away from BGC vaccination. If so, parents and public representatives need to be advised about what exactly is happening.

Deputy Brendan Smith

I am taking the matter on behalf of my colleague, the Minister for Health and Children. I thank the Deputy for raising this matter as it provides me with an opportunity to outline to the House the importance to the Department of Health and Children and the HSE of the issue raised.

The BCG vaccine protects against TB and is usually given to newborn babies, but can also be given to older children and adults who are considered to be at risk of developing the disease. The BCG vaccine has contributed to the dramatic decline in TB in the past 40 years. My Department has been informed by the HSE that, owing to regulatory difficulties being experienced by the manufacturer of the BCG vaccine, there is a shortage of the vaccine throughout the country. This is a Europe-wide problem as the manufacturer in question is the only company which supplies the vaccine to the European market. The HSE is in regular contact with the supplier and is doing all it can to ensure delivery of the vaccine at the earliest possible juncture. Unfortunately, it is not possible to stockpile the vaccine in advance as it has a very short shelf-life. It is anticipated that the HSE will receive fresh stocks of the vaccine early next month.

Parents of any new-born baby who has not received BCG vaccine owing to the current shortage will be contacted by their local health office with an appointment to receive the vaccine when the new stocks arrive. As the Deputy pointed out, immunisation is a safe, effective way to help the body prevent or fight off certain diseases. Immunisation is provided through vaccinations where a vaccine is administered to induce immunity. Under the childhood immunisation programme all vaccines and their administration are provided free of charge for all children. Parental consent is required for the administration of vaccinations to children and young people up to the age of 16. Vaccination is not mandatory in Ireland but is strongly advised by the Department of Health and Children.

The objective of the primary childhood immunisation programme is to achieve an uptake level of 95%, which is the rate required to provide population immunity, and to protect children and the population generally from the potentially serious diseases concerned. Ireland's recommended immunisation programme is based on the guidelines of the national immunisation advisory committee of the Royal College of Physicians of Ireland. These guidelines are prepared with the assistance of an active committee from associated disciplines in paediatrics, infectious diseases, general practice and public health. I again urge all parents to have their children immunised against the diseases covered by the childhood immunisation programme to ensure their children and the population generally have maximum protection against the diseases.