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Dáil Éireann debate -
Tuesday, 30 Sep 2008

Vol. 662 No. 1

Priority Questions.

Promised Legislation.

James Reilly


113 Deputy James Reilly asked the Minister for Health and Children the date she expects legislation on the fair deal nursing home support scheme to be published; the reason for the delay in publication; and if she will make a statement on the matter. [32673/08]

Both the Minister for Health and Children and I are fully committed to introducing the new nursing homes support scheme in 2009. The legislation required in order to introduce the scheme is complex and has involved careful drafting to ensure that the interests of older people requiring residential care are fully protected. The Minister expects to publish the Bill within the next two weeks or so and to bring it before the Houses of the Oireachtas for debate in this Dáil session.

On publication of the Bill, further engagement will take place with stakeholders on the details of the new scheme. This will take place under the auspices of Towards 2016.

The necessary funding for the scheme will be addressed as part of the forthcoming budget.

This scheme was first announced in 2006 and was to be introduced, we were told in 2007, in January 2008. We are now being told it will be published in two weeks. I hope it will be published on this occasion and that we will have a full and proper debate and plenty of time to consider it, as I requested previously. This is a considerable issue for patients and their families.

With regard to the funding for 2008, some €85 million was saved. Was it allocated to the nursing home refund scheme? Where is it now? This is a very important issue for many families. It is not just pertinent to nursing homes but it is having a considerable impact on hospitals. Patients in north Dublin cannot get into Beaumont Hospital because the beds are filled with patients who cannot be discharged.

It is a fact that there are 22 long-stay and rehabilitation beds per 1,000 over-65s nationally. In Dublin North, which has the second highest population of over-65s, there are only three such beds. Some days ago, the Minister and I were in a new modern facility in Balrothery in Balbriggan which has 40 spare beds, yet people are screaming for beds in Beaumont and the Mater. Three weeks ago the Mater had 130 people awaiting discharge and the accident and emergency department had discharged all its patients into the day-care beds such that surgery could not take place.

This issue is real for people, including an 80 year old man who was sent home from Beaumont Hospital last week. Two days later he had a number of falls, culminating in a fall at 11 p.m., and he was found on the floor at 10 a.m. the next day covered in his own faeces. This man worked all his life and paid his taxes, yet this is all we can offer him.

Will the Minister put the funding available for the fair deal scheme in 2008 back into subvention to allow people obtain long-stay care for their loved ones and to take the pressure off hospitals? While we do need more beds, there are beds available as we speak without our having to build new ones. Why can we not avail of them?

A number of legal issues led to the undesirable delay that occurred in respect of the finalising of the Bill for Government. Legal issues emerged in the discussions with the Parliamentary Counsel and these had to be cleared before the Bill could come before Government for approval. Thankfully we are now at a very advanced stage.

On Deputy Reilly's question on the €110 million for the scheme, to date €13 million has been allocated from those moneys provided in budget 2008 for the provision of 200 contract beds. Approval was also given to the HSE to utilise a further €12 million in meeting the costs associated with nursing home subventions and existing contract beds. This brings to €25 million the total funding redirected from the nursing home support scheme and committed to nursing home supports in 2008. The intention was that the balance of the €110 million would be used to meet certain other additional costs facing the health services this year as part of the budgetary consolidation measure announced by the Government in July. The necessary funding for the scheme dealt with in the Bill, which will be published in the next couple of weeks, is an issue to be dealt with in the forthcoming budget.

There will be no additional funding for the people this year. There is no relief for them.

I have made clear what has been allocated at this point.

Health Service Executive Expenditure.

Jan O'Sullivan


114 Deputy Jan O’Sullivan asked the Minister for Health and Children the information she has been given on plans by the Health Service Executive to reach its budget targets for 2008; if her attention has been drawn to the proposals to cut back on services; if her attention has further been drawn to plans by the HSE to introduce or increase charges to the public; if she has an arrangement in place whereby she would be made aware of such proposals; and if she will make a statement on the matter. [32183/08]

In the first half of the year the Health Service Executive identified a projected deficit for this year in the region of €300 million if no remedial action were taken. The executive brought forward proposals to address the deficit and bring expenditure back in line with its Vote. The proposals were agreed by the board of the HSE. I was advised of the measures by the chairman of the HSE and that the goal for the remainder of the year would be to ensure an overall balanced Vote outcome on expenditure while optimising patient services and continuing the reform agenda.

These proposals, which were designed to ensure the delivery of the service plan, contained initiatives to further maximise value for money and reduce spending in areas where excess expenditure was occurring. The measures taken included bringing levels of service back in line with the targets set out in the service plan, as well as a range of cost savings in operational overheads. The latter included a reduction in travel and subsistence, a reduction in consultancy and advertising costs and the cancellation of all non-essential training. Other initiatives included increasing the collection of hospital charges and addressing absenteeism.

Implementation of these measures is being monitored by the executive and reported in line with the accountability procedures in place for monitoring the executive's expenditure and implementation of its service plan. These procedures include monthly meetings between my Department, the Department of Finance and the executive, quarterly high level meetings between my Department's Secretary General, the executive's CEO and their respective management teams. There is also ongoing liaison between my Department and the various directorates of the executive.

In respect of statutory charges, there were increases in accident and emergency and in bed charges at the beginning of the year.

On a day when the Government can find an estimated €400 billion to €500 billion to guarantee the banks their money will be safe, I must question whether the Minister for Health and Children can guarantee in any way that vulnerable patients will be protected from health cuts, service cuts and increased charges. I find it extraordinary that the Minister is standing by — she said she has been advised of measures and that she is having ongoing information meetings.

Has the Minister been told increases in charges may be introduced before the end of the year? It has certainly been suggested to me that increases may be proposed to hospital charges and other charges, as well as new charges for people using the health services. Has the Minister been told that, as part of the proposals to reach the figure of €300 million, there are suggestions of cutbacks to home care packages and home help, as well as an increase in waiting lists because of reductions in services in the hospitals, and a variety of other proposals that will directly affect patients?

Can the Minister do something specific about this? If she feels the proposals with regard to both charges and cuts are unacceptable, can she take action to protect the public good and protect vulnerable patients from the effect of these reductions? In these circumstances, why did the Minister and her Department accept the biggest cut of all in the cutbacks announced earlier in the summer for various Departments?

To deal with the last issue first, some of the matters covered by that saving were not proceeding this year, for example, the fair deal. It is also——

The Minister could use the money for families who need it.

It is also the case that a number of issues must be addressed for the remainder of this year, one being the repayments, which will be funded separately.

By way of general comment, the Government has not found €400 billion to bail out banks. What the Government has done is given a guarantee against a very strong asset base, a matter we will be debating in the House later today.

With regard to the health services Vote, like any other country where health services are funded by social insurance or private insurance, people must live within budgets. Public spending on health here has increased by 4.5 times in the past ten or 11 years, which is a considerable investment. There will be a 6% increase this year over last year in the number of home help hours.

The HSE produced a service plan, which I approved at the beginning of this year, and has given me an assurance it will meet all the targets provided for in that plan. However, we do not and cannot have the capacity for the provision of unlimited resources. The HSE, or for that matter any other State organisation, must live within the budgets that are voted through by the Oireachtas on an annual basis. To be frank, it is clear, given the financial challenges that face the country, that the position will be even more challenging next year.

I am not aware of any charges to be imposed on patients later this year or of any charges that could be imposed without my approval, and I have no intention of approving any additional charges for 2008. If the Deputy is being specific about an issue of which I am not aware, she should bring it to my attention. However, with regard to charges for beds, accident and emergency services or services of that kind, hospital charges require ministerial approval and cannot be imposed by the executive without ministerial approval.

The time for that priority question has expired. The next priority question is No. 115 on the Order Paper and is in the name of Deputy James Reilly.

Patient Safety Authority.

James Reilly


115 Deputy James Reilly asked the Minister for Health and Children her views on the establishment of a patient safety authority or patient ombudsman, either in conjunction with the Health Information and Quality Authority or independent of HIQA, in which patients who have serious concerns can have their concerns addressed without having to go to the media or court system in view of recent statements by her and the head of the Health Service Executive that there may be many more cases of misdiagnosis. [32674/08]

The health sector is one of the most complex areas of activity in every country and it must by its very nature command the confidence of those who use it. While I am confident that the majority of patients in Ireland receive effective and safe treatment, unfortunately, errors do occur in any health service and it is important that we have systems in place to detect and respond appropriately to them. Patient safety is everyone's concern and needs to drive all our decisions.

Patient safety has always been high on my agenda and that of the Government, as is evident from various initiatives we have taken in recent years. The Health Information and Quality Authority, HIQA, was established in 2007. One of the main functions of the authority is to set standards and monitor health care quality. The authority also has the power to undertake investigations as to the safety, quality and standards of services where it is believed that there is serious risk to the health or welfare of a person receiving services. Recent developments have led to the authority carrying out a number of investigations and it is acknowledged that there is public confidence in the work of the authority.

In addition, and as part of my commitment to prioritise the patient safety and quality agenda, I set up the Commission on Patient Safety and Quality Assurance. The commission's report, Building a Culture of Patient Safety, was published on 7 August 2008. The report contains proposals on patient advocacy and suggests appropriate arrangements for the involvement of patients and carers in service planning and evaluation. I am currently considering those recommendations in detail with a view to bringing an implementation plan to Government shortly.

The overall approach to implementation endorsed by the commission is to avoid short-term structural changes and, instead, to build on the structures already in place. The commission considered that this was the best way to deliver results quickly. On that basis, I am not proposing the establishment of a separate patient safety authority or ombudsman.

I thank the Minister for her clear reply but I am sorry she has taken that approach. We could save people much pain and anguish if we had a patient safety authority. I note the report of the Commission on Patient Safety and Quality Assurance which fell short of recommending a patient authority, but I still feel that is the obvious way to go. We need a clear identifiable body that can deal with the anxieties of patients and their relatives when things do not go right.

The Minister stated previously, as has Professor Drumm and others — it is accepted fact — that there will be more mistakes throughout the country. Are we to ask other families to endure what the families in Ennis endured and what Rebecca O'Malley had to endure, that they have to go public to get satisfaction, clarity and justice? A patient safety authority or ombudsman would allow people to go in confidence without recourse to publicity or the expense of litigation to find out what went wrong. Most people are good people and they do not want trouble, publicity or to have recourse to the law, but they want information. They do not want to be treated as if they are stupid and to be fobbed off with weak excuses. They want the truth, often they want an apology, but most of all they want to be assured it will not happen again and that their own misadventure or that of their loved one will at least produce changes in the system that will make it less likely to happen again.

I urge the Minister to review the decision because HIQA is all very well but it was not able to act in this instance until the Minister instructed it. The Minister referred to its terms of reference, namely, when there is "serious risk to the health or welfare of a person". What happens when the event is over and the patient has passed away? People want answers and they are not getting them.

I am familiar with a case in my constituency where somebody wrote to the Minister who rightly referred them on to the HSE. It referred them on to the hospital safety committee, which said there was no case to answer. From what I know of the case, I regret to say there is a case to answer. It may not be the case that the person thinks there is to answer, but there is a case to be answered because a patient was allegedly prescribed three times the dose of a drug for a prolonged period of time that may have had a detrimental effect on them. It may or may not have been the cause of their demise but if it is true, in my view it certainly had a detrimental effect. I use the word "true" advisedly. Why not put this in place? It makes sense, would not be very costly and would not be another quango. The Health Information and Quality Authority can come in under it and can take, rightly I believe, the matter off this floor and off the politician's table. Several colleagues have come to me with examples in their constituencies, such as the matter mentioned by Deputy Michael Noonan last week. Why must people go through politicians to get satisfaction in these matters? They should be able to go to a clearly identifiable body, a patients' ombudsman or a patient safety authority.

I will take the last issue first, namely, the case raised by Deputy Michael Noonan. I was not aware of this when I was answering questions last Wednesday, but in fact the patient was contacted and given all the facts before I was aware of the need to establish facts. The authorities had made contact directly with the patient and given him the facts. That remains the position in the vast majority of cases. The issue of patient safety is not just for one organisation. It is not correct to say that HIQA needs my approval or needs to be asked by me to carry out an inquiry. It is totally independent in the exercise of its functions and if it wishes to carry out an inquiry it is free to do so. The current Ombudsman can deal with what could broadly be called administrative errors and does so all the time. The issue of clinical error, however, is a different matter. I do not envisage that could ever be dealt with by another organisation when we have the Medical Council. Under the new legislation that established the recent Medical Council, now with a lay majority, one of the provisions allows for a plenary inquiries committee where patients can complain and have matters inquired into. I know the new council is currently in the process of putting that in place.

As Deputy Reilly knows, mistakes occur in every health system and some of the best doctors make errors. What we are trying to do, especially with cancer care and in other areas, is arrange and configure services in such a way to minimise the capacity to make errors. We should not have had breast cancer services in a hospital like Ennis General Hospital because we did not have the clinical expertise. We could never have it in a hospital with such low volumes of patients or deliver the kind of care to which the late Ms Edel Kelly and Ms Ann Moriarty were entitled. This is why it is so important to reorganise services with patient safety in mind.

Medical Insurance.

James Reilly


116 Deputy James Reilly asked the Minister for Health and Children her views on the recent Supreme Court decision to strike down the risk equalisation scheme enacted by her in view of the fact that it was founded on the basis of an incorrect interpretation of law which is likely to see health insurance premiums soar for older and sicker people; the steps she is taking to stabilise the health insurance market and ensure community rating in order that health insurance remains affordable; and if she will make a statement on the matter. [32675/08]

A primary objective of Government policy in health insurance is that it should be affordable for the broadest possible cross section of the community including older people and those who suffer ill health. This policy objective has been implemented through a substantial body of primary and secondary legislation providing for open enrolment, community rating and lifetime cover.

Although the Supreme Court found the particular risk equalisation scheme to be ultra vires, it did not strike down the principle of risk equalisation or any of the other important elements of the regulatory framework that supports private health insurance in Ireland. However, the decision of the Supreme Court gives rise to some complex issues that now need to be addressed.

I have yet to hear any argument made against the continuing need for community rating. It is a fundamental principle of the health insurance market in Ireland. Following the liberalisation of the market in 1994 every political party and successive Governments have supported the maintenance of community rating. It is an inescapable fact, supported by international evidence, that community rating cannot be sustained without some scheme to support the higher costs of claims of older or sicker people, effectively a risk equalisation mechanism. There may be differences of opinion in how such a mechanism must work, but few dispute the need for one.

I am currently assessing all available options. Since the judgment was delivered, I have engaged in consultations with officials, the Attorney General, advisers, the Health Insurance Authority and with the companies operating in the market. I also received submissions from all the operators in the market and we are in dialogue with them on an ongoing basis. There are complex financial, legal and policy matters involved. It is my intention to bring forward measures to ensure that health insurance remains affordable for older and sicker people at the earliest opportunity. I will be bringing such proposals to Government shortly.

On the last question, HIQA may be empowered to undertake investigations but the reality is that this time it took the Minister to instruct it before it happened.

On this question, this was a mess-up in terms of legislation brought in by the Minister and then misinterpreted. While it is good to hear the Minister say she wants insurance to continue to be affordable to people, particularly the elderly, the consequences of that is that it is likely to cause a rise. I fully support the Minister in the community rating principle. I would have issues with her in the manner in which it was being implemented, the amounts being sought, the percentages and the timing, given that the VHI currently is in good health, so to speak, with €70 million plus in reserves. Specifically, what action is the Minister taking and when does she hope to come to this House with further legislation or to indicate her plan to deal with this issue? More importantly, does the Minister expect more legal challenges?

The legislation that was struck down had its origins in the 1994 Act. It was initiated by the then Government and the Minister was Deputy Brendan Howlin but I am not making an issue of that. I am simply saying that is the factual position. Every Minister for Health who has been in office since 1994 has strongly supported, through legislative measures, risk equalisation. The Supreme Court found that we should have risk equalisation, or community rating, within the plans. Obviously, we must accept the decision of the Supreme Court but if there is a plan that is particularly attractive to young people, particularly young couples who have children, and a different plan involving cataracts and so on that is only attractive to older people, it is difficult to see how we can have community rating within that environment. We must deal with the realities and I would like to find a solution that would be legally sound — I have to take the advice of the Attorney General — and one that would be immune from legal challenge, but I do not believe any of us have that luxury because we have been involved in litigation in this matter for a considerable length of time, both at national and European levels. The advice we are taking currently involves looking at all options as to how we can ensure that younger people support older people.

The VHI is required by law to be authorised by the end of this year. That means it must have a reserve capacity of 40% of its premium income. It currently falls far short of that. That is the position. It is not a question of the amount of profits a company makes, it is a question of whether the company is capable of being authorised on the same basis as all of its competitors. That will be a challenge. The reason it is important that the VHI is regulated on the same basis is to ensure we have a level playing field. It has been a bone of contention, which I understand fully, among the VHI's competitors that they have to put 40% of their premium income into a reserve fund and their competitors do not have to do that. That creates an unequal playing field. To be fair to the VHI, however, it has 68% of the market here and approximately 70% of the over 65 and 60 year olds in the market where most of the costs occur. The only way we can sustain community rating on an affordable basis is by ensuring that younger people support older people.

I hope to bring proposals to the Government in the next few weeks if we can but I must await the advice of the Attorney General and other advices from our actuarial advisers before I can proceed further.

Mental Health Services.

Dan Neville


117 Deputy Dan Neville asked the Minister for Health and Children the outcome of her discussions with the Health Service Executive regarding the allocation of €51 million in 2006 and 2007 in respect of the introduction of the recommendations contained in A Vision For Change of which €27 million of allocated money has been spent on the purpose for which it was allocated. [32678/08]

The estimated additional cost of implementing the report of the expert group on mental health policy, A Vision for Change, is €150 million over a seven to ten year period.

I am advised that of the €51 million provided in 2006 and 2007 for the implementation of A Vision for Change, about €30 million has been invested. It has not been possible to proceed with the other planned service developments because of competing expenditure pressures.

However, it is fair to point out that in its 2008 service plan the HSE prioritised the development of child and adolescent mental health services. This included the recruitment of eight additional child and adolescent mental health teams and the development of 18 additional child and adolescent beds at St. Anne's, Galway, St. Vincent's, Fairview, and St. Stephen's Hospital, Cork. The provision of these beds will increase the number of beds from a current provision of 12 to 30. Four of these beds have already been commissioned, with the remaining 14 beds to be provided before the end of this year.

Implementation of A Vision for Change is dependent to a greater extent on the remodelling of existing resources than on new additional funds. In this regard, the HSE has advised that its detailed implementation plan for A Vision for Change will be submitted to me before the end of the year.

The Minister, Deputy Harney, freely accepted on 8 May last that moneys should not have been hived off from the allocation of €51 million that was provided for under A Vision for Change. Just €27 million of the €51 million package has been spent. The Minister argued that there is no point in providing money if we do not know where it will be used. Therefore, she allocated no money this year. Do I understand correctly that just €3 million of the outstanding €24 million has been spent this year under A Vision for Change? At that rate, it will take nine years to spend the balance of the €51 million that was allocated in 2006 and 2007. Can the Minister confirm that the process which is under way at the moment involves a discussion on the allocation in question? What was the outcome of the discussion on the moneys which have not yet been used for the purposes for which they were allocated? Will the Minister tell the House whether the Government is committed to addressing the important recommendation outlined in chapter 17 of A Vision for Change? I refer to the recommendation that an additional €25 million be allocated each year for seven years to facilitate the non-capital investment demanded in A Vision for Change. The Minister has already committed herself to selling current resources to fund the capital requirements of A Vision for Change.

It is important to point out that €30 million has been invested in new consultant psychiatrists, the new forensic mental health service and the implementation of the most recent Mental Health Act. The Minister has referred to the need to remodel existing resources, which was mentioned by Deputy Neville. It is explained in A Vision for Change that most of the plans are based on the remodelling of existing resources. I made it clear at committee meetings that the Minister, Deputy Harney, and the HSE have given me permission to proceed with the disposal and remodelling of the assets in question. That is happening as I speak.

That is for capital, not for——

I will come to that. I said before the summer that I would tell Members of the Oireachtas who represent the areas affected by the proposed sales exactly where the funds which will be raised will be spent in the specific area of mental health treatment. I outlined in my initial response the level of funding that has been secured for existing services in the 2008 service plan. I remind the House that I referred to the development of child and adolescent mental health services. I have given the relevant figures. Eight additional child and adolescent mental health teams will be recruited. Eighteen child and adolescent beds will be developed in three hospitals. It is clear that the implementation of this programme is going ahead. I emphasise that €30 million of the €51 million that was mentioned has been invested in essential services.

The €51 million was supposed to have been spent in 2006 and 2007. I would like to raise another issue relating to reconstruction. In 1984, Planning for the Future recommended the development of multidisciplinary community-based psychiatric services. The more recent A Vision for Change contained the same recommendation. However, various non-governmental organisations involved in this area have made it clear that there are no fully multidisciplinary community-resourced psychiatric teams in Ireland today. Therefore, it is totally inadequate to reconstruct the current services. A Vision for Change clearly states that there is a need to recruit additional staff to all parts of the psychiatric service, including community-based psychiatric services. Adequate resources are needed to ensure our multidisciplinary teams are fully constituted. That is not the case in Ireland, 24 years after it was first recommended.

I agree totally with the Deputy and in that regard I also see the need for multidisciplinary resource teams and A Vision for Change underlines that fact. By way of making the suggestion, I have started the process of visiting psychiatric hospitals throughout the State. I visited St. Senan's Hospital in Wexford and it and its staff are to be commended. They are moving towards what the Deputy suggested, namely, providing multidisciplinary teams. It is by way of the Government's commitment of realising the asset values of our lands and embankments that we will provide the services and the structures.

It should be ongoing.

It has been in operation for three years and it is a ten year programme. It will be delivered.