John Gormley
Question:74 Mr. Gormley asked the Minister for Health and Children his views on whether certain aspects of the Hanly report may not be implemented due to a lack of support; and if he will make a statement on the matter. [27648/03]
Ceisteanna – Questions (Resumed). Priority Questions. - Health Service Reform.
The Government is committed to implementing the Hanly report and my colleagues in Government will work with me to secure its implementation. In doing so, we will have full regard to the demographic and geographic factors affecting each region. The measures proposed will greatly improve services for patients. The proposals will bring services closer to local communities by providing a range of specialties not available there. A central tenet of the report is that patients should not have to travel outside their own region other than for the limited number of treatments that, for quality reasons, must be provided on a supra-regional or national basis. The report offers substantially improved acute hospital services to all, and the Government is committed to implementing it on this basis.
My original question was altered somewhat. It asked whether there was a lack of support within the Cabinet. The words "within the Cabinet" were deleted.
Censorship.
Yes. Does the Minister accept that there is a lack of support within the Cabinet and Government circles, as witnessed by the statements of the Minister for Defence, Deputy Michael Smith and the presence of Fianna Fáil Deputies at the 15,000-strong demonstration in Ennis last weekend?
Does the Minister believe that these Deputies have, somehow, misunderstood the implications of the Hanly report? Did the 15,000 people who demonstrated in Ennis misunderstand its implications or are they simply misguided or misinformed? What is the Minister's definition of downgrading? Does the removal of acute beds and accident and emergency services constitute downgrading? Why can the Minister not tell the House the unvarnished truth?
We have seen endless procrastination on the first Hanly report. We now understand that Hanly II, the sequel, is in the pipeline. When will Hanly II be published and what does the Taoiseach mean by demographics and geographics?
On all sides of the House many people who are close to the health policy, such as health spokespersons and so on, see merit in the Hanly report. Many have argued for multidisciplinary teams and a consultant-provided service to be put in place. There has never been an argument about those central tenets. We all agreed that we should have a consultant-provided service and greater services to the regions across a range of specialties, including dermatology, rheumatology and neurology, where regions currently lack basic services in some of those specialties. No one in the House has argued that we should not reduce junior doctor hours to 48 per week. We are all in favour of doubling the number of consultants, providing a consultant-provided service, reducing doctor hours and establishing multidisciplinary teams and centres of excellence.
At this point some people part company with the model. I hear these differences articulated at national level by party spokespeople. Across the House there are genuine concerns among Deputies from particular regions about what the report means for their local hospitals. That is a reasonable position and I accept that Deputies will have concerns. The challenge for those of us who formulate policy is to listen to those concerns and try to meet them within the parameters we have set ourselves. Mr. Hanly was given challenging terms of reference, not least the 48 hour working week.
It is important that we do not move to an extreme interpretation of the task force report. Mr. Hanly has not proposed the closure of any hospital or any accident and emergency department.
Has he proposed downgrading?
The Hanly report is concerned with patient care. The task force makes it clear that before anything can happen the first major development needed is further training and investment in the ambulance service, particularly training to the level of advanced emergency medical technician. That is a key component part of the Hanly recommendations, and nothing can happen until that happens.
The industrial relations issues of the renegotiation of the consultants' contract and the reduction of the working hours of non-consultant hospital doctors must be resolved. No service will be transferred from one hospital to another until the necessary investment is made and the necessary facilities put in place to enable hospitals to fulfil the roles given to them.
We intend to put project teams in the Mid-Western Health Board and the East Coast Area Health Board regions which will include representatives of the local hospitals and will be independently chaired. These project teams will work out the details on the ground in each region. Phase two, which was signalled in the Government decision of last June and in the October announcement of the Hanly report, will cover the rest of the country.
Demographic and geographic considerations mean that people living in Donegal and on the western seaboard, for example, have considerations. Of course there are geographic issues which must be considered in organising acute hospital services in the future. That is what the Taoiseach meant and that is why the Government put it into the decision.
When will Hanly II be published?
After the local elections.
Deputy Neville is very cynical.
Have the doctors and all those who spoke so eloquently from Ennis on "Prime Time" last night got it wrong? One of them even said the Hanly report would cost lives. Are they exaggerating or have they got it completely wrong?
One can speak very emotively about measures costing lives.
It was said last night.
One could equally argue that failure to do certain things could cost lives in the future.
Dan Neville
Question:75 Mr. Neville asked the Minister for Health and Children the stages, timescale of same and detailed costings of the introduction of the national task force on medical staffing in each pilot region; his views on the refusal of some to endorse the recommendations of the report; and if he will make a statement on the matter. [27646/03]
The Government is committed to implementing the recommendations of the national task force on medical staffing. The measures proposed will greatly improve services for patients by developing a consultant-provided service, reducing the working hours of non-consultant hospital doctors and reorganising acute hospital services, including the achievement of regional self-sufficiency.
In the two phase one regions studied in depth by the task force – the east coast and mid-west – I will shortly be appointing project groups to progress detailed implementation at local level. This will include identifying the exact services to be provided in major and local hospitals in the two regions and the medical staffing implications of these changes. No changes will be made in services until hospitals have the required facilities and staffing to take on the new roles proposed for them.
I will shortly appoint a group chaired by Mr. David Hanly to examine how acute hospital services in the rest of the country should be reorganised in line with the principles of the task force report. These principles include taking full account of geographic and demographic considerations. The group will work closely with my Department and, on its establishment, with the national hospitals office.
In the two phase one regions, I anticipate that implementation of the changes in acute hospital services and increases in consultant staffing will progress over the coming years. For the rest of the country, I propose that implementation should commence as soon as the phase two report has been completed in conjunction with the national hospitals office and considered by the Government. The task force report envisages that the full implementation of its proposals for a consultant-provided service would take place over a ten year period.
I will shortly be appointing project groups to progress detailed implementation at local level in the two regions studied by the task force. The project groups will be asked to identify the exact services to be provided in major and local hospitals in the two regions.
In addition, I will soon appoint a group to advise on the reorganisation of acute hospital services nationally. This will be chaired by Mr. David Hanly. It will be asked to apply the principles of the task force report to the rest of the country and to devise a national plan for the reorganisation of acute hospital services.
The Hanly report clearly states that the local hospitals would have staff necessary to provide a full range of out-patient and day sur gery. Mr. Hanly is very clear about the accident and emergency services to be provided by local hospitals. Having taken demographic and geographic issues into consideration, does the Minister agree that Ennis General Hospital, St. Joseph's Hospital in Nenagh and St. John's Hospital will be graded as local hospitals, as interpreted by the Hanly report?
Deputy Neville's interpretation is very narrow.
What about section 371?
I am talking about the template provided by the report. Critical to the template is the first responder service, the ambulance service. This is the No. 1 critical provision which must be made. There must be training to emergency medical technician level. Second, there must be a strong primary care infrastructure, which is manifested in the GP co-operative approach and gives better round the clock primary care cover. Third, Hanly recommends the provision of an additional range of services to hospitals and more services to those hospitals than they currently have. There is provision in terms of what each hospital should do.
We must appoint a project team for the two regions to work out the details of the Hanly recommendations in so far as they apply to the hospitals. There will be representatives on the project team from the areas and from the hospitals in the areas who can influence developments. I also envisage the team being chaired by an independent chairman.
The Irish Hospital Consultants Association has calculated that there is a need for 104% bed occupancy in the mid-western region's hospitals to cater for the recommendations of the Hanly report. That involves considerable capital expenditure. How much money has been set aside in next year's Estimates for capital expenditure to implement the Hanly recommendations in the two areas?
It is a matter for the project team to assess what needs to be done and what current and capital expenditure will be required. It would be foolish to ring-fence anything in advance. There will be funding.
Why did the Government cut the budget?
An Leas-Cheann Comhairle
Supplementary questions are confined to the Member who asked the original question.
The project team will assess what is required from a capital perspective, not just in Limerick but also in Ennis and Nenagh. Ennis hospital also needs upgrading and the Hanly recommendations will not stop this, if this is what people fear. I have made it clear that services will not be switched or changed until there has been investment in specific facilities in hospitals to accommodate that change. One should bear in mind that much of what Hanly has proposed is de facto already in place in many regions.
In Ennis on Saturday the representative of the consultants, Dr. Hennessey, stated that the golden hour, which is the first hour after an emergency, be it a serious accident or a heart attack, is vital. I have verified this statement. During the day, it takes two and a half hours to travel from west Clare to the Mid-West Regional Hospital. Does the Minister agree with the view of Dr. Hennessey and the consultants that, based on their calculations and experience, nine to ten lives are likely to be lost annually?
The medical advice to Hanly is that a first response based on good training is critical in the cases of heart attacks or road accidents. Many accidents happen in locations that may be an hour or two from a hospital, as we know. What is needed is a strategically well-resourced and expanded service in the regions thus affected.
The ambulance will replace the consultants in the hospitals.
I am not saying that. At present, senior consultants are not in hospitals after 8 p.m. anyway. We have junior doctors in place who can certainly be of assistance in the case of an accident. We do not have senior clinical decision makers in our hospitals at midnight or 2 a.m.
Does the Minister accept the concept of the golden hour?
As I stated in my speech on the Hanly report, the critical intervention has to be the first response. This can often be on the part of the emergency medical technician. We should not eliminate this from the equation.
The Hanly report was largely influenced by medics of significant experience, qualifications and status who would not want to make proposals that would risk life. It is not the business of the medics on the Hanly group to make proposals in a premeditated fashion that would somehow cause injury, damage or loss of life.
An Leas-Cheann Comhairle
There are other questions on the Hanly report and therefore we will move on to Question No. 76.
That should also be accepted as we enter into this debate.
Caoimhghín Ó Caoláin
Question:76 Caoimhghín Ó Caoláin asked the Minister for Health and Children the way in which his Department's allocation in the Estimates for 2004 will be spent; the increased charges to patients arising from the Estimates; the way in which the promised further acute hospital beds will be delivered from this level of funding; the way in which the promised widening of eligibility for medical card cover will be provided; and if he will make a statement on the matter. [27789/03]
The Abridged Estimates for 2004 were published last week by my colleague, the Minister for Finance. They show an increase of €891 million in health spending, bringing the total spend for 2004 to €10.05 billion, including capital. This is an increase of 10% on the Revised Estimate for 2003 and an increase of 10.4% on the Revised Estimate of last year in respect of day-to-day current spending. Given the overall increase in spending on public services, this additional €891 million underlines the Government's commitment to maintaining health spending into 2004.
Having secured an increase of 10%, which is almost double the overall Government increase in spending, my challenge is to manage this budget in the best interests of patient care. In accordance with legislation, the letters of determination to the health boards must be sent out by my Department within three weeks of the publication of the Abridged Estimates.
The additional funding will provide for the effects in 2004 of Sustaining Progress, benchmarking for public servants in the health sector and a number of technical adjustments to the health Vote. Pay costs form a significant part of overall expenditure in a labour-intensive sector such as that of health. The pay bill, inclusive of benchmarking, will require an additional €500 million in 2004. The health service depends critically on being able to continue to recruit high-calibre staff in all disciplines in a highly mobile area where the international competition for health staff is intense.
Additional funding of €187 million is being made available to meet the increased cost of the general medical services scheme. This represents an increase of 19%. Additional funding of €50 million is being provided to meet the increasing costs of the drugs payment scheme.
The Estimate also provides €32 million for the treatment purchase fund, which will ensure that 9,500 of those waiting longest will be treated in 2004. This is in addition to €43 million for waiting list activity.
Capital funding of €509 million will be provided in 2004 to facilitate further improvement of health infrastructure. This will allow for progress, from planning to construction, on projects throughout the country. Funding for information systems and related services has doubled to €60 million. This capital funding will be used to bring the health services into the information age.
On the provision of additional beds in 2004, my first priority will be to maximise capacity within the existing hospital system. I will have the flexibility to prioritise selected areas within the overall funding available to me, but that will not allow for the commissioning of new capacity in the acute hospitals during the coming year.
There will be an increase in the income for public hospitals from the charges raised by these hospitals from private beds. This increase will be 15%, thus providing additional income of €20 million. This income goes towards supporting services in public hospitals and therefore is part of their budgets. Even with this increase, the cost of providing services to private patients in those hospitals is far greater than the income from the private insurance companies. In the major teaching hospitals, for example, it is estimated that the income from private beds represents less than half the cost of treating private patients. In the interests of equity, it is Government policy to eliminate this subsidy gradually. The increase being implemented will, in a small way, close the gap.
There will also be an increase of €5 in the statutory in-patient bed charge, bringing it to €45 per night. Accident and emergency charges are also being increased by €5 to €45, which will contribute to meeting the growing costs of providing accident and emergency services but will also help avoid inappropriate attendances at accident and emergency units where an alternative may be available. There will also be an increase in the current threshold of €70 per month to €78 per month for the drugs payment scheme.
Additional informationAs the Deputy is aware, the health strategy includes a commitment that significant improvements will be made in the medical card income guidelines to increase the number of persons on low income who are eligible for a medical card and to give priority to families with children, especially those with a disability. This should be viewed in the broader context of the strategy's emphasis on fairness and its stated objective of reducing health inequalities in our society. Due to the prevailing budgetary position, I regret that it will not be possible to meet this commitment next year, but the Government remains committed to the introduction of the necessary changes within its term of office.
I thank the Minister for his comprehensive reply. Does he agree that raising the qualified threshold for refunds of the cost of medicine under the drugs payment scheme and the increased cost of access to accident and emergency services will further penalise those to whom the Minister's party promised to extend the medical card scheme in advance of last year's general election, that is, some 200,000 citizens? These are the very people who, in the first instance, are marginally above the income limits for qualification for a medical card and yet clearly cannot afford private medical cover. They will now be charged more, in many instances – I do not say this glibly – for lying on trolleys in accident and emergency units in different sites, given that time will show that many sites will actually remain in different parts of the country, as I know from my experience in Monaghan. When the Minister talks of the Hanly report as a blueprint, we know exactly from where he borrowed the idea. My area was the experimentation ground.
My question sometimes seems to have fallen off the table over the past 12 months. Where is the provision in this Book of Estimates to cover the political promise made to the 200,000 people to extend to them the general medical card scheme? A commitment was made and I see no provision in the Estimate. Will the Minister address this specifically?
I noted the Minister's reference in his reply to private beds in the public hospitals. He indicated he has increased the cost in that area by some 15%. I noted that BUPA has stated it does not intend to pass on this charge at least until the coming year. This is no big deal because it is only a month away. What of the VHI? In recent years the Minister approved substantial increases in the cost of voluntary health insurance. What guarantees can he give that we are not faced with a further year of significant increases in VHI costs which many find difficult to afford? Many families place themselves in financial hardship to obtain private health cover. What does the Minister propose to do or what guarantees can he offer that they will not now face a further significant rise in the cost of private health care?
Does the Minister agree that all these factors demonstrate the wholly unacceptable folly of the continual acceptance by his Government and previous ones of the two-tier system that obtains in our hospitals? Does he also agree that, until such time as we have a real reforming Minister with the support of a reforming Cabinet dedicated to health care provision, these injustices and inequities will continue?
Despite his great final flutter of rhetoric, the Deputy still attacked the increase in private bed charges.
I am asking the Minister what guarantees he plans to give ordinary people.
This is the kind of rhetoric I have to put up with from time to time and it is hypocritical.
It is not hypocritical.
It is paradoxical. One cannot say on the one hand—
A large body of people, who should not be in the private health care sector, has been forced to take private health insurance.
If there are genuine equity issues in terms of the taxpayer, we need to agree on whether there should be a subsidy from the taxpayer for private health insurance.
What is the Minister providing?
To be fair, the Deputy has made a broader proposition. We need to look at the wider picture. For example, investment in the treatment purchase fund is a considerable commitment which we are honouring. It is also delivering significant equity in terms of waiting times which have dramatically reduced for those waiting longest.
They have fallen by 3%.
This is particularly the case with regard to those who were waiting more than 12 months when the treatment purchase fund was initiated. Virtually all of them have since been treated. In terms of equity in cardiovascular and cancer policy, we have made dramatic improvements in cancer treatment in the areas of diagnostics, screening, treatment and interventions and a number of additional consultants have been appointed. These improvements apply across the entire population, irrespective of whether one has money. We have made significant progress on the cardiovascular front in terms of surgical interventions. In addition, I receive positive feedback from patients every day about the cardiac rehabilitation programme.
One can isolate certain areas in which there has been a negative development. I do not like increasing charges and agree with Deputy Ó Caoláin on this issue. Every politician would prefer to be in a position not to have to increase charges. The Government has, however, dramatically increased access to the drug payment scheme. Under the previous scheme, people had to apply to their health board for refunds, which many did not bother to do. We changed that system with dramatic results. The combined cost in 1998 of the two older schemes was, I believe, around €94 million, while the cost of the current scheme is €192 million each year.
We are, therefore, increasing resources for the drug payment scheme and more people are availing of it. Drugs are becoming more expensive and as a consequence we have increased the threshold from €70 to €78. While I am not enthused about having to impose this increase, which will probably yield about €10 million, it is taking place in the context of a budget which has risen from about €98 million to €192 million.
The Minister did not respond to my question concerning the commitment given by the Government prior to the general election that it would extend the medical card scheme to a further 200,000 people. This is not the first time I have not received an answer to my questions.
The Deputy asked about ten questions.
The Minister chose not to answer a very important one.
I will answer it now.
I have a further question. How will the promised additional acute hospital beds be provided for from the Estimate? Is the Minister aware that the Irish Nurses Organisation has indicated that rather than providing for additional beds, the current complement will be difficult to maintain under the figures provided in the Book of Estimates?
I have already answered the question on medical card provision. We regret we are not in a position to provide for the expansion of the general medical card scheme to a further 200,000 people. Notwithstanding this, the budget for the scheme will increase by €187 million. The commitments made in the programme for Government have a five-year lifespan attached to them. We do not do everything in the first two years of Government and if the budgetary position improves—
The Minister promised the additional beds within two years.
We are not in a position to do so given the budgetary position.
We will hold the Minister to that.