Dáil Éireann debate -
Tuesday, 19 Jun 2012

Vol. 769 No. 1

Priority Questions

Universal Health Insurance

Billy Kelleher

Question:

105Deputy Billy Kelleher asked the Minister for Health the estimated total cost of implementing the universal health insurance; the cost of implementing free general practitioner care; the estimated charges being imposed on persons with and without medical insurance for universal health insurance; the way medical card patients will be included in the scheme: if Troika approval will be required for the implementation of the model; and if he will make a statement on the matter. [29551/12]

Minister for Health (Deputy James Reilly)

The Government is committed to fundamental reform of health care that will deliver a single tier health system, supported by universal health insurance, where access is based on need, not income. A new insurance fund will subsidise or pay insurance premiums for those who qualify for a subsidy.

As part of the reform programme, the Government is committed to introducing universal GP care within the current term of office. It has given its approval to the preparation of the heads of a Bill to progress the phased introduction of free GP care. It is envisaged that the first phase will provide for the extension of access to GP services without fees to persons with illnesses or disabilities to be prescribed by regulations under the new legislation. A provision of €15 million was made available in the 2012 Estimates for the first phase. Funding for later phases will be addressed during the budgetary process.

In February I established an implementation group on universal health insurance which will assist in developing detailed implementation plans for universal health insurance and driving implementation of various elements of the health reform programme. It will also assist my 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. It will be published as early as possible within the Government's term of office.

The reform programme is a major undertaking that requires careful sequencing for a number of years. The implementation group will continue in existence throughout the health reform process and oversee implementation of the reforms and consult widely. The introduction of universal health insurance and universal GP care is a policy matter for the Government, not a matter for the troika. However, in implementing policies the Government must have regard to the targets agreed with the troika and set out in the national plan for recovery.

Deputy Billy Kelleher

I thank the Minister for his reply. He has outlined the steps he is taking for the introduction of universal health insurance. It will be some years before we see the type of model on which the system will be based and the cost implications for the State. The perception is that universal health insurance and universal GP care will be free, but they will have to be paid for by someone somewhere along the line. The issue must be discussed early on as it is a fundamental shift in how we fund the health service and make it available. The people have a right to know who will bear the cost.

An Leas-Cheann Comhairle

Will the Deputy, please, ask a question?

Deputy Billy Kelleher

Does the Minister agree that a difficulty arises in the meantime in that the private health insurance system is in crisis? Many families are opting out of private health cover altogether. We now have a situation where people are downgrading the insurance package they normally take out. There is increasing evidence that health insurance providers do not provide adequate cover in the sense that they are changing the terms and conditions of policyholders, in particular of older people. Does the Minister agree that VHI has failed to cover the Mahon private hospital in Cork and that it remains closed? In the context of having competition within the health insurance industry there must also be competition among health service providers and that is an indication that the Minister's policies, even at an early stage, are being undermined by VHI because it is not covering a hospital that could provide adequate care for its policyholders.

Deputy James Reilly

The Deputy has asked a number of questions. We all understand that nothing is free and that somebody must pay. However, we are discussing making something free at the point of delivery so that no one need be concerned about being able to pay. I hope all sides of the House agree on this point. We do not want a situation in which someone must make a decision between attending a doctor or paying an ESB bill.

Regarding the Deputy's contentions on the health insurance market, 46,000 people have left the insurance market since the end of March 2007 to the end of March of this year. This is a modest decline in private health insurance coverage, 2% of the overall market. Some 2.139 million people, 46.6% of the population, are still covered by private health insurance.

Deputy Billy Kelleher

Everyone is in favour of universal primary care, but we do not know its exact cost or who will bear that cost. If the cost is taken from the Minister's current health budget, services elsewhere will be cut. A couple of weeks ago, we were counting the number of incontinence pads available to people in Kilkenny. This is how serious the situation is.

The Minister is the major stakeholder in the VHI on behalf of the Irish people. In the context of universal health insurance, does he agree that it is flying against his policy of covering private hospitals to increase accessibility and make treatments available to its policyholders?

Deputy James Reilly

The Deputy has raised a number of issues. I assure him that I, as the VHI's major shareholder, have made it clear that it is not the company's job to determine the market. However, as a court case involving a particular hospital is ongoing, it is not wise for me to comment on the specifics of this issue.

Medical Inquiries

Caoimhghín Ó Caoláin

Question:

106Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will establish an independent inquiry into the manner in which the Lourdes Hospital, Drogheda, the then Health Board, the Department of Health, the Medical Council and An Garda Síochána dealt with complaints of abuse by former consultant Michael Shine; if financial assistance will be provided to Dignity 4 Patients for secretarial and counselling support services; and if he will make a statement on the matter. [29553/12]

Deputy James Reilly

In 2011, I indicated that the issues raised by the case of Michael Shine would be the subject of an inquiry by an Oireachtas committee. This was dependent on the powers that had been proposed under the Thirtieth Amendment of the Constitution Bill. As I cannot now proceed as proposed, I am considering how best to deal with these issues. I must take into account the fact that Garda investigations are continuing, with investigation files having been submitted to the Director of Public Prosecutions, DPP. I also understand that civil cases are pending against Mr. Shine. It would be wrong to initiate any other inquiry that might impede these investigations and possible cases. However, I remain determined to reach a fair and satisfactory outcome that will help to give closure to the victims concerned.

Dignity 4 Patients has requested ongoing funding from my Department, including funding for counselling services. Ongoing funding for any service is a matter for the HSE. The HSE recently granted Dignity 4 Patients €22,500 for one year's office supplies and voluntary support. The HSE advised Dignity 4 Patients that it could not provide any funding towards staffing costs, particularly given the fact that the HSE provides counselling services. The HSE has suggested that Dignity 4 Patients should consider working more closely with other similar agencies to continue to support its client group.

In conjunction with the HSE, my Department is also considering an application for lottery funding from Dignity 4 Patients, which could cover one-off spending.

Deputy Caoimhghín Ó Caoláin

In the Minister's responses to me last week at the health committee and again today, he indicated giving consideration to how best to deal with the issues involved in the Michael Shine case. As he has already indicated, some of the possible options in terms of an inquiry or how it would be constructed may not be open to him at this time. What consideration is he therefore giving and what options do he and his Department have for that consideration? The Minister suggests that any ongoing Garda investigation or specific individual cases may be an impediment to proceeding in a full way. Is there potential to look at the distinction between an investigation of Michael Shine and an examination of the system from the hospital to the Garda and from the Health Service Executive to the Department of how they actually responded in this and the many cases presented around his abuse of young hospital patients?

I also stress the need for support for Dignity 4 Patients. I take some hope, as I did from the Minister's replies last Thursday and this morning at the health committee, that additional supports will be provided to help to anchor secretarial backup for Dignity 4 Patients which is a significant organisation providing important support and making representations for a body of men who need help and support. I urge the Minister to make every effort to approve national lottery funding for it.

Deputy James Reilly

All options are being looked at, but it would be premature at this point to go into specifics. I am concerned that we need to bring closure for those who have suffered in this instance. I am, however, somewhat hamstrung by the fact that there is litigation pending.

Deputy Caoimhghín Ó Caoláin

Is it possible for the Minister to establish for how long this investigation by the Garda is likely to continue? It has been ongoing for years. If it is to be trundled out as a reason we cannot progress a logical stepped investigation, we must ask what is causing the delay. Why is there such an absence of progress on the Garda's part in this regard? We need to know the facts. Is there a multiple of cases being brought? We do not know all the facts. It was regrettable that the referendum on Oireachtas inquires did not succeed, one that I supported and in which I campaigned with the Minister. It was an all-party supported proposition and it is regrettable that it was not adopted, but the people are sovereign.

An Leas-Cheann Comhairle

That is another issue.

Deputy Caoimhghín Ó Caoláin

Is there not potential within existing arrangements in the Oireachtas configuration to allow such an investigation in this case?

Deputy James Reilly

On the Deputy's last point, I am afraid there is not. I share his frustration at the delay in the investigation. I understand it is not with the Garda, but there is a multiple of files with the Director of Public Prosecutions who is, correctly, independent of the Government. It is a cause of concern, however, that it seems to take forever to have a decision made on some files. As things stand, I cannot influence the matter one way or the other, nor would it be proper that I could. At the same time, I understand how it frustrates people. It frustrates the Government too, not just in this area but in several others where there are major issues of public concern.

Services for People with Disabilities

Stephen S. Donnelly

Question:

107Deputy Stephen S. Donnelly asked the Minister for Health if his attention has been drawn to the fact that the Health Service Executive has recently informed severely mentally and physically disabled young adults in County Wicklow and their parents that there will no longer be any funding to support the young adults once they leave their school at 18 years of age, and that as a result the young adults will not be able to take up available spaces in local rehabilitative training this coming September; if he will reverse this decision; and if he will make a statement on the matter. [29683/12]

Minister of State at the Department of Health (Deputy Kathleen Lynch) (Deputy Kathleen Lynch)

The demand for day services, including rehabilitative training, for school leavers continues to grow. The HSE expects approximately 654 school leavers will require services in 2012. This year disability services are required to cater for demographic pressures such as new services for school leavers from within their existing budgets. In previous years demographic funding was provided to meet this need. The 2012 budgets have been reduced by 3.7% and the moratorium on staff recruitment gives rise to additional challenges in service provision. In excess of 4,500 individuals avail of day services in Dublin-mid-Leinster. Nationally over 25,000 individuals take part in these day programmes, including almost 3,000 in rehabilitative training. Significant investment has been made in this area during the years, particularly in respect of young people leaving school. In Dublin-mid-Leinster 164 individuals will be leaving school in 2012 and a further 103 will complete rehabilitative training. Potential solutions have been identified for almost 80% of these individuals and considerable progress has been made.

It is not correct to claim that there will no longer be funding to support young adults leaving schools. However, current funding must be utilised to best effect. The HSE is working with all relevant service providers to maximise the use of available places. The HSE and disability service providers have agreed that families will be notified by 10 July if a place is available or if an individual is to be placed on a waiting list. Some funding will be made available through Genio and the outcome of these applications will be made known in the coming weeks. The HSE and disability service providers acknowledge that the waiting period is a difficult time for individuals and their families, but every effort is being made to achieve an equitable and sustainable outcome.

Deputy Stephen S. Donnelly

This issue was brought to my attention by a constituent in County Wicklow who is the sole carer for his daughter who this year will graduate from a special school. With other parents, he met an official from the HSE who told them and the service providers, including Sunbeam House in Wicklow, that additional funding would not be made available. Sunbeam House has indicated that places are available, but it lacks the €14,000 required to fund them. My constituent also applied for carer's allowance. I recognise this payment involves a different Department, but I want to explain his situation.

An Leas-Cheann Comhairle

I ask the Deputy to frame a question.

Deputy Stephen S. Donnelly

I will. My constituent was refused carer's allowance based on the Chief Medical Officer's assessment that his daughter could take care of herself. I have a copy of the assessment made by the educational psychologist and a letter from a GP, both of which are ambiguous in stating his daughter needs full-time care. He has been told, therefore, that he will not receive carer's allowance, even though he has submitted paperwork and clinical testimony that show he should receive it. A few days ago he was called by the HSE and told that it would read his letter in 13 weeks if he was lucky. The HSE official has told him he is not getting a place, but he has not been told that there are potential solutions and that he will hear further about them. For the small number of people in this position, I ask the Government to make a commitment that funding for rehabilitative training will be made available. We know there is funding available in other areas. The figure for public sector pay increments has increased by €180 million. The majority of State agencies under the supervision of the Minister for Public Expenditure and Reform have increased their stationery and travel costs.

An Leas-Cheann Comhairle

I ask the Deputy to give the Minister of State an opportunity to respond.

Deputy Stephen S. Donnelly

I ask her to commit to providing the small amount of funding the people concerned need.

Deputy Kathleen Lynch

There is no way I can make such a commitment, as I think the Deputy is aware. Nobody will receive a definite refusal or placement until 10 July. We continue to work on the matter.

This is an issue that arises every year. I acknowledge what the previous Government did in this regard, but the difficulty is that a long-term sustainable plan was never put in place. This is not something that falls out of the sky; it happens every year. The Department of Health alone spends €1.5 billion on disability services annually. I do not know how much is spent on social welfare, education, transport or enterprise supports, but I know we are spending a significant amount. Equally, I know we cannot continue to have this sort of emergency arising every year. We must have a sustainable plan going forward. That gentleman and his daughter need to have security going into the future and we are working on that.

Deputy Stephen S. Donnelly

The phrase was "demographic pressure" and, as the Minister of State acknowledged, the HSE is acting like it is surprised that these young adults turn 18 each year and that their conditions remain the same. What will the Minister of State and the Minister do to fix a ridiculous process that causes a great deal of trauma for the parents and young adults involved?

Deputy Kathleen Lynch

This is no surprise to anyone when it happens. In fairness to the HSE, it has worked exceptionally hard since April to resolve this issue and we can see from the decrease in numbers that there has been significant success. I have just left the Royal Hospital Kilmainham, where a forum is taking place to bring together those with disabilities, their carers and their advocates to engage in a process which will give us an implementation plan for disability. It is amazing; we have an Act, we have strategies and sectoral plans but no implementation plan. We are now working on that and I believe it will give us a solution.

Early Retirement Scheme

Billy Kelleher

Question:

108Deputy Billy Kelleher asked the Minister for Health the number and cost of rehiring retired staff in his Department, in the Health Service Executive, the National Treatment Purchase Fund and all agencies under his remit since February 2012; if he will provide a breakdown of grades and specialties; the number of clinical posts that remain vacant; the impact this is having on the safe delivery of services; and if he will make a statement on the matter. [29552/12]

Deputy James Reilly

The Government is committed to reducing the cost of the public service through reducing the numbers employed, combined with measures to increase efficiency. We must ensure the maximum levels of safe services are provided within the resources available. I acknowledge and welcome the improvements in productivity being achieved by health service staff through the public service agreement through, for example, redeployment, streamlining of management structures, changes in skill-mix and more cost-effective rosters. In dealing with the significant number of retirements during the recent pensions grace period, the HSE focused in particular on protecting and maintaining critical front-line services.

It is HSE policy not to rehire retired staff members. In exceptional circumstances, however, it may be necessary to rehire on a short-term basis to meet critical service needs. A total of 38 recently retired staff have been rehired. These comprise 11 consultants, four other medical staff, 19 nurses, a radiographer, a senior orthoptist, an attendant and one clerical officer. The HSE is not in a position to provide cost information in the time available, and this will be supplied to the Deputy as soon as possible. Pension abatement rules apply to all appointments of retired staff in the HSE and elsewhere in the health sector.

No retired member of staff has been rehired by the Department. Arrangements are in train to engage three retired staff members on a temporary basis for the forthcoming Irish Presidency of the EU. No costs have arisen to date in this regard.

In the non-commercial State agencies, two retired staff have been engaged on a consultancy basis. One former public servant was recruited, following open competition, on a part-time basis for a fixed term of five years. The nature and cost of these three positions is detailed in the tabular statement. No retired staff have been rehired by the National Treatment Purchase Fund.

Grade	Expertise/Role	Cost (1 March - 31 May 2012)
Business Consultant	Procurement Processes and Procedures	€12,233
Consultant	Toxicology	€4,059
Principal Clinical Psychologist	Assistant Inspector of Mental Health Services	€7,535

Deputy Billy Kelleher

I hope the HSE will live up to that commitment that it should not, where possible, rehire those who retired under the incentivised scheme for early retirement. The real difficulty is when we pare back the figures and look at the number of agency staff being employed by the HSE. We are talking about a potential €204 million this year, which does not take into account the full impact of locums. The budget could be dramatically more than €204 million.

The Minister gave a commitment last year in the Dáil when he said the costs of agency staff were horrendous. So far, in the first quarter of this year, there has been an increase, to €51 million, in the amount of money being spent on hiring agency staff. That is not sustainable. On a quick, back of the envelope calculation, that could employ 3,000 full-time nurses or 1,000 consultants. We must recognise that €204 million is a sizeable sum every year. It has the potential to address the deficiencies in front-line services by having a streamlined system of recruitment in areas that need it rather than depending on temporary staff all the time.

Deputy James Reilly

The figure of 600 to 700 rehired retirees which has been quoted in the media relates to the years 2010 and 2011. Since the grace period, 38 people have been rehired out of a total workforce of 103,000, which is pretty minimal. I have made it clear that I do not want staff rehired if people are available to be hired. I want to give young nurses, doctors, administrators and anybody due to come into the system a job and not re-employ staff who have retired, but sometimes people in specific areas, particularly consultants must be. I know of a hand surgeon who was rehired but there are only two in the country and we could not do without his services until a new consultant is appointed. I hope that goes some way to explaining this.

With regard to the Deputy's contention about the use of agency nursing staff, we are very much focused on reductions in this area and I look forward to the public service agreement to address that issue.

Deputy Billy Kelleher

I accept the commitment of the HSE and the Minister not to rehire staff. I was first to accept in the context of the incentivised early retirement scheme that it was a necessity to do so in cases where people with the required skillset were not available immediately to replace those retiring. I have no difficulty with rehiring staff on short-term contracts to address deficiencies in skillsets.

However, I refer again to the broader issue agency staff. During the first quarter of 2012, €51 million was spent on these staff. If that continues, the spend for the year will be well in excess of €200 million. This does not include the cost of locums and other temporary measures. The total cost, therefore, could be between €220 million and €230 million by year's end. Does the Minister agree there was a commitment to reduce this expenditure by 50%? If that is to happen, no agency staff will be hired for the second half of this year because the entire budget was spent in the first six months.

Deputy James Reilly

There is very often a lack of clarity around this. The grace period to the end of February did not relate to an incentivised retirement scheme. Those who had the option to retire could do so on their current terms and conditions before-----

Deputy Billy Kelleher

One was disincentivised if one did not.

Deputy James Reilly

I did not interrupt the Deputy but I need to correct the record of the House. It was not an incentivised retirement scheme; it was simply a case of those who had the option to retire doing so on their current terms and conditions which were due to change. Some people took the option to retire while many others did not. We are grateful to those who did not because we had a challenge in the health service to maintain services but we managed to maintain a safe service through the grace period, despite dire warnings from the Opposition to the contrary. A great deal of work remains to be done on the reorganisation of the health service. When I leave the House later, I will attend the Royal College of Surgeons in Ireland to launch the new emergency medicine programme, which will improve matters in our accident and emergency departments.

Hospital Waiting Lists

John Halligan

Question:

109Deputy John Halligan asked the Minister for Health the reduction in the number of outpatients seen at the orthopaedic, dermatology and ophthalmology outpatient departments at Waterford Regional Hospital in 2012 brought about by budgetary cuts; if he will report on all current initiatives to specifically address the backlog in outpatient waiting times at Waterford Regional Hospital; and if he will make a statement on the matter. [29781/12]

Deputy James Reilly

There has been no reduction in 2012 in the number of scheduled outpatient clinics for the specialties referred to due to cost containment at Waterford Regional Hospital. I have circulated a table with the activity for the hospital for the first five months in 2011 and 2012. The current initiatives to address waiting times at the hospital are as follows: the existing patient administration system is being modified to facilitate reporting of patients waiting for an outpatient appointment to the National Treatment Purchase Fund from July 2012; all referrals are being uploaded to the patient administration system; and validation of the waiting list will commence once this upload is complete

I refer to regional dermatology services. In line with the Health Service Executive's southern area service plan for 2012, extra resources have been allocated to support the appointment of two additional consultant dermatologists to assist the existing single-handed consultant. One of these posts is a national cancer control programme, NCCP, post to assist primarily with the skin cancer workload. The second post is in the HSE's dermatology outpatient clinical programme.

The regional orthopaedic service provides the south-east trauma orthopaedic service based at Waterford Regional Hospital as well as the elective orthopaedic surgery service at Kilcreene Orthopaedic Hospital. There are 84 orthopaedic clinics held each month, of which 33 are trauma clinics. The majority of clinics are at Waterford Regional Hospital, with other monthly outpatient outreach clinics taking place throughout the region.

In line with the service plan for 2012, three additional physiotherapist posts have been allocated in line with the roll-out of the HSE's national musculoskeletal clinical programme. Two of the three appointees are now in their posts and it is anticipated this will result in approximately 1,000 appropriately selected patients being seen from the regional orthopaedics and regional rheumatology waiting lists.

Additional information not given on the floor of the House.

An internal initiative with nurse-led arthroscopy clinics is to commence, which is anticipated to reduce the orthopaedic waiting list by 500 patients annually. In addition, two other nurse-led clinic initiatives are due to commence - a glaucoma clinic and a macular degeneration clinic – both of which will assist with the provision of new clinic slots for patients requiring a consultant appointment. The fourth consultant post will be progressed once consultant appointment unit approval in place.

Deputy John Halligan

On assuming office, the Government indicated that tackling hospital waiting lists would be one of its top priorities in the area of health service provision. The Minister has spoken on several occasions about the pain and trauma associated with seriously ill people waiting months and years for treatment. The statistics for Waterford are horrifying, with 18,925 people on outpatient waiting lists for more than 12 months, one of the highest levels in the country. The main issue is not the total number of patients on the waiting list but the length of time they are waiting for treatment. For example, the latest figures show that 5,847 patients are waiting more than a year for orthopaedic outpatient appointments in Waterford, including 570 who are waiting more than four years. Surely the Minister will accept that these data indicate an index of pain that is unacceptable in the 21st century.

Deputy James Reilly

I assure the Deputy that it is the Government's priority to ensure waiting lists are tackled, and we have prioritised action in this area in a very logical fashion. The most acutely suffering patients are those awaiting treatment in emergency departments, a situation that is being tackled by the special delivery unit. I am pleased to report that the first five months of this year saw a 20% reduction in the number of patients on trolleys in emergency departments. There are still far too many in that situation, however, and a great deal of work remains to be done. Several clinical programmes will be implemented to address the problem, including the intermediate care programme which will ensure, in the first instance, that older people are admitted to a specialist ward and their acute medical care needs are addressed. Rehabilitation will commence immediately on the ward for such patients and, where it has to be prolonged beyond a week, they will be moved to an intermediate care facility for six to ten weeks. If, following a careful assessment which rules out the feasibility of a home care package, they are found to require long-term care, they will be accommodated in a transitional facility until their preferred long-term position is available.

To sum up, unscheduled care was the first priority of the Government on assuming office, and we are now moving to address problems in the area of scheduled care. Every hospital in the country, apart from Galway and another facility in the west, met its target of ensuring patients are waiting not longer than 12 months for an appointment. We have only recently begun, for the first time, to get the figures for outpatients. These are not complete figures, although we hope such will start to become available from the end of next month. I have no problem with people knowing the full extent and truth of the situation. The end figure may be 200,000, or it might even be greater. To put that in context, 200,000 people are seen every month at outpatient facilities throughout the country. I am very pleased Deputy Halligan agrees with me that those waiting longest should be treated first, once the urgent cases have been dealt with. It is not fair that people are left waiting years for treatment. We never had a handle on outpatient figures before this Government came into office but we are getting a handle on them now and are determined to address the problems in this area.

Deputy John Halligan

The response to what the Minister has said is coming from the staff of Waterford Regional Hospital, some of whom have publicly stated that the present situation is untenable. The problem must be addressed. I also understand data for differential waiting times for medical card and privately insured patients are not collected annually. The Minister spoke about tracking trends, but one cannot track them. Despite the lack of disaggregated data for waiting times, does the Minister accept that we would not find too many private patients who have been waiting for as long as public patients?

Deputy James Reilly

I have no difficulty in accepting that, which is why the Government has made it a priority that a system of universal health insurance will be introduced during its lifetime in order that people will be treated based on their medical need, not on what they can afford.