Vol. 737 No. 2
1 Deputy Billy Kelleher asked the Minister for Health if he has read the recommendations of the Health Information Quality Authority update on the implementation of the recommendations of the Ennis report received from the Health Service Executive in February 2011; and his views on the implementation of the recommendations relating to small hospitals. [18079/11]
I am fully aware of the recommendations of HIQA with regard to Ennis hospital and its subsequent report on Mallow General Hospital. Both reports deal with the types of service that can safely be provided in smaller hospitals and with the structures required for good governance and accountability within our hospitals. The report on Mallow reiterates the implications of the Ennis report for all hospitals of a similar size. I have said on many occasions that local hospitals can and should be a vibrant element of local health services, providing treatment and care at an appropriate level of complexity to patients in their areas. I have also said I will not stand over unsafe care that puts patients at risk.
The recommendations in these HIQA reports need to be implemented in order to ensure the standards of care delivered in smaller hospitals are as high as possible and that the type of care provided is appropriate to the clinical setting and to the needs of patients. I have had a number of meetings with clinicians and officials in my Department and the HSE about the progress being made in implementing the HIQA recommendations both generally and in specific hospitals. I intend to keep myself fully briefed about ongoing developments.
The Government is strongly committed to developing the role of smaller hospitals in Ireland so they play a key part in the services provided to local communities. Patients should need to travel to the larger hospitals only for more complex services. HIQA's reports on Ennis and Mallow are entirely in keeping with this approach.
The Minister has stated that he accepts and agrees with the HIQA reports on Ennis and Mallow hospitals and the recommendations with regard to the other hospitals named in the Ennis report. Obviously, nobody can stand over unsafe provision of care in any hospital, particularly in smaller hospitals. However, there are two ways of addressing this issue. We must either accept the report in full, agree with its findings and close the smaller hospitals, or address the deficiencies in the smaller hospitals and make sure acute services and accident and emergency services, for example, are provided safely. For many of the hospitals named in the report, the Minister intends to use these reports to downgrade smaller hospitals. This is clear and evident from the actions of the Minister today and over recent days with regard to Roscommon County Hospital, for example, which was to have a 24-hour accident and emergency service and is now to have none at all. This report should not be used as a mechanism by the Minister to retract promises made prior to the election and subsequently. Rather than withdrawing services entirely, he should address the deficiencies in the services.
I could not agree more with the Deputy. I do not believe HIQA reports should be used to close smaller hospitals. If they highlight problems, these should be addressed as far as possible.
The Deputy mentioned Roscommon County Hospital, which will be discussed later in another question. Roscommon hospital is faced with a number of difficulties at the moment. One is a shortage of non-consultant hospital doctors, and another is HIQA patient safety concerns, which arise because of the low volume of patients going through the emergency department — 30 people a day. There is also a difficulty in providing supervised training for doctors, which means these posts are unpopular. We are seeking to address this; I will cover it in a later question. However, the biggest problem facing the hospital is safety.
Let us be absolutely honest about what is currently available in Roscommon hospital. We have an unsafe service. The obvious question is why it is unsafe. I say it is unsafe because it deals with undifferentiated multiple trauma cases, undifferentiated medical cases, including heart attacks and strokes, and undifferentiated surgical problems. If people are brought there by ambulance, they have a right to expect that the skills are available to deal with their problems. However, if a person is suffering from multiple trauma, broken bones and blood vessel damage, there is no orthopaedic surgeon and no vascular surgeon. If a person has had a heart attack, there are excellent physicians, but there is no facility to insert a stent, if that is what is required.
I am happy to come back to the issue of Roscommon hospital in another question. However, I say this to the Deputy. The HIQA reports, particularly the Mallow report, are clear. The Deputy's question is a bit confused, if I might point that out. He refers to a report received in February 2011, but no such report was received. The Mallow report, which I have in front of me, is from April 2011.
The time has expired.
The answer to the Deputy's question is that the reports will not be used — I will not stand over them being used — to close hospitals or reduce services where they can be provided safely. I will return to this in the later question on Roscommon hospital, with the Ceann Comhairle's permission.
2 Deputy Caoimhghín Ó Caoláin asked the Minister for Health the action he has taken to avert a crisis situation in our public hospitals as and from 11 July 2011 in view of the hundreds of non-consultant hospital doctor posts which are vacant; his plans to reduce the excessive working hours of junior doctors and the programme he will put in place to end the over-reliance of our hospital system on junior doctors. [18076/11]
I am working with the HSE and other stakeholders to ensure the filling of as many as possible of some 475 non-consultant hospital doctor posts which are due to be filled from 11 July. I can confirm that as of 27 June, 221 of these posts have been filled, which leaves 254 vacancies. The HSE conducted an extensive recruitment drive in India and Pakistan in recent months and succeeded in identifying 439 potential candidates for NCHD positions in Ireland. I have held meetings involving my Department, the Medical Council, medical training bodies and the HSE with a view to identifying measures to facilitate the appointment of suitably qualified doctors from abroad. The drafting of a Bill to amend the Medical Practitioners Act 2007 to enable the Medical Council to register doctors in supervised posts for a defined period is at an advanced stage.
Notwithstanding this and other initiatives, it is unlikely that all NCHD vacancies can be filled by 11 July. Hospital managements are working with clinical directors in a planned way to devise contingency arrangements which can be implemented if required to ensure that any resulting impact on services is minimised and that the safe delivery of hospital services is assured.
I recognise and support the need to reduce the hours worked by NCHDs. If further progress is to be made it is essential that, over time, reliance on NCHDs to deliver services is reduced. An expanded role for nurses and a better skill mix generally in hospitals is one crucial way of achieving this. An increase in the number of consultants and greater team-working, with a consequential reduction in the number of NCHDs, is also required. The 2008 consultant contract and the 2010 NCHD contract allow for more flexible work patterns and the further development of consultant-delivered services in hospitals. The inclusion of a better skill mix in rostering arrangements has been identified as a priority in implementing the public service agreement in the health sector this year.
Ba mhaith liom buíochas a ghabháil leis an Aire as teacht isteach chun an cheist seo a fhreagairt.
On "The Frontline" on 20 June 2011, the Minister stated we may end up with some accident and emergency departments that cannot be safely manned. He continued the difficulty would not be with any of the major ones but small, rural hospitals. While I welcome the Minister's announcement this afternoon that 221 of the 475 posts have been filled, he must fill the remaining posts by 11 July which is the week after next. Will he inform us as to where the fault lines will present in hospital services? As of 11 July, what hospitals will not have the required number of non-consultant hospital doctor, NCHDs, to guarantee safe delivery of services? Will some accident and emergency departments have a diminished presence such as closing at night and weekends?
What will happen to services at Roscommon? I note some of the Minister's party colleagues who have a keen interest in that hospital are present behind him in the Chamber. What will happen to accident and emergency services at Navan, Portlaoise, Mallow, Bantry and Loughlinstown? Will the departments in Letterkenny and the Mid-Western Regional Hospital in Limerick be closed at night? Will the Minister outline the measures he will take to ensure the required number of doctors will be recruited to avoid such a scenario? How does he propose to ensure the problem will not re-occur, as has happened historically, in six months time?
The last part of Deputy Ó Caoláin's question is the easiest to answer. Whether we have the full complement by 11 July, we will still continue to recruit over the course of the next six months to ensure we do not face this problem again. It should be borne in mind that legislation will be introduced which will allow for temporary registration for two years. This will mean these doctors will have security of tenure for two years; likewise, we will have the security of knowing they will be here for two years.
Up to 254 places are unfilled. As the recruitment process is ongoing, it is difficult for me to tell the Deputy precisely which hospitals are going to suffer. On "The Frontline" I said it will more than likely be the smaller hospitals for several reasons, chief of which is that the regional centres serve the bulk of patients, including those from smaller hospitals with more serious injuries. Doctors who have already applied to the hospitals that will be affected will not be pulled away from them. Doctors recruited will be sent to the areas of highest need and according to their speciality. There is little point in sending a paediatrician to an emergency department.
I know today that 65 more doctors have chosen to sit the Medical Council's pre-registration examination, the PRES exam. Also, 70 visas were granted to doctors already recruited who have satisfied our requirements and are most unlikely to be unsuitable. Accordingly, with the PRES and those recruited already, we will not have unsafe or poorer quality doctors.
The number of recruited doctors is beginning to rise. I will have much clearer idea of the figures tomorrow by 5 p.m. Contingency plans are in train but are dependent on numbers we have recruited.
The Minister has gone over his time. I must ask him to conclude.
I know this is a great concern to many people who value highly their local and regional hospitals. Bad and all as the health service became over the past several years, people know that when they can access it, they get excellent service and care. I am doing everything in my power to ensure we have the required number of doctors and that we continue to recruit to ensure we do not face this problem again.
May I ask a brief supplementary question?
No, I am sorry. We are a minute and a half over time already.
Yet it is a huge issue.
I appreciate that. That is why I allowed the Minister a little longer to reply.
If it is of value, I am happy to revisit the matter when we come to other oral questions.
I have to go by the rules.
A Cheann Comhairle, there is huge frustration about this important issue.
I appreciate that but there are six minutes allocated to each priority question.
Every day it was raised with the Taoiseach, he signalled the Minister for Health would address it today. Yet, we have not even had a chance for a supplementary. It is so inadequate.
We are wasting more time now. Six minutes are allocated per question. Two minutes for the Minister and four for supplementaries. More than two minutes were taken up by Deputy Ó Caoláin and more than two minutes by the Minister. In fact, I allowed a minute and a half more on Question No. 2.
We are talking about something more than minutes in this case.
We are talking about lives.
3 Deputy Tom Fleming asked the Minister for Health if he will arrange for a person from the Office of the Comtroller and Auditor General to investigate the way that the VHI negotiate prices for various medical procedures with medical consultants and likewise the daily cost of beds; if he benchmarks medical charges paid for procedures in the republic against those paid by health insurers in Northern Ireland, the UK and the Netherlands; and the way it was possible that more than €1 million was paid to one consultant in 2010 from the VHI. [18077/11]
The Government is committed to reviewing costs generally across all sectors, including the private health insurance market and scrutinising where savings can be made for the Exchequer and the consumer. I am not satisfied that any consultant should be paid €1 million in a single year. This level of remuneration is grossly out of step with most ordinary people's expectations. The individual, whom I do not know, is working hard in a system that over-rewards that. There are only so many procedures one can carry out safely in a week. If this level of remuneration is available to people who work hard and safely, the service provided is grossly overpriced. I am also dissatisfied that several other consultants also earned enormous sums from the VHI, and to a lesser extent, from other insurers in recent years.
I have overall responsibility for policy on health insurance and, in particular, governance issues relating to the VHI, including such matters as board appointments and the receipt of its annual report and accounts. While owned by the State, VHI is a not-for-profit company operating in a competitive market and negotiates directly with service providers on pricing. While it would be inappropriate for any Minister to intervene directly in matters relating to prices set, I have concerns about the claim levels and, in particular, the cost of services being provided to and paid for by the VHI. It is after all a not-for-profit company which acts on behalf of consumers. The company could and should have done more to control costs.
I met with the chairman and chief executive officer of the VHI very shortly after my appointment in March 2011. At that meeting, I expressed my concerns about the VHI's significant claims costs. Due to its size and position in the market, it has a crucial impact on costs and I made it clear this issue needed to be addressed vigorously. Many of the concerns about the company's approach to costs were outlined in a report commissioned by my Department and conducted by the Department's actuarial advisers, Milliman.
The Comptroller and Auditor General's office has no audit powers regarding the VHI and is not the appropriate regulator.
Additional information not given on the floor of the House.
I also raised the important issue of the base cost of procedures with the company. They responded to me with an outline of how their payments to consultants were calculated. I am not satisfied that these costs represent best value for the consumer. For this reason I met with the Health Insurance Authority on 10 June 2011, as the regulator of the private health insurance market, and requested them to examine the issue of provider costs in the market. The authority will revert to me within one month on how this matter might be addressed.
In April, I welcomed the VHI's announcement of its financial outturn for 2010, which shows a significant improvement over the 2009 outturn. I acknowledged that, over the past two years, the company has taken steps to contain the rising costs of meeting customers' health care needs, including a 15% reduction in consultants fees per procedure, a 6% reduction in private hospital fees per procedure and an annualised reduction in internal administration costs of €14 million. These actions have generated annualised savings of €100 million. VHI pays professional fee benefits to medical practitioners for services rendered on a fixed fee per service basis. In 2011, VHI anticipates that the total remuneration paid to hospital consultants will be over €50 million less than the total remuneration paid in 2009.
However, I intend to ensure that clients and the taxpayers alike get much better value for money into the future and this will be a clear focus of the new board and CEO to be appointed next month.
I am disappointed the Comptroller and Auditor General does not have a role in this matter. The remuneration received by the consultant is mind-boggling and many people are incensed when they read about these exorbitant sums. This is also just one case of the charges levelled by consultants.
Consumers are being ripped off and are probably paying the highest premiums in Europe. I ask the Minister to consider what is happening in other EU member states. I welcome the fact that he is dealing directly with this matter. It is about time someone took action.
The Deputy should pose a question because he is running out of time. The Minister will not be in a position to reply.
I request that the Minister develop a step-by-step plan and that he ensure that by the end of the year it should be affordable for people to pay for private insurance. At present, many individuals have been ruled out of the market. The statistics back me up on this and indicate that people cannot afford to pay for private insurance. What is happening is not right. I accept the Minister is trying to establish a single-tier health system and dealing with the matter to which I refer is probably one of the most important aspects of achieving this goal. I request that he pursue this issue with all possible vigour in order that there be a level playing field and that ordinary people will be in a position to afford to pay for private insurance.
I thank Deputy Tom Fleming for raising this important matter. I am deeply concerned about the current position and I am extremely unhappy that it has been accepted, as a matter of course, that the rate of medical inflation is 9%. Why is that the case? We need to examine the position. Has anyone carried out a unit-based cost analysis in respect of what is paid for each procedure? The answer is that this has not been done. However, I have requested that such an analysis be carried out. We are seeking information from abroad in respect of this matter.
I must acknowledge that, in fairness, the VHI has made attempts to save money during the past year. There has been a 15% reduction in consultants' fees per procedure and a 6% reduction in private hospital fees per procedure. In addition, there has been an annualised reduction in internal administration costs of €14 million. These actions have generated annualised savings of €100 million but in my view they do not go far enough. Even though the Comptroller and Auditor General does not have any power in this area, I will, on behalf of the people, endeavour, by means of appointments to the board and through the appointment of a new CEO, to ensure that driving down costs will become the focal point of the VHI's activities. The costs that are charged through insurance are passed on privately to people who do not have insurance. This has implications across the health service and the entire tax base. The Deputy may rest assured that this matter will be aggressively and vigorously pursued.
4 Deputy Billy Kelleher asked the Minister for Health when the special delivery unit will be established and operational; the process by which it will begin receiving referrals of patients; the timeline for this process; the date on which the National Treatment Purchase Fund will no longer receive referrals; the functions the NTPF will have following the establishment of the SDU; and if he will make a statement on the matter. [18080/11]
I announced the establishment of the special delivery unit, SDU, on 1 June. This has been one of my key priorities since becoming Minister for Health because I am determined to tackle the delays in access to hospital services whether that is for emergency or elective care. The SDU is also a critical building block in the Government's plans to reform radically the health system in Ireland, with the ultimate goal of introducing a system of hospital trusts and access to services based on universal health insurance. Access to such a system will be determined by need rather than what someone can afford to pay. As part of this, free general practitioner, GP, care at the point of delivery will be put in place.
I have appointed Dr. Martin Connor as head of the SDU and to the interim board of the HSE. Dr. Connor is an international expert, with a proven track record in health service transformation. He has extensive experience in the NHS and led a similar initiative in Northern Ireland with considerable success. His principal task will be to build up the SDU and to prepare proposals for me on how best it can be placed on a permanent footing within the next six months.
Dr. Connor has already begun to work with the hospital system in order to put in place new arrangements to reduce waiting times in emergency departments and to improve access to elective inpatient and day-case services. This work includes a detailed baseline analysis of the emergency and elective access system. Part of Dr. Connor's remit is to advise me on the governance arrangements which will best ensure there is real accountability and responsibility for performance across all public hospitals.
For now, the National Treatment Purchase Fund, NTPF, will continue to operate as normal, accepting applications from persons who have been waiting for over three months for treatment. However, the establishment of the SDU will require a change in the current role of the NTPF. This is an issue I will be considering over the coming months.
An immediate priority for the SDU will be to ensure waiting lists for inpatient services are managed properly and that hospitals take responsibility for managing patient flows. I cannot accept a position where some hospitals allow small numbers of patients to wait more than a year for their procedures. I will expect this matter to be tackled quickly.
Most people accept that the National Treatment Purchase Fund has proven to be a very effective mechanism in the context of dealing with delays and reducing waiting lists. Some €30 million has now been taken out of its budget. Will the Minister confirm that this money will be spent by the special delivery unit on ensuring the capacity the National Treatment Purchase Fund would otherwise have had if there had been no reduction in its budget will be used to reduce the waiting lists relating to elective and emergency surgeries, MRI scans etc.? I am concerned the National Treatment Purchase Fund should continue to be in a position to refer people on to private hospitals in respect of having procedures carried out. The major issue that arises here is that the special delivery unit might use up most of the €30 million to which I refer in covering administration costs rather than in disbursing it in the form of direct funding to patients.
I wish to comment on the position relating to hospital trusts, particularly in the context of Roscommon County Hospital. Prior to the general election the Minister stated:
We will establish Roscommon County Hospital as a stand alone hospital. It will continue to be owned by the State, but will be governed and managed by a Local Hospital Board...
If that is the case, will legislation be required to establish the hospital as a stand-alone facility? Will the hospital be used by the special delivery unit in the context of the provision of elective surgery or will it be in a position to operate independently of the unit?
People know my view on the National Treatment Purchase Fund. I must seriously contest the Deputy's contention that it provides value for money and works very well. The fund has delivered a certain level of relief to the system. However, we must consider the fact that €300 million was spent by the National Treatment Purchase Fund over three years. Last year it spent a total of €90 million and 28,000 patients were seen. If I recall correctly, inpatient procedures were required in respect of 20,000 of these individuals. Let us compare that with the position in Northern Ireland, where the special delivery unit approach is used. In 18 months, and at a cost of £36 million — as opposed to €300 million — 57,000 people were treated.
There are ways of doing things a great deal better. I cannot suddenly turn off the tap in respect of the hospitals and patients that continue to use the fund. However, we are reducing the number of people in respect of whom the fund will purchase operations. We want to use the funding that will be saved as a result of this in more innovative ways. I refer, for example, to circumstances where the addition of a theatre nurse could double the output of a surgical unit. There are a host of other examples which could be offered in this regard in respect of accident and emergency departments, medical departments and various other procedural areas. The addition of staff — even half-time whole equivalents, etc. — can make a huge difference in the context of output in these areas. The prime example I might offer relates to Our Lady's Children's Hospital, Crumlin, where the addition of 0.4 of a whole-time equivalent of a nurse could double the number of scoliosis patients treated.
We are concerned with doing things in a different way. The special delivery unit will also be the agent of change, which is extremely important. I am not just referring to changes in clinical programmes and the way in which services are delivered, I am also referring to the unit being the agent of change in the context of how information and communications technology is used.
It is deeply disturbing that there is a major training hospital in this country to which no non-consultant hospital doctor, NCHD, wants to go as a result of the way in which they are treated. Protocols will be put in place to inform people how they should deal with their peers, with junior staff and with patients. Those who stand outside of this will be brought to book.
5 Deputy Catherine Murphy asked the Minister for Health if his attention has been drawn to the fact that paediatric services in Dublin have become inundated with referrals; his views that children with diabetes should be seen four or more times each year in order to properly manage their condition and minimise problems in adulthood; if he has considered the re-organisation proposal from Diabetes Action who are seeking a re-organisation of the service into eight networks in order that there is an equality of distribution/access to services; and if he will make a statement on the matter. [18078/11]
The HSE's national clinical programme for diabetes, which includes the care of children and adolescents with diabetes, has estimated that there are between 3,000 and 4,000 children and young adults with diabetes in this country. It was established by the HSE in 2010 with the express aim of defining the way diabetic clinical services should be delivered, resourced and measured. One of the key priorities is to facilitate future organised care and screening for diabetes related complications.
Type 1 diabetes is a particularly complex condition in children and young adults and so it is recommended that their care be delivered in a multidisciplinary setting, with access to a consultant paediatric endocrinologist and other diabetes health care specialists and psychological support. For young people this diagnosis presents great difficulties and life changes, particularly in the teen years.
One proposed national model of diabetes care is based on eight to ten regional networks, with the three existing Dublin centres acting as a tertiary hub of excellence and continuing to see one third of the national paediatric and adolescent diabetic population. This model has been proposed by the Diabetes Federation of Ireland. The second model came from the expert advisory group, chaired by Dr. Colm Costigan, paediatric endocrinologist in Crumlin Hospital. This proposes that care be centralised for each region in a dedicated paediatric and adolescent diabetes centre, looking after at least 150 children and adolescents. Ideally the centre should be in a regional hospital that has an adult diabetes centre to facilitate transition to care in adulthood.
The national clinical leads for diabetes and paediatrics are to meet in the next couple of weeks to assess current services across the country, to agree a model of care and to standardise these across the country. They will also develop criteria for use of CSII therapy — insulin infusion — in children and adolescents with type 1 diabetes and work on policy to prevent and aid the early detection of diabetes in young children and adolescents.
Ultimately, the function of the HSE national programme for diabetes, among others, is to consider which model is most appropriate and the executive is working to this end. In parallel, my Department and the HSE will be meeting the Diabetes Federation of Ireland with a view to progressing the issues around the appropriate model of care for children and adolescents with diabetes.
Finally, the Deputy may wish to note the following important developments in this area. The national diabetes programme is continuing the development of a national diabetic retinopathy screening programme. While retinopathy screening is continuing in the north west region, the intention is that services be rolled out nationally, probably during 2012. This programme is significant because diabetic retinopathy is the leading cause of blindness and serious visual impairment in Ireland. Some 90% of people with diabetes will develop retinopathy, while 10% will be sight threatened if undetected and untreated. I met community ophthalmologists on this issue and discussed their plans for rolling this out. I will also meet optometrists who may also have a role. A national footcare model has also been agreed. The aim for 2011 is to establish 16 specialist multidisciplinary foot care teams across the country in line with indicative national hospital reconfiguration which will have different levels of care for patients, depending on their risk of diabetic foot disease.
I rely on people who contact me to tell me about the level of care they feel they and their children, in particular, receive. I am sure most of us, including those on the other side of the House, have had significant communication on the issue of the structure of the diabetic services. I hear that the Dublin hospitals are inundated with people looking for services. People are making contact because they are concerned by the queues and the fact that children are not seen as often as desirable to minimise damage that might occur later. I take it from the Minister's response that he will agree some changes to the system. Does he have a timeframe for when he expects these changes to be fully rolled out? The change is about doing things smarter and will not necessarily cost more. However, if the system is done differently, it may well save unnecessary damage and bring about better outcomes in the long term.
I thank the Deputy for raising this issue and I hear her concerns loud and clear. Many people have the same concern. In my response I indicated that in the next couple of weeks a meeting will be held between the clinical leads for diabetes and paediatrics to assess the current services across the country and, most importantly, to agree a standard model of care. Without going into too much detail, I imagine we are talking about a matter of months and that something concrete will arise from that meeting. I will certainly push them to come to an early conclusion. Much work has been done in the area and while I know there are varying views on how best to achieve the end, I have no doubt that all parties concerned are interested in and committed to the well-being of children with diabetes and that they will expedite a plan that we can implement.
