Robert Troy
Question:6Deputy Robert Troy asked the Minister for Health the steps he is taking to tackle hospital deficits; and if he will make a statement on the matter. [1195/12]
Other Questions
Health Services
According to the latest available information, the HSE managed to achieve financial break-even within its overall Vote last year. While it was assisted in this regard by the Supplementary Estimate of €148 million, it is important to acknowledge that €58 million of this was attributable to a shortfall in the funding provided to the HSE earlier in 2011 for the pay savings arising from the voluntary exit schemes which ran up to the end of 2010 and departmental savings on its Vote of approximately €40 million which reduced the net impact on the Exchequer.
It was recently stated in the headlines of a newspaper that the Department of Health had handed back €40 million which it had not spent. This is a technical issue. The Department of Health cannot hand over the €40 million to the HSE. It must hand that money back to the Exchequer which in turn allocates it to the HSE in a Supplementary Estimate. That is the way it works. Given the scale of the HSE Vote and difficulties that any health service faces in managing within budget, this has to be seen as a very satisfactory outcome.
Given the €750 million saved last year and the year before that and the requirement to save €750 million this year, real innovation will be required to maintain the service. We now are at a point at which we depend on real innovation to maintain the service. However, such innovation and the new clinical leadership behind it are coming to the fore. That said, I am aware the acute hospitals are entering 2012 with an underlying deficit based on their rate of spending in the latter part of last year. This clearly will add to the difficulties facing hospitals this year in managing within reduced budgets and staffing levels. The HSE estimates at this stage that the overall underlying deficit for acute hospitals is in the region of €160 million, but this is subject to revision in the light of detailed end of year figures. This is an average figure and the challenge facing individual hospitals varies. I am advised that some hospitals achieved a break-even position or are carrying forward relatively small underlying deficits, whereas others have substantial deficits. A number of hospitals are facing particularly difficult challenges in this regard and therefore must focus on maximising cost reductions, income collection and effective clinical changes.
I thank the Minister for his reply. Obviously I accept there is huge pressure on hospitals in the delivery of front-line services in particular. However, this goes against every statement made last year by the Minister and the Government in the context of protecting front-line services. As a fair and reasonable person, I wish to give the special delivery unit time to work to ascertain whether it is having a real impact and is effecting change. However, there is a belief abroad that there was a massaging of the figures regarding how the waiting lists were analysed in respect of a 12-month period in the first instance and, in the context of waiting lists, on what patients were waiting for more than 12 months as a part of this assessment. As for people waiting on trolleys, the claims made by the Minister that fewer people are now waiting on trolleys on a daily basis in the accident and emergency units is correct. Equally, however, if one speaks to anyone who works in the front-line services, as I acknowledge the Minister does, they also will state the wards now are being overcrowded. In other words, the issue simply is being shifted from one area of a hospital to another and there has been no real, meaningful increase in the output and throughput of patients.
To reassure the Deputy opposite, protecting the front-line services still remains a priority and everything will be done to achieve this, notwithstanding the extremely challenging financial position in which we find ourselves. I reject any notion that there has been a massaging of figures. In a previous answer, I made clear how the figures were reached. Anyone waiting on a list before December 2010 was included as being a possible person who was still waiting and had to be treated by the end of December 2011. This amounted to 14,000 people and the fact this number now is in the low hundreds, all of which relate to Galway, speaks for itself in respect of the great efforts made by the service to achieve this goal. Moreover, as I stated, the target for the coming year is nine months, that is, no one will be left waiting for a procedure for longer than nine months.
As for the hospitals which are in severe difficulty and are bringing forward deficits from 2011 to 2012, I refer to the Minister's proposed changes to how hospitals charge private patients. Is there not an added incentive that in future, hospitals will prioritise private patients, given their ability to recoup the full costs from such patients? Moreover, in the context of hospitals being individualised into trusts over a period of time, could this not incentivise private patients over public patients to reduce budget deficits?
I thank the Deputy opposite for confirming there are fewer people on trolleys. The figures are there for people to see, and they speak for themselves. It is not good enough. I have said that.
The Minister should not deny the facts.
We wish to go further. By the middle of the year we wish to bring in the six hour target in respect of the patient experience. The goal is that the time from when one enters an emergency department to the time one leaves or is admitted should be six hours for 95% of patients.
The Deputy is absolutely correct. I have considered this issue and have had quite a number of discussions in this regard with both Ministers of State, Deputies Shortall and Kathleen Lynch, on the danger that public hospitals would be incentivised to treat increasing numbers of private patients. This has been accommodated within what is planned because once the hospitals pass a certain quota, they will not be allowed to keep any of the money. Consequently, there will be no incentive for them to continue to do this.
Briefly, Deputy Ó Caoláin.
I note the Minister now has given assurances twice to his junior ministerial colleagues that he will be consulting them on issues and, at the outset of 2012, I am sure this will be a highly welcome development both on their parts and those of all Members.
The Minister should make no mistake but that hospital deficits have a direct impact on patient care. Never mind the long term, Members are witnessing short-term temporary closures of wards and beds. The situation is serious and part of the solution to deal with it pertains to developing real efficiencies. However, the Minister is not consistent. For instance, he has cited his appeal to the management at both Galway and Limerick to consider redirecting certain procedures, which from their perspective are non-intensive, from their respective sites to smaller hospitals in the region. The Minister instanced how hernia operations or procedures are to go to Ballinasloe or Roscommon. This is welcome because Members want to see decentralisation-----
Deputy, can we have a brief question?
-----to some of the smaller hospital sites. The Minister lauded and applauded the situation-----
A question please, Deputy.
Yes, it is a question. The Minister lauded and applauded the position in Louth County Hospital, Dundalk, in respect of cataracts. At the same time, however, why does the Minister continue to preside over closures of critical outpatient services at several hospital sites throughout this State, while signalling even further cuts in that regard? There is no consistency in the Minister's position-----
Thank you Deputy. I must call the Minister for a final reply.
-----only confusion, and people are suffering as a consequence. How does the Minister respond?
In response to Deputy Ó Caoláin, it is very early in the year to be working oneself up into a rage.
Members already have had 12 months of the Minister and I can be excused for it.
Not yet. Only ten months.
We can all make good resolutions now. The Minister to reply.
It will be 12 months, please God, and I can have my assessment then.
God, what will that be like?
The Deputy should check the position in the North. It is exactly the same.
The Deputy should not worry.
Please allow the Minister to respond.
Equally, Deputy Ó Caoláin deliberately mishears when it suits his purpose.
No, these are things the Minister has said.
Please allow the Minister to respond.
What I stated only a few moments ago was that I had consulted and had been consulting with both of my colleagues in government a number of times. Moreover, I will continue to so do and, contrary to what the Deputy wishes to imply, this is no new development.
I am pleased to hear that.
However, the Deputy is quite right to mention Louth County Hospital because it exemplifies what is achievable in a smaller hospital and how no longer having a 24-hour emergency department does not mean one's hospital does not remain vibrant and a source of great service to its community. As the Deputy noted, approximately 1,000 cataract operations have been carried out there where none was performed previously, as well as 3,000 colonoscopies, several thousand phlebotomies, while more care of the elderly cases have been looked after, more surgery, more day cases and so on. I perceive the future for smaller hospitals to lie in the provision of a safe service in good surroundings by caring and highly professional staff.
However, this is not being done across the board.
Mental Health Services
Seamus Kirk
Question:7Deputy Seamus Kirk asked the Minister for Health his plans to cut respite facilities in psychiatric units like those in Ballina, County Mayo; and if he will make a statement on the matter. [1177/12]
The expenditure reductions necessary in 2012 will challenge all areas of the health system to provide continuity of services that is both appropriate and safe for patients. In common with other care areas, efficiencies and other savings will be required from the mental health service. However, I am glad it was possible to announce a special allocation of €35 million for mental health in line with the programme for Government.
Funding from the special allocation for mental health will be used primarily to strengthen community mental health teams in both adult and children's mental health services. It is intended that the additional resources will be rolled out in conjunction with a scheme of appropriate clinical care programmes based on an early intervention and a recovery approach. Some provision also will be made to facilitate the re-location of mental health service users from institutional care to more independent living arrangements in their communities, in line with the strategy of A Vision for Change. This necessarily will involve some rationalisation and re-organisation of services at a local and regional level.
Mental health services are continually reviewing the provision of service to their population to maximise the balance of service access within the available resources. Services include acute community mental health services, acute inpatient services, rehabilitation and continuing care. Some high support facilities also are used when required to provide respite care.
The case in Ballina referred to by the Deputy involves a community-based residential unit that provides inpatient and respite beds, as well as a day care centre and outreach services to patients with severe and enduring mental health conditions. These services are currently under review and a planning process for the future of mental health services for the area, which will include consultation with service users, is scheduled to commence shortly.
While I have stated publicly that the Minister of State has a strong commitment to the issue of mental health and the implementation of the strategy of A Vision for Change, what clearly is needed now is action beyond the words and commitment. It is beginning to become evident there already has been a downgrading of psychiatric services. While we welcome the ring-fencing of a sum of €35 million in this respect, the closure of the two ten bed units in Teach Aisling and the other facility in Ballina, County Mayo is an indication that the reverse of what A Vision for Change is about is happening.
A question, please, Deputy.
Will the Minister of State agree that people are being centralised back into the system rather than being treated in the community in line with a proposal made in A Vision for Change? Clearly, the decision to close these two units indicates what was proposed in A Vision for Change is being reversed.
The units are not being closed, rather the position is under review. On what is proposed in A Vision for Change, we have not got our heads around what community care means in the context of mental health services. For instance, there is a community-based team in Cork, the members of which visit people in their homes, of which I am sure the Deputy will be well aware, not only on a regular basis but when there are acute emergency episodes in order to maintain them within the community. That is what A Vision for Change is about and what we should be seeking to achieve, whether it be in Cork or Ballina, County Mayo. We need to examine seriously how we can keep people out institutions and maintain them in good health in their own communities. While there will always be a need for acute beds when people have acute episodes, such care should be for as short a period as possible in order that we maintain people in their own communities.
I read the Minister of State's comments on the late Sean McCarthy who was a champion of people with a psychiatric illness and a fond colleague and friend of ours in this House. It is clear that there is a downgrading of services, even though there is a commitment to ring-fence a sum of €35 million. On 15 December the Minister of State said the Department had sanctioned the lifting of the moratorium to recruit 100 staff, yet the HSE has paused such recruitment. What has happened in respect of that recruitment process? Has it been paused? Has the moratorium been lifted? What is happening with regard to the recruitment of an additional 100 staff, as announced by the Minister of State on 15 December?
I did not say that. I said that in the previous two years there had been a lifting of the moratorium in order to allow provision to be made for an 100 additional places and that we needed to examine seriously how we could get specific posts back into the service. We still do not know how many will leave the service at the end of February. If the numbers who left in previous years are anything to go by and given the fact that psychiatric nurses, in particular, can leave at an earlier age, we will probably lose more from the psychiatric services than from any other sector of the health service. We will have to examine seriously how we organise the posts in the system that will be necessary to deliver on the measures contained in A Vision for Change. That is to what the figure of €35 million relates. It is not to fund capital programmes but specifically to fund additional posts.
What steps does the Minister of State propose to take to address the situation in psychiatric services in the senior Minister's constituency of Dublin North and particularly the HSE's attempts to arbitrarily introduce changes for psychiatric nurses and in terms of patient care in breach of the rulings of the Labour Relations Commission? This could have resulted in industrial action as and from today, but, thankfully, it was suspended yesterday; however, the matter remains to be addressed. What steps does the Minister of State proposes to take to ensure it is addressed full on, while recognising that the crisis has been compounded by the closure of the admissions unit at St. Ita's Hospital and that there has been massive displacement of persons presenting for psychiatric services and mental health support services in north Dublin?
Staff relations issues need to be dealt with under the mechanisms put in place. That has always been my belief and should happen. It is not the case that we are not aware of the issue, as we are very conscious of what is happening. We are keeping a close eye on the matter which I hope will be resolved, as such issues are usually resolved.
On there not being a unit available for admissions to St. Ita's Hospital, there are other units available. Again, this is about getting our heads around the fact that people do not always need to be admitted when they have an acute episode. We need to start to examine different ways of dealing with such persons.
Deputy Kelleher mentioned the late Sean McCarthy who has been a huge loss to the mental health community. He would have been the first to say and the person who convinced me that people in difficulty in terms of their emotional wellbeing did not always need to be placed in an acute unit. When the directorate is in place and we give it the sum of €35 million, we will see a fundamental change in how services are delivered to people with mental health difficulties.
I accept that, but we will need some additional staff.
Universal Health Insurance
Niall Collins
Question:8Deputy Niall Collins asked the Minister for Health the model of health care on which universal health insurance is likely to be based; the other models being examined; and if he will make a statement on the matter. [1169/12]
Billy Kelleher
Question:17Deputy Billy Kelleher asked the Minister for Health the provisional estimates for the total cost of universal health insurance; and if he will make a statement on the matter. [1164/12]
Caoimhghín Ó Caoláin
Question:42Deputy Caoimhghín Ó Caoláin asked the Minister for Health when the promised White Paper on Funding Universal Health Insurance will be published; and if he will make a statement on the matter. [1316/12]
Micheál Martin
Question:958Deputy Micheál Martin asked the Minister for Health if he has attended meetings at which the universal health insurance model and hospital insurance fund was discussed; the progress made on same; and if he will make a statement on the matter. [32720/11]
I propose to take Questions Nos. 8, 17, 42 and 958 together.
The Government is committed to fundamental reform of the health system. This will see the delivery of a single-tier health service, supported by universal health insurance, which will ensure equal access to care based on need, not income. The universal health insurance system will be based on the principle of social solidarity. Every citizen will have a choice of insurer and equal access to a comprehensive range of curative services. A new insurance fund will subsidise or pay insurance premiums for those who qualify for a subsidy.
Key features of the reform programme which will underpin the introduction of universal health insurance include the strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients. It is a paradox of the current system that that which is the most efficient and cost effective, that is, primary care, has a cost associated with it and a barrier and that which is most expensive, that is, hospital care, does not. The work of the special delivery unit will continue in tackling waiting times - this relates to both scheduled and unscheduled care. The key features include the introduction of a more transparent and efficient "money follows the patient" funding mechanism for hospitals, and the introduction of a purchaser-provider split, whereby hospitals will be established as independent, not-for-profit trusts.
In addition, I recently announced significant changes in the governance of the Health Service Executive, under which the current board-chief executive structure will be replaced with a directorate or transitional governance structure. This new directorate structure will facilitate greater transparency, accountability and efficiency, and is a key component in the move to universal health insurance.
The reform programme is a complex and major undertaking that requires careful planning and sequencing. Detailed consideration must be given to the optimal structures for delivery of services and the critical inter-relationships between services, as well as best practice in health care reform. My officials and I have attended numerous meetings with interested parties at which various aspects of the reform programme have been discussed. These included a study visit by my officials to the Netherlands in June last year to examine the Dutch health insurance model. In addition, my Department organised a seminar on universal health insurance which was attended by experts from the Dutch Health Ministry, the World Health Organization and the European Observatory on Health Systems and Policies. Such contact with relevant bodies, both at national and international level, is vital to enhancing our knowledge and informing policy. I see it as imperative that we continue to engage with interested parties and gain from the experiences of other countries in this area. Ultimately, however, the Government's reform proposals will be designed to meet the needs of the Irish people and system and ensure the best outcome for Irish patients.
In order to assist in developing detailed and costed implementation proposals for universal health insurance and help drive the implementation of various elements of the reform programme, the Government has approved the establishment of, and the terms of reference for, an implementation group on universal health insurance. I am finalising details of the implementation group, including its composition, which I will announce shortly.
The implementation group will have responsibility for assisting the Department in preparing a White Paper on Financing Universal Health Insurance which will outline the estimated costs and financing mechanisms associated with the introduction of universal health insurance. The White Paper will be published towards the end of the year. However, it must be borne in mind that the precise cost of universal health insurance will depend, to a large degree, on the implementation of various reform measures as outlined. This highlights the importance of driving performance improvement and progress on reform across the health system as quickly as possible.
This is an extremely important issue and it must be discussed. The Minister referred to the publication of a White Paper at the end of this year. At that stage, he will have been in office for almost two years. He has made commitments in respect of health insurance and he referred to a long timeframe and a lead-in period. In the meantime, we are faced with a crisis of major proportions in the private health insurance industry. Many people are giving up their private health insurance because they cannot afford to pay their premiums. In addition, there is the question of the ruling of the European Court of Justice in the context of the VHI requiring a capital injection of €220 million. Then, there are the problems associated with Quinn Healthcare. While the Minister is discussing his grand designs, people cannot afford to pay for private health insurance and the Government may find itself in a hugely difficult position if it is obliged to provide VHI with a major injection of cash to bring it into line with other health insurers.
The Minister has a major problem but he does not appear to be addressing it. He is discussing something that will occur way down the road. In the interim, we are facing into a crisis of major proportions in the context of private health insurance. It is fine to discuss and be fascinated by the Dutch model. However, and regardless of whether Deputy Buttimer approves of our doing so, we must discuss bread-and-butter issues such as that relating to families not being in a position to afford private health insurance. Last year, the Minister referred to the increases that were introduced as being appalling and horrendous. The position in this regard has become even worse in recent months.
What would have been the nature of the increases if the Government of which his party was a part had introduced a risk equalisation scheme rather than merely bringing forward a levy so that it might continue to kick the can down the road?
There were many reasons for that, including legal ones.
As I am sure he is aware, the question is rhetorical.
We are engaged with Europe in respect of matters relating to the VHI, the need for its position to be put in order by the Central Bank of Ireland and the exigencies and strictures that obtain. We will not allow a scenario to evolve whereby the urgent will continually displace the important. We have a short-term strategy to allow us to deal with the immediate situations we face. Hence, the establishment of the SDU, the development of the clinical programmes and our discussions at Cabinet on the current position of the VHI and in respect of the market, which must be regulated and regularised. One thing that will prevent other insurers entering that market is uncertainty. That is why it is awaiting the publication of the risk equalisation scheme, on which the Cabinet has signed off and which will emerge shortly. That scheme will increase competition and will lead to prices being driven down.
We also have medium and long-term strategies. Our long-term strategy is to introduce universal health insurance as quickly as possible. Our plan for the medium term is to do what we always said we would, namely, make the best use of what is available to us. That is what we are doing. We are obtaining efficiencies through the clinical programmes. We are also bringing in the money-follows-the-patient model so that there will be transparency and that it will no longer be the case that hundreds of millions of euro will be dispersed into different parts of the system without our knowing about it. We will introduce universal health insurance so that every man, woman and child, regardless of income, will be treated on the basis of need and as equals.
Deputy Buttimer is very quiet today.
The final line of the Minister's reply comes directly from Sinn Féin policy. The only difference is that the Government intends to introduce an insurance-based model as opposed to universal entitlement to health care. Before the general election, the Minister promised a detailed breakdown of Fine Gael's proposed insurance-based model. However, that information has not been forthcoming. Following the Minister's initial reply to these questions, we know nothing more about what is proposed. Will the Government's model be based on the State as insurer or will the existing insurance companies form part of what is intended? Is the Minister in a position to indicate what might be the actual contribution per citizen or what the State might be obliged to contribute if it is intended that it pick up the tab for those who cannot afford to make payments themselves? Can he comment on any or all of those critical matters? When will we see the real detail of what is proposed? I welcome the Minister's clarification to the effect that the White Paper will be produced earlier than he indicated in the House not that many weeks ago.
There are many similarities and differences between ourselves and Sinn Féin. One of the differences is that Fine Gael and Labour will deliver because they are in government. We are in a position to do what I have outlined and we will do it. We do not aspire to do what is proposed, we intend to deliver on our promise.
The Deputy asked a number of extremely reasonable questions in respect of the shape of the proposed universal health insurance system, the likely level of premia, the way matters will be organised, and so on. It would be wrong of me to pre-empt or second guess the implementation group on universal health insurance which will study this matter and produce well thought out recommendations on how we might proceed. What is proposed is a major step for health reform here and there are many who feel it will not be possible to deliver what is envisaged, particularly at a time of such economic difficulty. We will deliver but it will be necessary to engage in careful planning, thought and implementation in respect of the proposed system. Approaching this matter in the way in which we previously stated we would - namely, by fixing what is already in place, obtaining better results in respect of the resources at our disposal and then moving towards a universal health insurance model - offers the best chance of success. Citizens will not be interested in everyone being insured if people are obliged to wait nine months for a colonoscopy.
Written Answers follow Adjournment.