Priority Questions

Health Service Staff

Billy Kelleher


1Deputy Billy Kelleher asked the Minister for Health if he will publish the contingency plans for dealing with the public sector retirements; the effect the retirements will have on frontline services; and if he will make a statement on the matter. [8730/12]

Caoimhghín Ó Caoláin


2Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will confirm the final number of persons who will have retired from the public health services between September 2011 and the end of February 2012 under the current retirement scheme; if he will outline the dynamic contingency plan to deal with the loss of such large numbers of staff to which he has referred; and if he will make a statement on the matter. [8729/12]

I propose to take Questions Nos. 1 and 2 together.

The most recent information available to me indicates that approximately 4,200 individuals will have left the health service between September 2011 and the end of this month. The corresponding wholetime equivalent figure is about 3,700. These figures are subject to change for various reasons, one being the time lags involved in collating data at national level. However, management at local and regional levels have full details of the staff who have already left or will leave by 29 February. Over 2,000 individuals had already left by the end of January. The figures are subject to further change because those who have indicated their intention to leave can change their minds right up to 29 February. Others may choose to leave who have not indicated this to date.

Planning for the impact of the end of the grace period began last autumn and a formal transition team for the health service, chaired by an assistant secretary from my Department, is in place. It comprises key HSE national and regional directors. Contingency plans have been developed locally for hospital and community services, reflecting risk assessments undertaken by each hospital or community manager. These have been reviewed at regional and national levels to ensure appropriate contingency measures are in place across all services.

I am satisfied that suitable arrangements are in place at national, regional and service-specific levels to manage proactively the impact of staff exits on front line services. The focus is on protecting and maintaining critical front line services such as emergency department, maternity, critical care and neonatal services.

The recently approved HSE National Service Plan 2012 acknowledged that there will be an inevitable and unavoidable reduction in services this year because of the scale of the financial and staffing challenges facing the health service. Obviously, I would prefer to have more funding available for our health services but the reality is that this is not possible right now. There is, therefore, an onus on all of us working in the health services to be as innovative and flexible as possible in order to mitigate against the impact on services of reduced budgets and staffing.

The mitigation measures in place include the backfilling of certain critical posts. However, the main focus is on reform and achieving greater productivity. The national clinical programmes are already delivering improvements in day-of-surgery admission rates, increases in the proportion of care that can be delivered on a day-case basis and other productivity improvements designed to provide a better quality service to patients at less cost. I very much welcome the clinical leadership that is being provided in this regard. I acknowledge and welcome the improvements in productivity that are being delivered by staff at local level through the Croke Park agreement. Examples pertain to staff redeployment, streamlining of management structures, including clinical management roles, changes in skill mix and more cost-effective rosters.

The national service plan has already been published and the regional service plans are in the process of being finalised and published. However, the need for dynamic and proactive management of the impact of reduced budgets and staff will remain and will continue beyond 29 February.

I thank the Minister for his reply. The publication of a contingency plan was raised on numerous occasions on this side of the House. The plan would not only give reassurance to us but also to the public and those involved in health services.

In response to questions from the leader of Fianna Fáil and other Deputies, the Taoiseach was unsure whether there was a plan. He stated at one stage we can take it the HSE has a plan. However, when we asked for further detail and specific information, it became very evident that a plan was only being put in place. The Minister has known since taking office that a large number would be retiring on 29 February 2012, many of whom will be highly skilled specialists in front line services. Merlin Park hospital in Galway should have 21 nurses but it will have only 11 at the end of February. Clearly, there will be considerable difficulties faced by the HSE and hospital services in providing front line services. Does the Minister agree with some eminent professionals at the coalface in maternity services who say people may pay with their lives because of the lack of highly qualified midwives?

Why will the plan not be published? Does the Minister agree that the efforts of the Department and HSE in ensuring adequate front line cover for those retiring are an indication that the plan was not well thought out?

In response to Deputy Kelleher, the Taoiseach is very clear, as am I, about the presence and completeness of the contingency plans in place. As I said, the situation is dynamic. We do not expect significant change between now and the end of the month but there has been much change heretofore. We had a very long meeting last night at which the CEO and four regional directors of the HSE were present, along with members of the clinical programmes. A comprehensive plan is in place.

Let me address specifically the issue raised in regard to the inflammatory and very upsetting remarks made by a leading professional which caused needless upset and anxiety among women looking forward to the birth of their babies. There is a very coherent, stringent, clear plan in place to deal with identified risks, including midwifery. In Limerick, 16.5 wholetime equivalents are to leave and there is provision for 15 to be in place when that happens. The clinical lead there is quite happy about safety.

When going through our contingency plans for different hospitals, as we did last night, we noted that, in some cases, one third or half the staff are being replaced and that, in other cases, perhaps only one fifth, one sixth or one seventh of the staff are being replaced. The service can be delivered with different types of rosters and skill mixes than we have at present. This must be achieved when there is a restricted budget and a moratorium on recruitment and a ceiling on staff levels.

I have to hand a copy of the Dublin North East Service Plan. I find no more dynamic contingency planning within this than I did within the national service plan, which was introduced a couple of weeks ago. It is important to deal with this because it is the only specific information we have. I expect it will be replicated in the other three regions of the HSE. It actually demonstrates that, by 29 February, we will witness the retirement of a further 400 staff. Worryingly, we also learn, for the first time, that a further 551 staff "will need to leave the service this year". It is not a case of voluntary retirements but it is stated very definitely that they will need to leave the service. Will the Minister acknowledge that the departure of 961 health service staff within one region will have devastating consequences for service delivery and, make no mistake about it, for patient safety, which is something the Minister is not happy to address?

Will the Minister confirm that what we are looking at in this plan is what presents across Dublin mid-Leinster, the west and south? The plan states there will be no replacement in terms of recruiting priority staff who will have left until such time as the entirety of this exodus is achieved.

I see Deputy Adams is at Deputy Ó Caoláin's side. I was here this morning when he made his contribution. It seems to me when words such as "there will be a devastating effect" are used, it is almost as if Sinn Féin wished for there to be a disaster.

It is as if they hope there will be some sort of calamity or catastrophe so they can continue on shroud waving. The reality is that Dublin north-east, Dublin mid-Leinster, west and south have all got their contingency plans. Individual hospital managers have their contingency plans and are fully conversant with the number of staff leaving, as well as what must be done to maintain a safe service. In each case they are acutely aware that not alone are they responsible for formulating that plan, but they must also be prepared to go on local radio to explain its effects to the public. I am confident that a comprehensive piece of work has been done. I congratulate all those involved and thank in particular the staff for the flexibility they have shown concerning the required changes, including rostering issues. I am confident we will be able to maintain a safe service, particularly in areas of high risk we have identified, such as emergency departments, maternity services, intensive care and paediatrics.

The Minister's reply did not address the questions I posed. Government Deputies from the north east will be shocked to learn for the first time that this report has signalled the departure of those taking up the early retirement option by 29 February. In addition, following that, there is a requirement for a further exodus - "need" is the word used - of 561 staff across the health service. Is that also the case in the service plans for the other three areas? If so, I ask the Minister to withdraw these service plans which are a recipe for disaster. We already have a crisis of untold proportions in our health services, so at the very least, the Minister should indicate that he will set a date for lifting the recruitment moratorium. In that way we could replace essential front line staff.

The director of the HSE's obstetrics and gynaecology programme, Professor Michael Turner, said staff reductions could have an impact on Ireland's maternal and infant mortality rates.

He said "could", but the Deputy should finish the professor's sentence.

I am just making the point. The Dublin north-east service plan and the projected number of maternity cases presenting this year, indicate that maternity hospitals will be under huge pressure in that region and elsewhere across the country. Will the Minister publish the detailed plan for emergency and maternity services so we can have some idea of where we are going with those services? There is concern among both the public and staff who are working at the coal face and are trying to provide safe services.

As regards Deputy Ó Caoláin's question about the three other service plans, there is not a need for the same number of exits. The lowest number of exits is from Dublin north-east. The contention that this is a recipe for disaster is utterly untrue - in fact, it is a formula to prevent any such disaster and ensure a seamless transition. We have put in place several different contingencies to allow for any problem areas that might arise unexpectedly. A comprehensive study has been undertaken of all people leaving the health service, including their grades and posts, so that replacement staff can be put in place where they are needed. In some places, one may find that where 16 people leave, they will all be replaced. In other places, however, where 35 leave only six have been replaced which is due to the nature of the service and the areas of expertise involved.

We are not lifting the moratorium but I have greater flexibility around it, by agreement at Cabinet, so we can examine specific areas where there is a risk and replace people accordingly. That is exactly what we are doing in this contingency plan.

Deputy Kelleher quoted Professor Michael Turner, but he will note that the word "could" is in there. If the Deputy was prepared to read the remainder of Professor Turner's statement he would find there is a big "if" there also. The statement said it could be a serious problem if proper measures are not put in place. However, the plans are in place and the measures will be in place also. Maternity is an area we were particularly concerned with, but the Deputy will find that many of the midwives leaving our service will be replaced.

The staff are not saying that.

I have talked to the people in charge who have responsibility, including the national director and regional director of the operation who are in charge of hospital directors and managers. The contingency plans are in place and there is no way we will have an unsafe service. We have had two major meetings on this matter and will have a further one before the end.

Care of the Elderly

Thomas Pringle


3Deputy Thomas Pringle asked the Minister for Health the level of services he expects in 2012 for elderly patients in our communities with the closure of nursing home beds, reductions in home help hours and without any increase in home support levels across the country but particularly in County Donegal; and if he will make a statement on the matter. [8863/12]

Government policy is to support older people to live at home and in their communities for as long as possible. This is achieved through a range of community based services such as mainstream home help, enhanced home care packages, or through various other supports such as meals-on-wheels and respite or day care.

The central challenge facing the health service this year is to use the reduced level of resources available to meet as best it can the increasing needs of older people for health and personal social services. This means we have to prioritise those in greatest need and accelerate reform of our services.

In the case of public nursing homes, the recently approved HSE service plan for 2012 makes it clear that a business as usual approach will result in the closure of a minimum of 555 beds because of reductions in staffing and issues like the age and structure of such units. Accordingly, we need a more proactive approach to the provision of public nursing homes, which seeks to protect the viability of as many units as possible within the funding and staffing resources available.

The HSE is already carrying out a viability review of all its long-stay nursing homes. The review is focusing on a number of areas including the location of units, demographic pressures and the ability to meet HIQA standards on environmental structures and staffing.

In the case of community services, there will be no reduction this year in the level of home care packages being provided. About 10,870 people are expected to receive this important service in 2012, as was the case last year, including about 4,800 new clients.

It is not possible to prioritise every service and there will be a reduction of about 4.5% in the total number of home help hours provided nationally. However, the HSE will still provide about 10.7 million home help hours this year to about 50,000 people. By ensuring the available hours are used to better effect, the number of people benefiting from home help services will fall by approximately 1.2%. We do not have the level of detail requested in the Deputy's specific question. I have asked the Health Service Executive to transfer the information to Deputy Pringle as soon as it collates it.

Additional information not given on the floor of the House.

A number of operational improvements are being implemented in order to deliver the most effective and best quality service possible within available resources. These include a new procurement framework for home care packages as well as new national home help guidelines.

While the national service plan has been finalised, regional and area plans are still being completed. As a result, I am unable to provide details at this time of planned services in Donegal. However, I have asked the HSE to let the Deputy have this information as soon as it is available.

As we do not have the service plan for HSE west, we do not really know the impact bed closures will have in County Donegal.

There will not be any good news in it anyway when it comes out.

The HSE service plan flies in the face of the Minister's reply and the Government's stated policy. It shows in fact there is no policy in place. According to the 2012 service plan, there will be a reduction of 113,000 home-help hours in HSE west services for the elderly. Maintaining home care packages at the same level as last year will in fact result in a reduction because of the rising aging population. As fewer people will receive home help hours and with a reduction of up to 900 beds in community nursing homes, more pressure will be put on the community nursing system. These, along with cuts of 700 people in receipt of subvention and enhanced subvention, fly in the face of the Minister's reply.

With these serious cuts, how can the Minister expect to support elderly people to stay in their homes which is agreed to be the cheapest and most desirable form of treatment and care? How can such a policy be implemented when the Government has savaged the home help hours, made no increase in home care packages, closed nursing home beds and reduced subventions?

Opposition does what Opposition does. I understand that perfectly and it is a legitimate position to take. However, if Deputy Pringle read the answer to his question, he would see it stated we will be dealing with an additional 4,800 people requiring home care packages this year.

Those involved in putting together the regional plan for HSE west have a clear focus. For the first time ever, we are beginning to see the coming together of various agencies on how to deal with older people. The notion that the only service available is long-stay care is wrong. There are all sorts of pieces in between on which we need to bring the agencies together, such as the Department of the Environment, Community and Local Government, to address supported and supervised living for older people.

The Deputy is not correct that 900 beds will be taken from the community nursing home system. As a matter of fact, having spoken to the four HSE regional directors of operations, RDOs, I understand the reduction will more than likely be less than 555. We are working to a clear plan on this.

The HSE's 2012 national service plan states between a minimum of 7,089 to a maximum of 7,432 public beds will be closed. In the minimum range, the reduction in community nursing beds will be 900.

Is it acceptable elderly people in County Donegal receive home help of just 15 minutes a day? If we do not support home help or home care packages and community nursing beds are reduced, elderly people will be left on their own which I would contend is a form of elderly abuse.

As I stated in my formal reply, we are going to have to do more with less. It is difficult to know how to do that with reductions such as these. We are going to have to seriously examine putting together a plan as to how we deal with our aging and elderly population. Up to this point, we did not have one. However, we are beginning to put it together. I agree with Deputy Pringle we cannot afford to leave a vulnerable group of people isolated and alone.

Medical Cards

Billy Kelleher


4Deputy Billy Kelleher asked the Minister for Health the additional resources that will be assigned to deal with the backlog of medical card claims; and if he will make a statement on the matter. [8731/12]

I thank Deputy Kelleher for raising this issue as I know this is a matter of concern to all Members which I very much share.

Last July, the HSE centralised the processing of medical card applications and reviews at the primary care reimbursement service, PCRS, in Finglas, Dublin. The aim is to have a single uniform processing system to replace the different systems previously operated through more than 100 offices across the country. It is expected the new arrangement will ultimately provide for a far more accountable and better managed medical card processing system.

However, I am conscious there have been serious difficulties for many patients resulting from the centralisation process. For its part, the HSE has now accepted it needs to review the overall operation of the central office with a view to ensuring an acceptable level of service for the public is in place. This review is being assisted by a consultancy firm which will review current processes, develop proposals for improvements of the processes and for improvements in customer service.

Notwithstanding this review, I have had extensive discussions with the HSE on this matter. Several changes have been introduced to streamline operations and to make the process for renewing a medical card simpler and easier for the public. The HSE has introduced a self-assessment system for medical cardholders who are 66 years or over. The self-assessment review model has been extended to medical cardholders under 66 who were granted their medical card on the basis of a means assessment. The HSE is standardising eligibility periods from two years to three years for people aged under 66 with a new four-year eligibility period for medical cardholders aged 66 or over. It is providing GPs with a facility to maintain the eligibility of vulnerable patients going through the renewal system. To make the application process easier, the HSE has asked the National Adult Literacy Agency to review the medical card application form.

Additional information not given on the floor of the House.

An additional 20 staff were redeployed to the central office in January to bring its complement up to 150. The most important initiative, however, is that the HSE has decided that any medical cardholder undergoing a review, and who genuinely engages with that review, will not have their entitlement withdrawn before that review is complete, regardless of the expiry date shown on their medical card. In addition, the HSE has examined medical cards that were withdrawn between July and December 2011 to ensure a standardised approach to applications.

I am determined the HSE will comprehensively address all of the difficulties that have arisen as a result of the centralisation of medical processing in the shortest time possible.

I want to put on the record of the House my appreciation of the staff in the Minister's office and the HSE in dealing with individual queries concerning medical card applications. However, the system is in absolute chaos which must be addressed quickly.

For the life of me I cannot understand why a review of medical card eligibility must be carried out for those with incurable diseases. What circumstances are going to change? I met a woman who was blind but was asked for further information on the renewal of her medical card application. It is beyond belief that a system would have reviews of medical cards that we know will be granted again. I have no difficulty in people going through a due process when applying for a new medical card. However, those renewing a medical card who are suffering from an incurable disease should be exempt from these reviews. That would allow PCRS officials to deal with the existing backlog for new medical cards. I urge everyone involved to get to grips with this problem.

This week, I had a case of a woman who passed away on Monday morning but the PCRS was looking for further medical evidence from her during the week. The office dealt with it sympathetically but the system should not have allowed that to happen in the first place. Will the Minister resolve the backlog of medical card claims quickly?

When the case the Deputy just referred to was first brought to my attention on Monday morning when the parliamentary question came in, I dealt with it promptly. I too was concerned about the manner in which it had been dealt with. The errors made in that unfortunate response from the PCRS were not as a result of any policy change but human error. It should not have happened. I was concerned about it and I have a detailed report for Deputy Kelleher which I just received last night. I am happy to discuss it with him later on today. Applications made on behalf of patients who are terminally ill are supposed to be dealt with as matter of urgency and in a straightforward manner.

I put on the record my appreciation for the manner in which the Minister's office dealt with this matter. However, in general, there are many other issues with the medical card renewal process. The idea a person waiting for a medical card renewal can claim back medical expenses they incurred when it is re-issued is not happening. I have several cases where individuals have had to pay pharmacists for medicines because they were not allowed to backdate the costs incurred when they were in transition between their old medical card and the issuing of a new one.

Apart from the changes I outlined, an additional 20 staff were made available to the PCRS to bring it to its full complement of 150.

Members should be aware of the important provision that if a person engages with the HSE on the renewal process, he or she will not lose eligibility during that period. We are seeking to explain clearly that there will be no question of eligibility being withdrawn during the renewal process until such time as a decision is taken. I am requesting the HSE to produce an information sheet for Members, GPs, pharmacists and citizens information centres to bring people up to date on the current policy. I hope we will start to see improvements in the processing of medical cards as a result of these changes.

Hospital Staff

John Halligan


5Deputy John Halligan asked the Minister for Health the number of whole time equivalent positions that have been reduced at Waterford Regional Hospital since the recruitment moratorium was introduced in March 2009; the amount that has been spent on agency staff at Waterford Regional Hospital in that same time period; the target of the recruitment moratorium by the end of 2012; if he will consider lifting the moratorium for frontline staff if that whole time equivalent downsize is reached in 2012; and if he will make a statement on the matter. [8864/12]

I have explained in an earlier reply that reducing public service numbers is an integral part of the Government's drive to reduce public expenditure. Health service employee numbers must be reduced to approximately 102,000 by the end of this year and further reductions will be required over the coming years. The regional service plans are currently being finalised and the exact ceiling for each service has not yet been determined. However, Waterford Regional Hospital is subject to the same restrictions as the rest of the health service.

Expressed as whole time equivalents, there were 1,851 employees in Waterford Regional Hospital in March 2009. By December 2011 this figure had reduced by 131 to 1,720. A significant portion of the reduction is accounted for in the management administration and general support staff grades. The hospital is aware of a further 41 employees, whole time equivalent, who will be leaving during 2012. This equates to 2.43% of current staff and is well within the national target of 3%.

The total amount spent by the hospital on agency staff was €800,000 in 2009, €3.1 million in 2010 and €3.2 million in 2011. Medical agency costs, which accounted for the bulk of agency expenditure, were €300,000 in 2009, €1.9 million in 2010 and €2 million in 2011. However, I am informed that since October 2011 the hospital has eliminated its expenditure on medical agency costs through a combination of cost saving measures and the recruitment of non-consultant hospital doctors. The remaining agency costs are largely for paramedical and support staff. In 2012 the challenge for the hospital is to address its remaining spend on agency costs in the same effective way in which it has tackled the issue with medical cover. The HSE national service plan commits to a reduction of up to 50% in agency costs.

Additional information not given on the floor of the House.

The 2012 employment control framework will be finalised shortly. I envisage that the HSE will still have discretion to decide on exceptional appointments to minimise service, quality and safety risks. I am not suggesting there will be wholesale replacement of staff or that there are easy options. Part of the solution must be to implement the national clinical programmes to improve efficiency along with quality, manage performance relentlessly, contain costs and investigate all available options, including redeployment of staff.

I requested the figures in light of the retirement of approximately 60 service workers by the end of February and the rising waiting lists for elective procedures at Waterford Regional Hospital that will inevitably follow the closure of two operating theatres. I have been advised that staff shortages will also lead to the closure of a further 30 beds.

Thousands of health graduates have left Ireland since the introduction of the moratorium yet the HSE has increased the amount of money spent on agency workers by 75% over the past three years. Between March and October 2010 alone it spent €67 million on temporarily filling full-time posts, including 167 non-consultant hospital doctors and 489 agency health care assistants.

May I ask the Minister the following question?

Under the terms of the temporary agency worker directive the HSE must offer agency staff the same pay and terms as direct employees. The cost does not end there, however, because it must also pay the wage cost commission, which ranges from 5.5% to 11.75%.

This is important and I have one supplementary question. It also pays PRSI at a rate of 10.75%, holiday and public pay at 12% and VAT at 21%. It has been estimated that in employing this workforce the HSE must pay a premium of between 30% and 40% on top of wages. These figures point to the fact that the recruitment embargo is failing.

It is not true to say the embargo is failing. The Deputy is right to point out the additional costs that agency staff incur. The agency staff directive, which insists that they be given the same terms and conditions as permanent staff, equally indicates that the base rate for agency staff will have to fall. The reason they were paid more was because they did not have the same rights. They cannot have it both ways.

I have no argument.

The reliance on agency staff has been reduced considerably by the increased use of non-consultant hospital doctors.

Waterford Regional Hospital is working with the National Treatment Purchase Fund and the special delivery unit to focus on the strict chronological management of patients. It successfully reached a 12 month maximum waiting time at the end of 2011 and it is making reasonable progress this year. Like many hospitals, it will need to redouble its efforts between now and the end of March to maintain the 12 month maximum and avoid triggering the penalty mechanism but it is expected to meet its target. It is doing very well in regard to trolleys. The trolley count yesterday morning was six, with no long waits.

Unlike many other hospitals, it does not incur significant expenditure on agency nurses. Between December 2010 and December 2011 medical and dental staffing increased by 15 whole time equivalents. Nursing staff has decreased by 14, or 1.84%, which is below the national average.

I recognise it faces challenges but hospital management are on top of the situation and I expect it to deliver on its targets of ensuring that, by the end of the year, nobody will have waited longer than nine months for inpatient surgery and, from May onwards, anybody who attends its emergency department will not be waiting longer than nine hours before leaving for home or a ward. For 95% of people the figure will be six hours.

May I ask a brief supplementary question?

I gave the Deputy a lot of time.

The Leas-Cheann Comhairle did not give me a lot of time.

I gave him the same amount as everybody else.

My question concerns what will happen after 60 people leave the service in February. The regional manager has stated the departure of such numbers from the public service at Waterford Regional Hospital will inevitably lead to the closure of beds. I do not think the Minister answered that question.

The note before me does not indicate how many, if any, beds are going to close but the closure of beds will not necessarily result in a reduction in services.

The regional manager has indicated how many beds are going to close.

I am trying to explain to the Deputy that the hospital can make increased use of existing beds, day case surgeries and theatres. The productive theatre initiative in Cork and elsewhere has resulted in a significant increase in the volume of work that theatres can manage. It saved €2.5 million in one year across five theatres. That is only 2.5% of the total number of theatres.

I have criticised the HSE in the past for its inability to transpose excellence across the system. Initiatives which were successful in one area were not being mirrored elsewhere. The special delivery unit and the clinical programmes are ensuring successful initiatives are implemented across the system. This takes time but we will no longer have islands of excellence, such as the ophthalmology service in Waterford, which are not transposed elsewhere.

We are operating under financial constraints in the context of a considerable budgetary reduction of €750 million. However, I have made sure that we do not have a linear reduction in services alongside budgets. A 7% cut does not lead to a 7% reduction in service. The maximum service cut in any hospital should be 3% and in most cases it will be considerably less than that. I am very confident that with the clinical programmes, the special delivery unit and co-operating with the excellent people on the front line, this will be achievable.