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Dáil Éireann debate -
Wednesday, 18 Jun 2008

Vol. 657 No. 1

Adjournment Debate.

Hospital Services.

Does the Minister of State believe the best interests of the women of Cork are served by transferring the breast unit at the South Infirmary-Victoria University Hospital to Cork University Hospital, CUH, where the treatment experience of breast disease is much less significant? Does she believe the closure of the internationally acclaimed unit in favour of a service that is yet ill-defined constitutes progress in patient care?

The services at the hospital are recognised internationally to be in accordance with best practice. Instead of dismantling the existing unit and moving it to an already over-congested campus at CUH, we should be consolidating the good practice already established. As the saying goes, "If it ain't broken, don't fix it." We have a centre of excellence. To date, every evaluation and examination of the breast care unit at the South Infirmary-Victoria University Hospital has shown it to be a leader in its field. This is particularly reflected in the fact that the current referral period for women availing of the service is no more than two or to three weeks. I am very concerned that any tampering with this excellent service will ultimately result in poorer provision, at a cost to the taxpayer that is completely avoidable at this stage.

Given the long delays in the arrival and opening of the BreastCheck service in Cork, which is located directly next door to the South Infirmary-Victoria University Hospital, the idea of transferring the cancer service unit to CUH makes no sense whatsoever. CUH campus is already becoming overdeveloped and congested, particularly in light of the Government's plans to co-locate a hospital on the campus. Any rational examination of this matter would clearly indicate that the existing cancer unit should not only remain where it is but should also be expanded. Given the economic downturn, why are we spending so much money relocating an existing service when it has proven to be working properly and effectively?

The Government is proposing to relocate a service in light of an ill-defined proposal that constitutes no progress in terms of patient care. I seriously urge the Minister of State to remove the idea from the table and consider the services currently in place with a view to improving and developing them.

I welcome the opportunity to address this issue, which is of considerable concern to the people of Cork, particularly the women who will unfortunately have to avail of breast cancer services, their families and the specialists and experts working in the field.

The national cancer strategy proposes to establish centres of excellence, a term I dislike as I prefer to refer to specialist centres, in a number of areas nationwide, one of which will be in Cork at Cork University Hospital. That campus is also to include breast cancer care. At present, the South Infirmary-Victoria University Hospital, Cork, treats breast cancer patients. Its throughput is 210 diagnoses per year, as opposed to a figure of 140 at Cork University Hospital. A figure of 210 diagnoses is certainly above the norm and would ensure excellence. A specialist centre has been established at the South Infirmary-Victoria University Hospital. The people from counties Cork and Kerry who use this service speak highly of it. The population is entirely satisfied with the service provided. Under the national cancer strategy, however, it is proposed to transfer these services. Professor Tom Keane, who is charged with implementing the cancer care strategy, has stated that he wants all centres for breast cancer care in place by the end of 2009, some 18 months from now.

Where on the campus of Cork University Hospital will this centre be located? Where will the building be located? Where are the architectural plans, theatre space, buildings and specialist and ancillary staff required to provide such a service? I have not seen them. No planning application has been made and no provision is in place to provide the necessary physical infrastructure to deal with the estimated 210 breast cancer diagnoses per annum that occur at present and will continue to occur in addition to the existing throughput at Cork University Hospital. The Minister of State should answer this simple question. Where are these women to be accommodated on the Cork University Hospital campus? There is no sign of any facilities. While I support the concept of a specialist centre, I cannot see the requisite physical infrastructure to provide it in Cork University Hospital. However, I see excellence in specialist care at present for women who are diagnosed with breast cancer in the South Infirmary-Victoria University Hospital.

As Deputy Lynch has noted, one should not try to fix something that is not broken.

I wish to be associated with these remarks.

I welcome the opportunity to set out the current position to Deputies Clune and Lynch in respect of the restructuring of cancer services, with particular reference to breast cancer services in the South Infirmary-Victoria University Hospital, Cork.

The implementation of the national quality assurance standards for symptomatic breast disease will ensure that every woman in Ireland who develops breast cancer has an equal opportunity to be managed in a centre that is capable of delivering the best possible results. In order to comply with the standards, the Health Service Executive has directed 17 hospitals to cease breast cancer services. Further staged reductions in the number of hospitals providing symptomatic breast disease services will occur over the next 18 months in line with the transfer of services to the eight designated cancer centres nationally.

The HSE has identified Cork University Hospital, CUH, as one of the designated specialist cancer centres for the southern region. The plan therefore will consolidate symptomatic breast cancer services in Cork University Hospital. This involves a transfer of the South Infirmary symptomatic breast service to CUH. The CUH has identified the necessary space to house the programme.

This is madness.

Planning is proceeding to achieve this consolidation by early 2009.

The decision to consolidate the symptomatic breast service provided by CUH and South Infirmary for the southern region into the designated cancer centre at CUH is consistent with the national programme for the centralisation of breast cancer services in eight designated specialist centres. The relocation of the South Infirmary symptomatic breast service to CUH will create a critical mass of specialists of all oncology disciplines on a single geographic site.

They already have a critical mass. It is the busiest centre in the country.

The Minister of State, without interruption.

It is clear from the wide-ranging, evidence-based work behind the national cancer control programme that the best interests of the women of Cork and of the southern region will be served by this consolidation. The Government is confident that the consolidated service will meet or exceed the national standards for symptomatic breast care as approved by the Health Information and Quality Authority.

This is a cutback.

The programme recently completed a detailed review of resource requirements to create capacity for the progressive transfer of all symptomatic breast cancer services to the eight designated cancer centres with the objective of completing 60% transfer by the end of this year and 90% by the end of 2009. Funding of €7 millionhas been allocated from the programme across the eight centres to support additional staff, including consultant, radiography, nursing and clerical posts. Funding also has been allocated for some necessary additional equipment.

The roll-out of BreastCheck, the national breast screening programme, also will reduce significantly the number of symptomatic breast cancer presentations. The Minister for Health and Children officially opened the new clinical static screening unit for the southern region last December and nearly 4,000 women from Cork have already been screened.

The Government is committed to providing symptomatic breast disease services in eight centres nationally. Roll-out of the national breast screening programme and a quality assured symptomatic breast disease service will ensure that women will have the best chance for early detection and treatment of breast cancer. The developments which I have outlined today will ensure that a comprehensive service is available to all patients with breast cancer in the southern region.

Mental Health Services.

I thank the Cathaoirleach. I raise this issue because there is great concern across County Mayo. Staff and patients have been notified that major cutbacks in the county's mental health services will take place. This is a cause of great concern for the most vulnerable in society in particular.

I attended a meeting last Monday at which representatives of the Health Service Executive confirmed there would be major cutbacks. They stated that they had expected to receive €1 million more than they actually received last year. The funds allocated were the same as the previous year's allocation. Given wage increases and costs in respect of fuel and the overall running of the hospital service, the representatives stated they simply cannot run it. The HSE now is obliged to begin to cut back on the services. It is outrageous that the first people to be affected are those with mental illness, who are the weakest in society. They will not be able to induce people to go out and protest or fight their corner for them. Shame on the Health Service Executive, the Minister, the Government and the county's health board for allowing this to happen.

A number of services were being provided. Although 90 hours per month were made available, those affected have been told that from 1 July they will be reduced to 12 hours per month and some of the services that were available will be lost. They had therapy, art classes, writing classes and gym classes to assist people with mental illness who needed to become fit. Such people also were taught how to feed themselves and how to read and write. What is happening is a scandal. It is wrong that at a time when one is told there is so much money in the country, the first people to be targeted are those with mental illness. I ask the Minister of State to contact the relevant HSE general manager and insist that whatever cutbacks must be made must not be inflicted on the weakest. Such cutbacks should not be made where they will hurt people's health or where they will affect those who are the weakest in society.

It is a disgrace the available services will be taken away and such people will be left without them. If Members do not protect those in society who are in most need of protection, why are they in this House? This is the reason the people felt disconnected last week from politicians and the decisions that are made. Decisions such as this are made by faceless people in the HSE and those on the ground are obliged to suffer. I refer to the staff, the families of those who are disturbed by mental illness and the people who must depend on the health service to look after them.

This reason there was a "No" vote last week is because Members have given away all the powers of this House. They have given them away to the HSE, which will not answer anyone and is not responsible to anyone in this House. The Minister has washed her hands. I call on the Minister of State, the Government and the HSE to provide the necessary funding to retain the exisitng facilities for the most vulnerable in societ.y If one is unable to protect them, there is no point in having a HSE or a health service.

I will take this matter on behalf of my colleague, the Minister for Health and Children, Deputy Mary Harney. I thank Deputy Ring for raising this matter on today's Adjournment and for giving me the opportunity to reaffirm the Government's commitment to mental health.

The document, A Vision for Change, represents our action plan for the development of a quality mental health service. The estimated additional cost of implementation is €150 million, that is, €21.6 million per year over seven years, or €15 million per year over ten years. The report is clear that new funding should follow implementation, and in this regard a total of €51.2 million has been allocated since 2006. Thus, in the first two years of a seven to ten year implementation period, one third of the overall requirement has already been allocated.

The development of our mental health service is not solely dependent on extra funding. The substantial existing resources within the mental health service must be remodelled and reallocated, and only then can we deliver a modern and efficient service. It is necessary, in the context of the ever-increasing demands for health resources, that health expenditure be closely monitored to ensure that services demonstrate both effectiveness and efficiency. Before any further additional funding is provided, it is essential that the HSE is in a position to demonstrate that the funds allocated for mental health services are efficiently used and that the substantial changes in the organisation and delivery of services envisaged in A Vision for Change are developed in a timely and appropriate fashion.

Owing to competing expenditure pressures and the overriding obligation to live within the approved overall allocation, some of the planned developments in mental health services in 2006 and 2007 were delayed. While this is disappointing, I note that some of these developments will proceed in 2008. I am also confident that there is scope within the HSE's overall allocation to deliver further service enhancements in 2008, over and above those outlined in its service plan, through improved performance, productivity and the realignment of existing resources.

The unprecedented investment in mental health services, which has trebled since 1997, has allowed for real improvements in this area. There is now a much greater focus on community services and the provision of multidisciplinary teams, early intervention and many other services. This modernisation and reform of services is in line with what patients want and need. It is real progress and we are determined to build on this reality. We are not yet where we want to be, but we are getting there. Each person receiving mental health care now has an individualised care plan, designed in consultation with the person and his or her therapeutic team. This care plan, which may or may not include complementary therapies, identifies the person's needs and another plan is then agreed to meet these needs.

The delivery of health services was assigned to the HSE under the Health Act 2004. In view of the budgetary situation, it was necessary to review the provision of complementary therapies in Mayo. In some instances where the therapies were not considered essential, they were reduced. I have been assured that each individual case is being closely monitored and will be reviewed in the event of a negative impact on the patient being clinically identified.

The Government's decision to establish the Office for Disability and Mental Health reflects its ongoing commitment to developing a more coherent and integrated response to the needs of people with disabilities and mental health problems. The office will support the Minister of State with responsibility for disability and mental health, and will facilitate cross-agency and cross-departmental work to deliver real benefits to clients and service users in the future. It will bring a new impetus to the implementation of A Vision for Change, working in partnership with the HSE and other stakeholders to achieve the implementation of agreed targets.

Services for People with Disabilities.

It has been repeated time and again in this House that there are no health cutbacks, and that what is being sought are efficiencies that will not hit the front line. Like me, a Chathaoirligh, you must have been appalled to hear the report this morning on St. Michael's House, which may now have to close down all services to new-born children with intellectual disabilities as a result of not receiving the commitment it was led to believe was forthcoming. That would mean that 16 parents every month would be turned away with no support, no counselling and no early intervention for children who suffer from a disability. That appals me.

There are currently 16 people who have been rendered homeless by the death of their carer, but since the State has not provided for them, St. Michael's House will have to use up six of its 30 respite beds immediately and a further seven over the year in order to accommodate them. That will have a tremendous knock-on effect. There are about 500 people who avail of respite care in St. Michael's House, but the respite capacity will effectively be halved. That means that parents who are caring for their disabled children on a full-time basis will have to give up their 20 day respite breaks. Those 20 day breaks will probably be reduced to 12 or even ten days.

All this occurs against a background in which the Government stated that there would be a five year plan that would commit to increasing funding for each year. The latest bombshell is that the HSE has informed St. Michael's House that it need not admit anybody into care services, even emergencies, without the written approval of an assistant national director at the HSE. The staff in St. Michael's House have been prevented entirely from extending any care to anyone, except in an emergency where they must still get written permission. That is the worst style of governance. We often talk about avoiding blunt cutbacks, but that is the most blunt front line impact one could come up with. It is a straight directive not to provide services to people, regardless of how serious their need.

To give the Taoiseach his due, he was committed to this area when he was Minister for Health and Children. He provided 70 residential places each year when he was in that role. This year, only ten places are being provided, down from 21 last year. In spite of this five year development plan, we have reduced the number of residential care beds to one seventh the amount provided by the Taoiseach when he was in charge of the Department all those years ago. We all know that there is an increasing demand on this service. People are living longer and their needs are becoming more complex, so it is more difficult to provide care. A third of the parents providing care are over 60 years of age, nearly half are over 70 and there are 55 carers over 80 years of age. We must get our heads around this.

Is it Government policy to tell St. Michael's House to cut everyone off at the knees unless there is written confirmation? These are the children who are most vulnerable in our community. It seems entirely in conflict with what Fianna Fáil espouses, which is to cherish people in need. Is this intentional or is it accidental? Is it some bureaucratic mix up? What has happened here? The House needs an explanation, but we can no longer get explanations by tabling parliamentary questions. Our only chance is to get a response on the Adjournment. However, the danger is that a defensive script has been prepared that will not answer the problems, so we will not be able to explain to parents what is happening. I cannot explain it, but I hope the Minister of State can explain it.

I will speak on this matter on behalf of the Minister for Health and Children. The Government is committed to providing a high quality service to all people with a disability. This commitment is illustrated by the substantial investment we have been making in disability services over the last number of years. The national disability strategy, launched in September 2004, reinforces equal participation in society of people with disabilities and provides for a framework of new supports for people with disabilities. This strategy, together with the other support services, is a key factor in building the additional capacity required to ensure that services best meet identified needs.

The strategy builds on a strong equality framework, which is reflected in several equality Acts. It puts the policy of mainstreaming public services for people with disabilities on a clear legal footing. The main elements of the strategy are the Disability Act 2005, the Education for Persons with Special Educational Needs Act 2004, the sectoral plans published in 2006 by six Departments, the Citizens Information Act 2007 and the multi-annual investment programme for disability support services for the period 2006 to 2009.

An integral part of the national disability strategy is the multi-annual investment programme announced in the 2005 budget, which provides a commitment to a cumulative capital and revenue programme of €900 million, with the bulk of this funding being spent on health services for people with a disability over the period 2006 to 2009. These commitments include the development of new residential, respite and day places for persons with intellectual disability and autism in each of the years covered by the programme.

With regard to the specific matters raised by Deputy Bruton, I understand from the HSE that St. Michael's House has received an additional €4 million in its 2008 annual funding, which has increased from €78 million in 2007 to €83 million in 2006. In addition, I understand from the HSE that St. Michael's House has been given an indicative allocation of new places across the greater north Dublin area in respect of 2008, as follows——

I want to make one brief point to the Minister of State.

——Residential places — ten; respite places — two; and day places — 15.

Will the Minister of State give way to allow me to make one brief point?

The HSE states that St. Michael's House also received an indicative allocation of five residential places in 2008——

I want to make the point that this is less than half of what was in the plan.

——for children in the Meath local health office. Two new residential places and two new day places have been allocated to St. Michael's House in 2008 from the Dublin mid-Leinster region.

As the Deputy is aware, an additional €50 million was allocated by the Government for the provision of disability services in the 2008 budget. The 2008 service plan, developed by the HSE and approved by the Minister for Health and Children, Deputy Harney, included the €50 million for the development of additional disability services. The standard expenditure sanction issued to the HSE for 2008 stipulated that the prior approval of the Department of Health and Children and the Department of Finance would be required in the event of any proposal to spend this money for any other purpose.

Is the Minister of State admitting that this money is now being veered away from disability services?

Clearly, it is essential that the HSE lives within is overall budget for the year. It needs——

Acting Chairman, the Minister is saying that money which was voted by this House for disability services is now being considered to be veered away for other purposes — to meet deficits elsewhere.

There is no provision——

This is worse. If the Minister of State would only listen instead of just talking through the thing. This is supposed to be communication.

——to manage its activity levels and cost drivers appropriately to achieve this and the Minister does not believe it is desirable to resort to using development funding to offset expenditure pressures arising in respect of ongoing health services.

I am around this House for a long time and any proper Minister would respond to issues raised in a serious manner. This is a disgrace.

I understand that the HSE is currently reviewing its overall financial position for the year and the roll out of planned development in disability services is being considered in that context. The Minister has been in communication with the HSE with a view to an early determination on the matter.

This is a disgrace. This is admitting the money we set aside for disability is now under consideration to be veered to meet deficits in the HSE, and the disabled, elderly people and the physically disabled will suffer the consequences of that.

The Deputy has made his point, but Standing Orders do not let me allow him to do that. I have to stick to Standing Orders and sometimes I have to apologise.

There is a certain level of understanding that we listen when there is a valid point to be made. There is no point in us listening to a prepared script off a word processor, without getting an opportunity for the Minister to even take in the points being made, let alone respond to them.

The Deputy will have to find another way of raising the matter, and I apologise.

Child Care Services.

In October 2007 a state-of-the-art child centre facility was opened in Ballybunion, County Kerry at a cost of €682,400. Additional funding was provided for equipment and facilities in the centre, bringing the total investment to approximately €800,000. The money was provided by the Department of Justice, Equality and Law Reform under EOCP funding and the project was five years in gestation and involved a considerable amount of voluntary input from local parents and members of the community. The centre received a grant initially, which was a contribution towards its staffing costs. This money was granted through the old scheme, which will be finished by the end of June and is to be replaced by a new system known as the community child care subvention scheme. Under this scheme the level of grant aid will be based on the number of disadvantaged parents using the service as well as the level of service. In return, the centre is expected to discount its fees by the amount of subvention it receives for each qualifying parent. Under the scheme disadvantaged parents are categorised as those in receipt of social welfare payments, on community employment schemes or family income supplement.

There are four subvention levels. Band A includes social welfare recipients and band B family income supplement, FIS, recipients. The people who do not fall into either category are in band D, and these are in full-time employment. They are not subsidised and have to pay the full costs. In response to the outcry from parents and child care providers when the new scheme was proposed originally, the OMC put band C in place, which offers reduced fees to people on low incomes who are marginally above the FIS threshold. As a result of the new changes, the people in employment — most of whom must travel 20 miles to Tralee or Listowel to work — will now have to pay €180 for a place. It was €120, so this is an increase of €60, which is considerable, for a full place. Also there is an increase from €45 to €90 for a preschool place — and the equivalent for shorter hours. There are few families in the locality in a position to pay this type of fee, so that the whole system including the staffing of the centre will not be sustainable.

The parents in band D who have contacted me will have to leave their children at home to be looked after by childminders. They might be able to pay a lesser rate to grandparents, perhaps, or in-laws, but it is not satisfactory because this particular centre is one of the finest of its type in the country. I do not know whether the Minister of State, Deputy Hoctor or her colleague, the Minister of State, Deputy Andrews is responsible for it. It is very progressive as regards the initiatives being pursued and those it has introduced. For example, there is an initiative entitled "Learn through Play", which is based on the Department of Education and Science's new curriculum, and it is operated very successfully. The parents, however, are now looking at the prospect of not being able to afford the child care payments. As I said, they have few options — either to leave the child or children at home or give up their jobs to get back on a qualifying band. It does not appear to make any sense, whatsoever.

I do not know what type of response the Minister of State will give. I asked a former Minister of State, Deputy Brendan Smith, to visit the centre and even officially open it and use it as an example of how other centres might operate. It does not make sense that a centre opened last October at a cost of €800,000 could now close this October. A survey has shown that the profile of those due to avail of the centre next October are mostly in employment, so they will not receive subsidies. The Acting Chairman will appreciate this.

This is just the first of many stories that will be raised in this House. I know that for a fact because there are similar child care facilities across the country that face this type of problem, and it has not struck home yet. Obviously, Deputies have not been contacted to date. Certainly, this is something that must be addressed. I look forward to the Minister of State's response and I hope she can offer some solution. Otherwise there will be a major problem and it will leave a significant deficit in child care facilities right across Ireland.

I am taking this matter on behalf of my colleague, the Minister of State at the Department of Health and Children, Deputy Barry Andrews.

The main supports the Government makes available to parents in respect of their child care costs are child benefit and the early child care supplement. The latter payment, in recognition of the higher child care costs of pre-school children, is the responsibility of the Office of the Minister for Children and Youth Affairs. It alone amounts to expenditure of approximately €500 million in a full year. These payments are universal and benefit all parents, regardless of income, labour market status or the type of child care chosen. In addition to these universal supports, the Government's child care policy also recognises the need to target additional supports towards disadvantaged families.

Under the Equal Opportunities Childcare Programme 2000-2016, co-funded under the European Social Fund, targeted support was provided through the staffing support grant scheme. Community-based and not-for-profit child care providers with a strong focus on disadvantage were awarded grant aid toward staffing costs to allow them to offer reduced fees to disadvantaged parents. Funding under the scheme was originally awarded for a limited period during which services were expected to move towards sustainability. This funding was subsequently continued to the end of 2007, where it was considered necessary to enable services to remain accessible to disadvantaged parents. This continuation of funding was subject to the condition that tiered fee structures were implemented by the services in question.

The National Childcare Investment Programme 2006-2010 has a funding allocation of €575 million and aims to create an additional 50,000 new child care places. It is expected that approximately 22,000 of these places will be in the private sector with 28,000 places in the community/not-for-profit sector. Up to 20% of the overall places will be for children in the three to four years age group and will provide an early childhood care and education focus.

These child care programmes have a combined budget of over €1 billion and are projected to create or support 90,000 child care places. Part of this investment includes the new communitychild care subvention scheme. Funding amounting to €154.2 million will be allocated to the new scheme over the next three years, a significant increase over the €37 million 2007 funding allocation for the support scheme under the equal opportunitieschild care programme. Services have been guaranteed that they will receive at least 90% of their current funding levels in the second half of this year and not less than 85% in 2009.

The community crèches, which account for approximately 20% of the service providers nationally, are central and valuable players in providing quality child care at prices affordable for all, including the most disadvantaged in society. The new scheme will continue to recognise and support the valuable investment in the community/not-for-profit sector and ensure the tiered fees necessary to make this a reality.

The provider of the service referred to by Deputy Deenihan recently contacted the Office of the Minister for Children and Youth Affairs. It stated the overall parental profile of the children using the service has altered substantially since its original application for inclusion under the scheme. Consequently the subvention which has been allocated to the service for the second half of this year no longer meets the specific needs of the service. The Office of the Minister for Children and Youth Affairs has advised the group to submit full details of the current parental profile to allow a full assessment of the group's concerns to be made.

The Dáil adjourned at 9.25 p.m. until 10.30 a.m. on Thursday, 19 June 2008.