Vol. 745 No. 4
38 Deputy Billy Kelleher asked the Minister for Health the public hospitals that he considers suitable to be turned into hospital trusts; if the introduction of external management consultants represents the beginning of that process; if the move is permissible under the Croke Park agreement; and if he will make a statement on the matter. [33230/11]
The health service requires strong management capacity to deliver on service targets in an effective and efficient way within available resources, and also to lead change in a complex environment. Over a period the HSE has identified a need to develop management capacity, especially in certain hospitals.
In June 2011, the executive invited tenders from potential service providers for a four-year framework agreement for personnel placement and supply services. Under this agreement, service providers can be asked to source and supply senior interim managers or more long-term senior management candidates. Following from this tender process, five companies were invited last month to participate in a mini-competition to source and propose candidates for an interim management support structure for HSE west. The competition has closed and the proposals are being evaluated.
Under these arrangements, it is planned to recruit a chief executive officer for the Galway university hospitals group. It is also intended to strengthen management capacity in the HSE mid-western region by putting in place other interim management supports. The successful provider will also be expected to assist in developing management capacity for the longer term. The HSE is engaged in discussions with the IMPACT trade union regarding these plans and does not regard them as conflicting with the public service agreement.
As stated in the programme for Government, in conjunction with the introduction of universal health insurance, public hospitals will become independent, not-for-profit trusts. This will require the development of the necessary corporate governance, management and clinical capacity to ensure these hospitals are equipped to function efficiently and effectively, once established as independent service providers.
In the context of the introduction of universal health insurance and the establishment of independent trusts, by now the stated position of the Government, nine months after taking office, given what was said prior to the general election and the time the Minister has had to prepare policy documents on his own vision of what the health service should look like in the years ahead, should at least offer a blueprint for us to analyse in the near future. We are awaiting the establishment of the implementation body in respect of universal health insurance, but it is imperative that we see the criteria laid down, with the instructions and parameters for the commission when making proposals on universal health insurance. In tandem, if we are to meet the commitments given in the programme for Government, in the near future hospitals must be identified that would be suitable for removal from the HSE, or whatever structure is left after the legislation is passed, to become independent trusts managed by a local board completely separate from the national body which will manage the health service. None of this has yet happened. Does the Minister know which hospitals will be involved? Will they be large hospitals, or the smaller hospitals which are being downgraded?
We are not of the view that hospitals are being downgraded; they are changing the emphasis on the care they provide. Our primary concern is that hospitals are safe. Decisions are still in the process of being assessed; therefore, no final decisions have been made. We are evaluating the matter. All of the hospitals are different and the universal health insurance implementation commission will examine the issue. It would be premature, therefore, to outline exactly what each hospital will do or which hospitals will be connected to which. There are different possibilities and there may be interim arrangements prior to final arrangements being made for connectivity between hospitals. There are considerations related to connectivity by road infrastructure and the complementary positions hospitals offer when in partnership with others; we do not want hospitals to duplicate services unnecessarily. This work is ongoing. It is a massive task that we are intent on completing and there has been a lot of activity to date. As soon as the implementation body produces its report, it will be brought before the Dáil.
Who will make decisions on the hospitals in which there will be further capital investment while we await the establishment of independent trust hospitals and the amalgamation of other hospitals? Who is going to make these decisions in the interim?
Each Minister receives a capital budget and it is his or her responsibility and that of his or her Department to make the relevant decisions in respect of that budget. That has always been and remains the case.
39 Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will put in place a programme to restore services to hospitals in the north east and, with immediate effect, maintain and sustain the minor injury unit at Monaghan General Hospital as a 9 a.m. to 9 p.m., seven days a week service, proceed with the medical assessment unit at the same hospital site and restore the rapid response vehicle to the ambulance service covering County Monaghan and north County Louth [33229/11]
I am committed to ensuring acute hospital services at national, regional and local level will be provided in a clinically appropriate and efficient manner. In particular, I want to ensure that as many services as possible can be provided safely in smaller hospitals. To this end, the Government will publish a framework for the development of smaller hospitals to set out how their future will be secured. The framework will give clear information on the role of smaller hospitals and address any safety issues arising from HIQA's reports. Consultation covering all the key stakeholders, including patients and public representatives, will be an integral part of the process. In addition to the framework, the organisation of hospital services will be informed by the clinical programmes being developed and implemented by the HSE. These interrelated programmes aim to improve service quality, effectiveness and patient access and ensure patient care is provided in the service setting most appropriate to people's individual needs.
In the context of the specific questions raised by the Deputy, the minor injuries unit at Monaghan General Hospital provides an eight hour service, from 9 a.m. to 5 p.m. This service came into effect on 1 November. The change in opening times is the direct result of the current budgetary and financial position facing the health system. The HSE has reviewed other possible options to save money or increase revenue but concluded that they would not generate sufficient savings in the short term. Following a detailed analysis of this issue, it has estimated that total annual savings of almost €400,000 will be generated with this alteration of opening hours.
I am favourably disposed towards the development of medical assessment units because they provide excellent service for patients. However, it is essential that such units be justified from both a service delivery and value for money point of view. The HSE has, as the Deputy is aware, established an independent feasibility study which will examine if there is a clinical need for a medical assessment unit in Monaghan General Hospital for the population of County Monaghan. It will also establish the pay and non-pay costs and internal-external support services associated with the establishment and running of a medical assessment unit in Monaghan General Hospital. The group commenced its work on 17 October and the timeframe for completion is six to eight weeks.
Additional information not given on the floor of the House
The HSE national ambulance service initially put in place a rapid response vehicle to assist with the smooth and seamless transformation within the area. This is a non-transporting vehicle, carrying advanced paramedics and an extended range of equipment to provide advanced treatment. This model is not sustainable locally because of the unavailability of appropriately qualified staff, but the matter will be kept under review, with a view to reintroduction when the national ambulance service is in a position to deliver it at the appropriate service level. Staff resources have been redirected to front-line ambulances to ensure there will be no change in the clinical levels available throughout the area. The region has a fully functioning emergency ambulance service.
Unfortunately, I cannot say "Go raibh maith agat" to the Minister because, not for the first time when addressing the people of County Monaghan, a Health Minister has made reference to a framework document. That phrase will have a serious echo for those familiar with the history of Monaghan General Hospital. The Minister referred to the minor injuries unit offering services between 9 a.m. and 5 p.m., but he did not indicate that such services are now only available Monday to Friday, the unit now closed on Saturdays and Sundays. This represents a significant contraction from the 9 a.m. to 9 p.m. service that was previously available seven days a week. Savings and cuts are the only matters about which the Minister speaks.
Only a couple of weeks ago the Minister tabled an amendment to a Private Members' motion which followed on from amendments I had tabled seeking to secure the future of the minor injuries unit at Monaghan General Hospital, ensure the establishment of a medical assessment unit there and have the rapid response vehicle recently removed from our county restored. Government Deputies supported that amendment which stated the House "supports the Government's policy of developing the role of smaller hospitals to their full potential rather than closing or downgrading them". At the same time, however, the services on offer in the minor injuries unit at Monaghan General Hospital on Saturdays and Sundays were being discontinued. In addition, they were being significantly reduced on every other day of the week.
What makes the Minister's approach different from that of his predecessor, Mary Harney, and the former Fianna Fáil-led Governments that introduced a series of cuts? That is what we are facing. There is no difference between this and the previous Administration; all there has been is a change in personnel.
There is just over one minute left.
I am not sure what was the supplementary question.
It is the same question I put to the Minister: will he restore——
I made the position clear. I made clear why we face the position in which we find ourselves. It is due to the current economic fiasco left by the preceding Government. The health sector, just like any other of the spending Departments, must make savings and we have had to make very unpleasant decisions to stay within budget. These are not decisions that I particularly like but they must be made.
It is not all one way action by any means. As I have told Deputy Ó Caoláin, a framework document on small hospitals is being worked on. There will be an opportunity for all Deputies to have an input. There will be consultation. There will be more services of a safe nature brought to smaller hospitals.
I mentioned previously the many new services that have evolved in Louth County Hospital which is close to Deputy Ó Caoláin's constituency of Cavan-Monaghan. The footfall of people through that hospital has increased dramatically as a consequence. The future for smaller hospitals is around services that can be delivered safely in those hospitals, not the very complex emergency department facilities which are restricted to the major hospitals.
Briefly——
We are over time.
——there was nothing of an overly specialist nature in the services at the minor injuries unit. It was an essential component part of what remained.
I thank Deputy Ó Caoláin.
It was never envisaged that there would be further cuts.
I thank Deputy Ó Caoláin.
All the Minister is doing is complicating an impossible situation in Cavan and Drogheda by further displacement of patients.
40 Deputy Luke ‘Ming’ Flanagan asked the Minister for Health if his attention has been drawn to grit weed (details supplied) and the health epidemic that this will cause, including cancer and other fatal illnesses; if he will investigate and analyse the various substances found in grit weed, which include industrial etchant sprays, glass particles, sugars, sands and other micro contaminants, and if he will publish the results of such an investigation; if he will, in liaison with the Department of Justice and Equality, arrange for An Garda Síochána to provide confiscated cannabis to his Department to sample; if he will consider, again in coordination with the Department of Justice and Equality and in view of the on-going prohibition of cannabis, introducing sentencing to reward the evil nature of those who impregnate cannabis with various grits, some of which are carcinogenic; his views on the health aspects of the prohibition of cannabis, and in particular the potential impact that grit weed will have for a future generation; and if he will make a statement on the matter. [33262/11]
Cannabis is a Schedule 1 controlled drug under the Misuse of Drugs Act 1977. Its cultivation, supply and possession is prohibited and unlawful in Ireland, except for the purposes of research.
Cannabis continues to be the most widely abused drug in Ireland and it is not the intention of Government to legalise its use. The Government has strong concerns that legalisation of cannabis use would be likely to lead to increased levels of experimentation with drugs, particularly by young people. Cannabis is also known to be a gateway drug, which facilitates individuals moving on to other dangerous drugs.
Cannabis misuse is detrimental to health, and significant physical and mental health risks are particularly associated with long-term use. In addition, as Deputy Luke ‘Ming' Flanagan has noted, cannabis users are also exposed to health risks associated with contaminants in cannabis products, such as chemicals, pesticides, bacteria and grit weed. Grit weed contamination occurs where microscopic glass beads are sprayed onto cannabis plant to give the impression that the cannabis is of good quality. The Forensic Science Laboratory has not found grit weed contamination in samples of cannabis seized on the streets in recent times.
It is a criminal offence for a person to import, export, produce, supply or possess cannabis. Possession and supply are subject to serious criminal sanctions of: up to seven years imprisonment and-or a fine for unlawful possession, and up to a maximum period on indictment of life imprisonment for unlawful supply.
Cannabis is illegal in this State as its use is harmful to human health. Contamination of cannabis with adulterants such as grit weed only increases the health risks associated with cannabis use.
The Minister of State said that the legalisation of cannabis would lead to increased use. They have not legalised it in Holland, but they have found, now that they have regularised it in a certain sense or adopted a policy of tolerance, that its usage has not increased. In fact, in comparison with Ireland, especially among young people, there is far less usage of it.
On the gateway effect, the Institute of Medicine in Washington DC has done a study on this and it would disagree with the Minister of State. When it comes to the gateway effect, I suppose one of the best examples at which one can look to show that it is not the case is, yet again, Holland. According to a study conducted by the Trimbos Institute in Holland, where one can openly but not legally purchase cannabis, fewer than one in 1,000 teenagers experiment with heroin. Depending on which organisation one listens to, the figure for Ireland is as much as one in 80. If the gateway effect is caused by the legalisation of cannabis——
May we have a supplementary question, please?
——why is the figure in Holland 90% lower?
Have tests of the samples of cannabis held by the Garda Síochána provided accurate results to show what is contained in the cannabis being sold? It is not ideal that people use cannabis, but its illegality makes it infinitely more dangerous. In particular, street dealers do not ask for identification. Were it legal, they could do so. Is there information on what is contained in contaminated weed? Would it be possible to consider imposing stronger criminal sanctions on those dealing in this substance, given that it is infinitely more dangerous than cannabis?
The contamination or adulteration found involved the use of crushed grass particles or grass micro-beads. Some evidence of this was found in 2007 and 2008 but recent testing has revealed no evidence of these materials. The Government's main concern relates to the physical and mental health effects of the long-term use of cannabis which have been associated with lung and throat cancer but clear links have also been established between cannabis use and the development of serious mental illnesses such as schizophrenia and depression.
International literature shows that the increasing number of persons presenting for drug treatment owing to cannabis-related problems is linked with increasing cannabis potency and contamination. It is claimed that more potent forms of cannabis are associated with higher risks of adverse health consequences. It is interesting to note that the United Kingdom and the Netherlands are moving to reclassify the stronger form of cannabis as a class A drug. In the case of the latter, evidence indicates that the liberalisation of the law has resulted in a significant increase in drug tourism. The Dutch authorities are moving to close this off.
Our principal concern which it is legitimate to have relates to the physical and mental health implications of the long-term use of cannabis. For this reason, there is no intention of decriminalising the use of cannabis.
41 Deputy Billy Kelleher asked the Minister for Health if he will provide an update on the crisis that a number of hospitals face in their budgets this year; the actions he will take to address the expected €320 million overrun; and if he will make a statement on the matter. [33231/11]
The figure of €320 million to which the Deputy refers is the overall projected overrun in the HSE Vote. The latest Vote data have reduced this forecast to €300 million. The HSE was required to make gross savings of €962 million in its national service plan this year. The plan which was approved in December 2010 requires the HSE to operate within the limits of its Voted allocation and has been framed to deliver service levels in 2011 broadly in line with 2010 levels, while reducing the cost of providing services.
In the acute hospital sector a significant variation in productivity between hospitals was identified, particularly in day case rates, same day admissions and length of stay. All hospitals have been advised that they must operate within their allocated budgets and meet the service level activity targets they agreed for 2011. It has been made clear that those hospitals which fail will face consequences.
Despite the fact that the hospital sector has managed to deliver some reductions in its cost base during the first nine months of the year, at the end of September there was an accumulated deficit of €145.6 million in hospitals. While some hospitals are on target to break even, having managed the reductions in their budgets, the deficit in the hospital sector grew again in September by €3 million. Although the rate of growth has slowed, demonstrating that the sector is now operating within a much more sustainable level of expenditure, there is still a significant deficit which falls to be addressed. The HSE is implementing measures to address its overall deficit, including measures to ensure that hospital activity levels, which are running over target in many cases, are brought back in line with the national service plan targets, and accelerating the collection of outstanding income due in respect of the treatment of private patients. I am on record as saying that every individual agency has responsibility for managing its budget and must take all necessary measures to stay within budget while delivering its planned level of service. Under its reform programme the Government has committed to achieving greater efficiency in patient care and service delivery. These efficiencies will not be easy to achieve but I am certain that over time they will help to ensure that more people get access to services within the resources available.
As the Deputy is aware, I established the special delivery unit earlier this year with the objective of addressing the obstacles that prevent patients being seen and treated quickly. In order to address the problems in emergency units, to date €2.3 million has been committed to 15 hospitals which represent 80% of trolley waits. Funding is approved on the strict understanding that it will be released only where the specific performance measures and specified conditions have been met, including the requirement that no patient will wait more than 23 hours in an emergency department.
In respect of the broader financial issues in the hospital sector, the HSE continues to work closely with all hospitals to ensure the service impact of cost containment is kept to a minimum and to ensure patient safety remains at the core of all decision making.
The fundamental issue is who is in charge of the health services. E-mails sent from Cathal Magee, the CEO of the HSE, to Michael Scanlan, the Secretary General of the Department of Health, state there is confusion and uncertainty about the governance of the system with regard to whether it is the Minister's advisers, the HSE, the Department of Health or the Minister who is in charge. There has been a substantial drift in dealing with the budgetary issues we now face. Decisions have not been made in recent months, other than on the PR exercises such as the special delivery units and the sacking of the board.
The substance of the issue is the clear problem with governance of the Health Service Executive because it does not know who are its masters. Is it the Minister's advisers, the Minister, the Secretary General or the board? Some of the e-mails being sent to and fro are quite disturbing because they deal with the very heart of the provision and delivery of health services. If there are to be changes in governance in the meantime, hospitals, hospital managers and HSE staff are unsure as to who is running the health services.
May I ask the Minister to respond?
Will the Minister tell the House who is ultimately responsible?
I made it very clear that I would be a far more hands-on Minister than my predecessor. The budgetary problems to which the Deputy alluded exist for the obvious reason I mentioned, namely, the performance of the Deputy's Government. Notwithstanding this, there is good news. Ultimately the buck stops with me; that is what I stated I would do and the Secretary General and the HSE report in. The board that was in place is gone and the current board will be gone by the end of this year. There will be a new plan for the supra-structure of the HSE until we come to the final solution later next year, hopefully by June.
The final solution.
That is a bad phrase.
It rings a bell.
Excuse me. I did not interrupt the Deputy. Perhaps he would like to hear some good news for the people of Cork and Cork University Hospital in particular. It has introduced new theatre practices, and their use in only five theatres, which is only 5% of all theatres in the country, has already yielded considerable savings. It uses its medical admissions unit in such a way that one quarter of patients who otherwise would have been admitted have been treated and sent home. This has resulted in approximately 22,000 bed days being saved. The savings are considerable and once it is spread throughout the system we will see even greater savings. We will seek to continue to transpose these good practices throughout the system. The failure in the past was that where excellence in care or process was identified it was not transposed throughout the rest of the system.
42 Deputy Richard Boyd Barrett asked the Minister for Health the position regarding his plans to alleviate the escalating trolley problem in accident and emergency units here; if it is his intention to review plans for the downgrading of accident and emergency units in smaller hospitals in view of the worsening problem; and if he will make a statement on the matter. [33484/11]
Immediately following my appointment, I set about establishing the special delivery unit, SDU, to unblock access to acute services by improving the flow of patients through the system. The SDU was established in June and quickly began work with the HSE to put in place a systematic approach to eliminate excessive waiting in emergency units. The SDU is establishing an infrastructure based on information collection and analysis, hospital by hospital, so that we know what is actually happening in real time. This will allow us to begin to embed performance management in the system to sustain shorter waiting times. I reiterate to the House that we can now see what is happening where previously we were in the dark. We used to find out months later what had happened but we can now tell what is happening in accident and emergency units at any given time. We can tell each consultant's waiting time on a weekly basis and it allows us to address those who are not performing to the level they could.
The SDU has identified the hospitals that account for the greatest number of trolley waits, which will benefit from intensive support between now and the end of the year. Liaison officers are working proactively to support these sites. As alluded to in a previous question, I have also agreed that some additional funding may be provided, on a strictly once-off basis and based on specific proposals from the hospitals, to reduce waiting times. We have identified the problems and we asked the hospitals to tell us what they would like to do to address the issue and what they feel the solution is. We will then sit down with the hospital and price the solutions. If it is a reasonable value for money initiative, we will support the hospital's idea.
Our problems did not arise overnight and they will take time to resolve, but they are being tackled in a systematic and relentless fashion through the SDU. I do not minimise the scale of the task before us but I am very confident that the SDU will facilitate real performance improvement in the hospital system and I already alluded to some of those in respect of Cork.
Additional information not given on the floor of the House
I also want to ensure that as many services as possible can be provided safely in smaller, local hospitals. A joint HSE-departmental group is developing a framework for the future development of smaller hospitals. Consultation with all the key stakeholders, including patients and public representatives, will be an integral part of the process.
The organisation of hospital services nationally, regionally and locally will be informed by the clinical programmes being developed and implemented by the HSE and by the framework for the development of smaller hospitals. These interrelated programmes aim to improve service quality, effectiveness and patient access and to ensure patient care is provided in the service setting most appropriate to individuals' needs. I expect to be able to report to the Government and this House on these important developments before the end of the year.
Some 366 people were on trolleys yesterday, with 34 in Galway, 38 in Drogheda, 31 in St. Vincent's, 27 in Beaumont and 24 in Mullingar. Some 20 people were on trolleys in Wexford before they realised the Minister, Deputy Howlin, was coming down. Additional staff were magicked into the hospital and another ward was opened to get people out of the Minister's way so that it looked nice when he got there. In some ways, that demonstrates the real issue. Behind all the talk of fair care and reconfiguration, reform and special delivery units, accident and emergency units throughout the country are in absolute chaos. None of this spin and jargon can mask——
Can I have a supplementary question from Deputy Boyd Barrett?
Is it not the case that they are in chaos and are not working? The idea that we get more from less when it comes to accident and emergency units is nonsense. We get less for less and we get more chaos. The only beneficiary of this are the people I hear day in, day out on the radio, such as the Blackrock Clinic and the Beacon Clinic, advertising for people to come to their private accident and emergency units. The policy of——
We will not have time for any supplementary questions.
The Ceann Comhairle did not interrupt anyone else like that.
Deputy Boyd Barrett cannot make statements.
These are questions.
They are not questions.
Is it not the case that money follows the patient in a situation where there is this level of chaos in accident and emergency units? The patients will walk out of public accident and emergency units, which are being slashed by cuts, and they will be encouraged to walk into private hospitals and public money will follow them. If the Minister wanted to do something about this and make some real savings——
It is Question Time. I ask Deputy Boyd Barrett to ask some supplementary questions.
——he would cut the €500 million or €750 million that is going in subsidies to private consultants——
This is Question Time. It is not a time for statements.
That is a question. Would it not be better — that is a question — if, instead of cutting staff and budgets in our public accident and emergency units, we cut the subsidies going to private consultants and other private health care providers?
I am not aware of subsidies going to private consultants. I want to correct Deputy Boyd Barrett. The figures he alluded to are an improvement on the 569 people in our accident and emergency units in January. We are going about this in a systematic way. As I said, we cannot change things overnight. I have told the House that no man is an island and, in the same way, no part of the health service operates on its own. One cannot fix the problem in the emergency department without fixing the problem in respect of inpatient beds and having more community facilities, including home-care packages, home helps and the provision of long-term care in order that people can leave hospital. One cannot fix it unless one fixes the problem in the primary care system to allow it to address more of the problems, including providing greater access to diagnosis and chronic illness care in the community, in order that people do not fall ill and end up in hospital. It is all interlinked. All of the hospitals to which we have given special support in the last week have included a combination of all these items as part of their initiatives, including an increased number of home-care packages, long-stay beds and short-term convalescent beds in associated hospitals, as well as more staff and beds in specific areas.
Much and all as we would love to be able to flick a switch and turn things around, that is not the way things operate. Specifically regarding money following the patient, since that initiative was introduced in the orthopaedic side, for hip and knee replacements, we have saved in the region of €6 million. We did this by insisting on patients being admitted on the day of the procedure, not the night before.
May I ask a supplementary question?
I am sorry, but we are over time. That is what I was trying to tell the Deputy — the more statements he makes, the more time he uses up for supplementary questions.
