Priority Questions.

Health Service Staff.

James Reilly


74 Deputy James Reilly asked the Minister for Health and Children if, in relation to her statement at the Irish Nurses Organisation annual conference on 21 September 2007 she is still of the view that patient care will not be affected by the ban on recruitment or the cost cutting measures imposed by the Health Service Executive; and if she will make a statement on the matter. [24453/07]

Jan O'Sullivan


75 Deputy Jan O’Sullivan asked the Minister for Health and Children if she is still of the view that the embargo on recruitment of staff by the Health Service Executive is not affecting patient care; the level of involvement she and officials in her Department had in decisions with regard to staff issues, including the increase in grade eight managers from ten in 2000 to more than 500 at present; the way the embargo is impacting on the implementation of Government health policies; and if she will make a statement on the matter. [24088/07]

I propose to take Questions Nos. 74 and 75 together.

There are close to 130,000 people employed in the delivery of our public health and personal social services, the vast majority of whom provide direct service to patients and clients. The current pause in recruitment must be viewed in this context. It is a temporary measure put in place by the HSE to live within its budget. It will be reviewed at the end of October and it is being monitored by the HSE on a week by week basis.

The HSE must be able to manage within the resources made available to it by the Government and voted by the Dáil. It should not come as a surprise to anyone that managing the budget in the health sector means managing staff. Staff costs make up almost 70% of the HSE's overall budget. It is unreasonable to suggest that in a service of this scale and with an employee cohort of this size, every vacancy which arises must be filled immediately and, if not, dire consequences will result. Living within budget and making the best use of the available resources is an essential task of any sound organisation. Reforming our health system is not just about extra funding and extra posts, it is about ensuring that the extra money which has already been invested by the Government on behalf of the Irish people is being used wisely and efficiently.

The gradeeight title was first introduced in 2000 as a result of an industrial relations agreement. Staff would previously have held other titles such as hospital managers, disability service managers, accountants, industrial relations officers and IT personnel. This explains why the numbers of posts categorised as grade eight was very low in 2000. However, I share the concerns about the growth in posts at grade eightfrom 521 to 713 between late 2005 to June 2007. As part of a new employment control framework introduced in December 2006, the HSE is now required to get my Department's approval for the filling of posts at grade eight or above. Despite the controls that are in place now, the numbers are running ahead of expectations. I am awaiting a report from the HSE on this.

Many of the actions taken by the HSE to control its rate of spending in the last three months of this year have demonstrably no effect on frontline services. Some of the claims made about alleged effects on services are without justification. For example, the cancellation of foreign travel and the release of temporary summer holiday cover staff cannot mean a reduction of services. Claims of this nature should be assessed in the context of the HSE's overall activity levels. For each of the last three months of this year, there will be more than 100,000 patients treated as inpatients or on a day case basis in publicly-funded acute hospitals. That will continue to be the case.

However, the HSE recognises the importance of staying within annual budgets and staffing levels, as well as managing activity throughout the year so that planned annual service increases are achieved in an orderly manner over the whole year. It is ultimately no service to patients if hospitals or any other cost centres overrun budgets and staffing levels in the early part of the year, causing a slowdown of activity in their own service or in any other service later on. Any postponement of an operation or service arising is naturally very disappointing to individual patients and clients.

I have listened to the Minister's response and it is nothing more than what we have heard before. The reality for people comes from the effects of the cutbacks which the Minister promised on "Newstalk" would not happen. When these cutbacks were exposed, she denied they would have any effect on patient care. Both these claims have been found to be false. People in Ennis have had their facilities cancelled so that they can be referred to a centre in Galway, but because of the cutbacks cancer services there have been reduced from five to three days. The Minister cannot tell us that those people will not suffer. Hours are being reduced in Beaumont Hospital, and in St. Joseph's Hospital beds have been occupied due to the detection of Legionnaire's disease in a nursing home, the consequence being that beds for elective surgery are occupied and surgery lists are being slashed.

Has the Deputy got a question?

The question is about the home care packages for the elderly that have been taken away, about the stroke care in Merlin Park Regional Hospital that has been taken away and about the removal of 22 beds that were to be transferred to a community facility to free up beds in the National Rehabilitation Hospital. Why will the Minister not take control or responsibility?

The HSE will not answer Deputies. When we ask questions we get facetious responses. I asked a question on ambulance services and trolleys and I was given an answer which made absolutely no sense. There is no transparency in the HSE and not even the Comptroller and Auditor General can get a response. Where is the evidence of the increased productivity of this large number of bureaucrats in the HSE? When will the Minister take responsibility for this?

There are quite a few questions to be answered. When I was commenting on the freeze on recruitment at the conference of the Irish Nurses Organisation, it was in the context of an increase of 2,500 in the numbers employed by the HSE during the course of 2007. There has not been a reduction in staff, but an increase. One of the challenges facing us is to make sure that staff numbers are in line with approvals from my Department and the Department of Finance.

I also spoke specifically about some hospitals. Where 40 nurses are taken on to cover holiday relief, when the holiday period is over there is no need to keep those nurses. Why is it that in Sligo General Hospital there are 1.8 nurses per bed but only 1.3 nurses per bed in Waterford Regional Hospital? We need to look at some of these wider issues.

In our health system, about 16% of the staff are in administrative roles, a figure which is at 18% in the NHS. The HSE is currently carrying out an audit of management and administration, which I support. I am not saying we have the right balance. There is scope for a voluntary redundancy programme and I hope that can be discussed in the new health forum that will be established.

What about the cancellation of operations in the orthopaedic department at the hospital in Navan? Up to 180 patients are being operated on per month in that hospital, but the Department has stated that a mere six operations have been cancelled.

The Minister must clarify that.

This is Priority Question time and it is restricted——

This is a priority issue.

——to the nominated spokespersons of each party.

I have been informed that six patients were given appointments for the month of December. I have also been informed that there has never been a month at that hospital when 200 procedures were carried out.

I said 180 operations were being carried out.

They carried out 1,600 in the first nine months of the year so the Deputy should divide that. It would be remarkable if the hospital carried out more operations in December than in any other month.

Was the hospital not shut for January and February?

The Minister is misleading the Dáil.

Allow the Minister to answer the question. The nominated spokesperson of the Fine Gael Party is the only Deputy allowed to speak during Priority Questions.

I want clarity, not untruths.

When we get to other questions, every Deputy can pose a question. These are the rules that you have laid down. I would now like to call Deputy Jan O'Sullivan, who has also tabled a Priority Question.

That is unfair. Will the Minister please clarify whether she believes the information about the six patients? This is very serious. Is it true or not true? Is this House not about truth?

The Deputy will have some respect for the Chair.

I will have respect for the Chair, but there should be respect for the truth as well.

Will the Deputy have some respect for the Chair? When the Chair is speaking——

I have no problem with respect. You and I both know it will not come up in later questions.

I call on Deputy Jan O'Sullivan to ask her question.

The Minister set up the HSE nearly three years ago to centralise the system so that bureaucracy could be reduced and more funding could be released for direct patient care. What monitoring does the Minister carry out on the HSE? The growth in senior management numbers is extraordinary, in spite of her explanation today. What hands-on relationship does she have with the HSE to ensure that we do not spend scarce health money on bureaucrats when it should be spent on patients? If she can give me a clear answer we might have some understanding of what is going on.

Does the Minister think it makes sense that patients who are ready to go home are occupying specialised beds in the National Rehabilitation Hospital? Patients who need to come in, such as a man who received serious head injuries in a farm accident, cannot do so because other people who are ready to go home are occupying beds. Can the Minister comment on this crazy use of funding for specialised health services?

I received a copy of a letter sent to the Minister by 93 general practitioners in Sligo. With regard to the HSE embargo, they say, "To state that these moves will have no effect on patient care is dishonest and wrong and is insulting to the professionals involved". Are these 93 doctors wrong when they say that patients are directly impacted upon by these cuts? Will the Minister use her power to ensure that the HSE does not continue with this embargo, which is hurting patients?

As the Deputy is aware, much analysis of our health system was done in the run-in to the reform programme. The Prospectus, Brennan and other reports all made the central recommendation that the fragmentation of services was not delivering efficient health care. That is a view I strongly share. We would never have established 11 boards to administer health care in a population of 4.3 million. We could not have introduced the cancer control programme if we had that kind of fragmentation.

The role of the HSE is clear. It is responsible, with the chief executive officer as Accounting Officer, for the delivery of services. The Minister remains responsible for policy and has overall responsibility for health. I take an appropriate role. I am not involved in operational issues.

Surely there are policy issues in how money is spent.

I meet with the CEO and chairman of the HSE at least once, and sometimes twice, a month. There is also a Cabinet sub-committee. The CEO does not report to me but to the board of the HSE. The chairman reports to me.

The HSE is required to get prior approval from my Department and the Department of Finance before an employee is given grade eight status.

Must the Minister approve these posts?

Yes, we must approve them. That has been the procedure since December 2006. Notwithstanding the need for that approval, the numbers seem to be ahead of expectation. I have asked for an explanation of that from the HSE.

We must be fair to those hospitals which are currently living within their budget. Hospitals such as the National Maternity Hospital, Holles Street, notwithstanding the huge increase in births, the Mid-Western Regional Hospital in Limerick and Waterford Regional Hospital can live within their allocated budget. We expect other hospitals to do so. The ratio of nurses to patients in Sligo is 1.8 per bed while in Waterford it is 1.3 per bed. Perhaps the general practitioners should look at some of these issues.

Spending on health has increased by 370% in the past decade, which is seven times the rate of inflation. The British Government is talking about a targeted increase in health spending of 4% above inflation. Unless we live within budgets, the health system has the capacity to be unsustainable and to damage the economy. We must all recognise that point. This should not be incompatible with providing services.

If patients are fit to leave the rehabilitation hospital and others need to go in there, it does not make sense for that not to happen. The HSE has confirmed that homecare packages will be made available so that patients can return home from the National Rehabilitation Hospital and others can be admitted there.

Community Pharmacy Services.

James Reilly


76 Deputy James Reilly asked the Minister for Health and Children the steps she has taken to ensure the continuation of services in the dispensing of methadone to people participating in drug treatment and rehabilitation programmes; and if she will make a statement on the matter. [24454/07]

I am disappointed that a significant number of pharmacists have chosen to discontinue providing methadone services to patients. This is the second time in recent years that pharmacists have targeted the methadone scheme in response to unrelated issues. It is unfortunate that community pharmacists have once again chosen to target some of our most vulnerable patients — recovering drug users who are stable enough to be treated in the community setting — in this way.

I understand that the Competition Authority is examining whether the action of pharmacists in withdrawing from dispensing methadone to patients may be in breach of competition law. Currently, the pharmacists' action is mainly in the Dublin area with threatened escalation countrywide later. As of Monday, 15 October, some 140 pharmacists in the Dublin area have withdrawn from the methadone protocol scheme. This action affects approximately 3,000 patients.

There is a significant clinical risk of overdose to patients who revert from a methadone maintenance programme to opiate use. In these circumstances, the HSE has developed a contingency plan to ensure continuity of service and to minimise any hardship to patients. Since last Monday, the HSE has been implementing that plan. The HSE has made alternative arrangements for the emergency dispensing of methadone to the patients involved in 13 centres. The HSE's drug helpline is available on a seven day a week basis to provide information to clients in relation to the contingency arrangements. The HSE has indicated that to date the contingency plan is operating satisfactorily. The situation in the rest of the country is being monitored closely and arrangements are ready to be implemented in the event of an escalation of the action nationwide.

I acknowledge the work the HSE is doing to ensure continuity of care to patients in these very challenging circumstances. I also appeal to the pharmacists who have withdrawn their service to reconsider their action in the light of their professional and ethical obligations.

I understand a contract to take 22 patients out of the National Rehabilitation Hospital to a community facility has been cancelled because of cutbacks.

Deputy Reilly, please ask a supplementary question.

Before I ask a question, a Leas-Cheann Comhairle, I hope you will allow me a little preamble.

That is normally permitted if it is relevant to the question.

Many people are seriously disadvantaged because of this dispute. I do not condone the action of pharmacists in putting patients at risk although, like many Members, I recognise their frustration with the HSE. The HSE has had ample opportunity to put its contingency plan in place and it is very poorly thought out. There was no consultation with communities and the only information I have has been gleaned locally.

Only one dispensing centre has been provided for all of Dublin North. It is on the most northerly peninsula in the area and is very inaccessible. Patients who have been off heroin for some time, are holding down jobs, have families and are making their contribution to society are being put at risk. They are being corralled into small areas in Dublin North and other parts of the city and drug dealers are circling them like sharks. People who have kicked the heroin habit need help and support. I ask that the Irish Pharmaceutical Union withdraw its action, that the Minister instruct the HSE to defer its action and that an independent impact assessment take place to allow the dispute to be resolved.

Does the Minister think it is wise for officials of the Competition Authority to be visiting community pharmacies in the company of gardaí? Does she agree that this action is likely to inflame the situation rather than help it?

I welcome Deputy Reilly's statement that he does not condone the action of the pharmacists. Most people would support that view.

Methadone users are a very vulnerable group of patients and the HSE has had to put a contingency service in place very quickly. The feedback I have received from a number of people has been positive. The service is not as good as that provided by pharmacies, which are much more accessible, but the HSE has done its best, in the circumstances, to provide a facility. I am not familiar with the details of all 13 centres but I will draw the attention of the HSE to the Deputy's concerns, particularly with regard to Dublin North.

The Government does not have responsibility for the Competition Authority. We are governed by European as well as Irish competition law. This morning, I heard a reference to changing the Irish Competition Act. When the HSE was negotiating a wholesale margin, the wholesalers produced legal advice that negotiation with the HSE contravened competition law. It was the wholesalers who first brought our attention to the fact that negotiating with a group such as pharmacists — this will subsequently apply to dentists and other professions — is in breach of Irish and European competition law and amounts to cartel behaviour. It is equally the case that people cannot act as a group to prevent a service in a market. These are matters for the Competition Authority, not the HSE or me.

Has the Attorney General given his opinion on the matter?

We have received an opinion from counsel on behalf of the Attorney General on this matter. The HSE has its own opinion, as do the pharmacists. At my behest, some months ago Mr. Bill Shipsey, senior counsel, was asked to act as facilitator, which is allowed. I understand a meeting was held last week and that another took place yesterday. I hope that through this process we can reach agreement on some of the issues involved. The key factor is money. As a result of the new arrangements in respect of the wholesale margin and the new deal with the producers of medicines, we will save approximately €660 million over four years. We pay the middle range price in the European Union for drugs. However, the Irish consumer pays the highest amount in Europe for medicines. This is not acceptable. We must reduce the escalating cost of drugs in the health care system — the figure currently stands at €1.5 billion — by getting better value for money and, in particular, paying pharmacists a professional fee to dispense rather than a fee based on a 50% margin which everybody will accept is not appropriate.

Cancer Services.

Jan O'Sullivan


77 Deputy Jan O’Sullivan asked the Minister for Health and Children the resources that have been and will be allocated for the implementation of the national cancer control programme; the immediate resources available to ensure continuity of care for patients affected by the ending of symptomatic breast services and surgical treatment in 13 hospitals in different parts of the country; and if she will make a statement on the matter. [24089/07]

Implementation of the national cancer control programme is a major priority for me and the Government. I fully support the appointment by the Health Service Executive, HSE, of Professor Tom Keane as interim national cancer control director. The delivery of cancer services on a programmatic basis will serve to ensure equity of access to services and equality of patient outcome, irrespective of geography.

The recent decisions of the HSE to designate four managed cancer control networks and eight cancer centres will be implemented on a managed and phased basis. A detailed transitional plan will be put in place to facilitate the progressive, gradual and carefully managed transfer of services during the next two years or so. The HSE plans to have completed 50% of the transition of services to cancer centres by end 2008 and 80% to 90% by end 2009.

To comply with the national quality assurance standards for symptomatic breast disease, the HSE has directed 13 hospitals with low case volumes to cease breast cancer services immediately. The 13 hospitals concerned performed a combined total number of 55 breast cancer procedures in 2005. A number of the hospitals had in practice already discontinued symptomatic breast services. The National Hospitals Office has planned the redirection of this symptomatic caseload. Further staged reductions in the number of hospitals providing breast cancer services will occur in the next two years in line with the development of quality assured capacity in the eight designated centres.

Professor Keane and the HSE have emphasised the importance of mobilising existing resources and redirecting them to achieve the national cancer control programme objectives. An additional €20.5 million was allocated to the HSE this year for cancer control, an increase of 74% on the comparable 2006 investment and includes €3.5 million to support the initial implementation of the national cancer control programme. Further investment in cancer control will be based on the reform programme now being implemented by the HSE.

I did not hear the Minister mention the resources that will be available in the future, although she did speak about those that will be available this year. The brave fight by Susie Long, who sadly passed away at the weekend, has shown how essential it is that there are adequate resources available in the public health service for cancer treatment services. I want a commitment from the Minister that there will be adequate public resources to address the development of this programme. What she said and what was contained in the press release following Professor Tom Keane's appointment appears to relate to a redirection of existing resources. We know that the incidence of cancer is growing at a rate of 4% to 5% per annum. Clearly, this will result in increased demand. I am concerned that the Minister is again setting up something that will be at a distance from herself as Minister for Health and Children and that as such, we will not be able to raise questions with her in respect of accountability to the public for the provision of adequate resources to address this most important issue which affects every family in the country.

The issue of standards is one for the Minister. Even with the establishment of the Health Information and Quality Authority, HIQA, standards have to be signed off on by the Minister. I appointed Professor Higgins who, if not the leading Irish expert in this field, is certainly at the top of the class in this regard. His recommendations on standards were endorsed by the Government earlier this year and have now been implemented.

Two issues arise. A great deal more money will be invested in cancer treatment services because as the Deputy said, many more people will suffer from cancer. One in three of us will suffer from some form of invasive cancer during our lifetime. This will be a big challenge for the health service. In addition, we will need to redirect resources. The provision of additional resources is not always the answer. Professor Keane did a good job in Canada and is the ideal person — he was educated in Ireland — to oversee implementation of the programme, which I welcome.

In the context of next year's budget for the health service, the existing level will be announced by the Minister for Finance tomorrow. Other initiatives will be announced on budget day. In that context, cancer services have a high priority, both in terms of screening, as the Deputy acknowledged, and on the service delivery side.

The death of Susie Long was a dreadful tragedy. Her situation should never have happened. She went to a public hospital, totally funded by the taxpayer, and was told if she had health insurance, she could have had her procedure the following week. Because she did not have insurance the procedure was not carried out until six months later.

There are thousands like her.

Changing this has been central to my approach and that of the Government in the context of the consultants' contract.

I do not understand how co-locating public and private hospitals on the same site with different doctors will change it. However, I do not have time to deal with that issue today.

On the list of hospitals which have been told they must cease immediately the provision of cancer treatment services, will extra resources be made available to the so-called centres of excellence in this respect? For example, a general surgeon who performs a small number of cancer related operations cannot be transferred to a centre of excellence. Will the Minister clarify that the required resources will be made available and that those patients currently being treated in the smaller hospitals will have access to services?

The Deputy referred to general surgeons. In 2005 one procedure was carried out at the Midlands Regional Hospital, Tullamore; two were carried out at St. Columcille's Hospital, Loughlinstown; two were carried out at Mercy University Hospital, Cork; two were carried out at St. Michael's Hospital, Dún Laoghaire, and three were carried out at Mallow General Hospital. The number of procedures carried out at the Mid-Western Regional Hospital in Ennis was seven. Portiuncula Hospital had the highest number, having carried out 17 procedures. No procedures were carried out at the hospitals located in Naas, Roscommon, Cavan and Navan. Clearly, as the volume of activity increases, resources will follow as far as possible. University College Hospital Galway has a staff of 2,674. The number has increased rapidly in recent years as a result not only of the availability of cancer treatment services but also cardiovascular and other specialties.

What about the hospital in Castlebar where 70 procedures were carried out last year?

That is not one of the 13 hospitals listed, as the Deputy well knows.

It is under threat.

The Minister should confine her remarks to the questions asked.

I am always nice to new Deputies.

When do we become old Deputies?

Not until after at least one term.

Accident and Emergency Services.

James Reilly


78 Deputy James Reilly asked the Minister for Health and Children the progress made to improve the situation within accident and emergency departments with regard to her ten point plan for accident and emergency services, her description of the accident and emergency crisis as a national emergency in March 2006, the establishment of a task force on accident and emergency services and the subsequent publication of the emergency department task force report; and if she will make a statement on the matter. [24455/07]

Improving the delivery of accident and emergency services continues to be a top priority for the Government and the Health Service Executive. Our objectives are to further reduce the numbers waiting for admission, the time spent waiting for admission and the turnaround time for those who do not require admission. The Health Service Executive continues to report a significant reduction in the number of patients awaiting admission as compared with the same period 12 months ago. During the first nine months of 2007 the average number of patients awaiting admission each day was 91. This compares with an average of 165 patients during the first nine months of 2006, representing an average reduction of 45%. The initial target waiting time of 24 hours from decision to admit is now being met by the majority of hospitals and the HSE has introduced a revised target of 12 hours since the beginning of this month. The ultimate objective is a total wait time target of six hours from the time a patient presents at the emergency department to the time he or she is either admitted to an acute bed or is treated and discharged home.

Following publication of the emergency department task force report on 1 June, the HSE has commenced a formal process of engagement with the Irish Association of Emergency Care Medicine. The association has agreed to work with the HSE on a range of issues, including the standardisation of patient processes and pathways within emergency departments.

Does the Minister accept that the HSE's method of measuring waiting times in accident and emergency departments does not bear scrutiny? The waiting period should commence from the time the patient arrives in the accident and emergency department. However, the clock does not start until a decision has been made to admit the patient. That is not the truth, because the time starts when the SHO or the registrar from the medical team comes downstairs to confirm the admission. The consultant in the accident and emergency department has already made the decision and the waiting period should be measured from that time. As the Minister admitted, the 12 hour target is not being met and I would like to know when it will. Furthermore, what is the timeframe for meeting the six hour target? Where is the acute medical unit for Beaumont Hospital which was supposed to speed up patient waiting times? The unit in Navan hospital started today. How late is that? The number of patients on trolleys in the accident and emergency department in Galway has increased because of the cutbacks. The Minister mentioned Ennis and Galway but the medical board is convinced that with the cutbacks, there will be fewer beds and more patients on trolleys in accident and emergency departments and as a consequence, longer waiting times. Does the Minister accept the closure of the orthopaedic unit in Navan, with a resultant loss in procedures, will cause more people with complications from long-term medication use to attend at the accident and emergency department?

The national plan was introduced because there was a national emergency. Is there still a national emergency? There are 100 more patients on trolleys this month than there were this time last year. How does the Minister intend to address the problem?

I think I said the aim was to have patients treated within six hours from arrival time. The period should be measured from the time a patient arrives rather than the time he or she is eventually seen by a doctor. An issue in the negotiations on the consultant contract is having more consultant cover to ensure patients will be seen by key decision-makers quicker than is the case currently. We must accept there have been significant improvements, but in addition to improvements at hospital level, we are trying to refocus on primary care — I know the Deputy is an expert in this area — and community care. However, one cannot switch it around overnight. Too many end up at accident and emergency departments who need not be there if we had appropriate out-of-hours cover and, in particular, if general practitioners had access to diagnostics. Many end up going through accident and emergency departments unnecessarily in order to access diagnostics. The HSE is working around a number of these issues. The 24-hour target was set about 18 months ago. The 12-hour target is now being set and we hope to have a six-hour target, but I cannot say when that will happen.

When the figure hit 500, I said the HSE had to deal with the matter as if it were a national emergency and focus totally on it. I am happy to say it has. By and large, each day 95% to 96% of patients who present do not have to endure a long wait on trolleys, but there are still too many who do.

The key decision-maker in the accident and emergency department is the consultant. Therefore, waiting for a member of the medical team to come down from upstairs just does not wash.

When will there be a realistic availability of diagnostics to general practitioners?

I agree with the Deputy that the key decision-maker in the accident and emergency department is the consultant, but there are only 52 such consultants. It is no fault of the consultant that we cannot provide cover for longer and until we recruit more consultants on a new contract. The HSE procured some diagnostic services for general practitioners in Dublin last year at the Charter Medical Centre and perhaps others. I want to see this project area expand in order that there will be no necessity to refer through accident and emergency departments or to the acute system for a general practitioner to access appropriate diagnostics. I hope we will see more progress on the issue next year.