Vol. 769 No. 1
110Deputy John Halligan asked the Minister for Health if, in view of the fact that no hospital in the country met the nine hour accident and emergency waiting time target for admission or discharge, he is contemplating the closure of a number of A&E departments in smaller hospitals; and if he will make a statement on the matter. [29435/12]
121Deputy Richard Boyd Barrett asked the Minister for Health if, in view of the fact that no hospital in the country met the nine hour accident and emergency waiting time target for admission or discharge, he is contemplating the closure of a number of A&E departments in smaller hospitals; and if he will make a statement on the matter. [29396/12]
I propose to take Questions Nos. 110 and 121 together.
In July last year I announced the establishment of the special delivery unit, the development of which is a key part of my plans to radically reform the health system in Ireland. I identified two key priorities for it, namely, addressing trolley waiting times and reducing the maximum waiting time for elective surgery. I am happy to say the SDU has delivered notable improvements on both objectives.
The next phase of work in the area of unscheduled care includes a focus on monitoring the total patient journey time, including time spent on trolleys, as part of the new national score card for measuring performance. New target times which are being introduced this year are for 95% of all attendees at emergency departments to be discharged or admitted within six hours of registration and that those who need to be admitted through emergency departments should wait no more than nine hours from registration. Galway and Roscommon hospitals will be expected to comply with these targets. This phase commenced in February.
Acute hospital services, including complex emergency medicine, must be delivered safely. We know that the requirements for safe delivery of a clinical service include a sufficient volume of activity to maintain clinical skills. The delivery of any service in a given hospital will be determined by the level at which that service, in the context of changing clinical and technical practice, can be provided safely.
All services provided by the HSE are carried out in the context of HSE service plans and informed by a range of issues, including clinical best practice and patient safety. The HSE is working with the Health Information and Quality Authority to determine the type of services that can be safely provided across the range of acute facilities. However, I have requested that no changes take place in service delivery without informing me before their implementation.
We are still not getting clarification from the Minister, even though others and I have been asking for a long time about the fate of accident and emergency services in places such as Loughlinstown, Bantry, Mallow, Navan, Dundalk, Ennis, Portlaoise and Nenagh and whether they will be downgraded, as mooted, a move I would consider to be utterly unacceptable. Can we have clarity as to when these decisions will be made and we will be informed?
The Minister spoke about the reduction in the number of patients waiting on trolleys and the new target that they would only be waiting six hours either to be admitted or discharged. Are these claims of success belied by the fact that in the first four months of the year 26,000 patients had to wait on trolleys? The reason there has been a reduction in the number is that the Minister is packing trolleys and beds into wards and essentially causing overcapacity. The real problem is that he is refusing to reopen the 2,000 beds which have been closed in the system and provide the necessary staff. He seems to be considering closing accident and emergency services in smaller hospitals. However, this does not add up. He cannot seriously suggest he is going to improve the position when the bottom line is that 2,000 beds have been closed, there are not enough staff and he is planning to close or downgrade accident and emergency services in a number of hospitals.
As I stated in response to an earlier question, we have reduced the number of people on trolleys by 20%. I have acknowledged there are too many people waiting on trolleys and that we are now to move to a model using the total patient journey time. There has been much criticism in some newspapers of the employment of consultants from the United Kingdom who have behind them the achievement of a four hour journey time from registration to either admission or discharge. They are in this country, on relatively short-term contracts, to help us get a handle on how our system is managed. The system and the management thereof have constituted the problem. We have excellent doctors and nurses, and some excellent managers and administrators, but the system itself, because of the central control and command, has disempowered the front-line staff and those at local level from making the sorts of decisions they need to make to have the service run more effectively and efficiently. We are addressing that.
Is what has disempowered the front line not the fact that it has been massacred in terms of numbers? Some 5,000 nurses and midwives have been lost from the system. Some 2,000 have been lost in the past year and, as I said, 2,400 beds have been closed. The front-line workers and the INMO and other organisations are saying that is the problem the Minister needs to address.
The target of six hours from registration to either discharge or admission seems utterly fantastic given the backdrop of cuts being imposed on staff and beds and the fact not even the nine hour target has been met. The HSE performance report shows not a single hospital in the health service has met the nine hour target, never mind the six hour target. Is it all a question of bandying figures, indicating targets that are unrealistic and massaging the trolley figures by simply packing too many trolleys and beds into wards that do not have sufficient capacity or staff?
The Deputy's contention on packing trolleys into wards is utterly untrue.
It is not untrue.
There is a full capacity protocol, which has four bars to it. It has been in operation. It is not ideal but it is far safer to have patients in wards than in emergency departments. International practice and research have proven that. It is a matter of working differently and having shorter stays in hospital, more primary care and chronic illness care in the community. All these developments will take time.
The Deputy asked about small hospitals. That issue is being addressed through a small hospital framework document, which will be circulated shortly to the various interested parties for consultation. Local politicians will be included.
We are about maintaining safe services and appropriate services in the hospitals. As I stated previously, all the brouhaha about the removal of some services from the small hospitals will be nothing by comparison with the riot that will occur when we start to remove from the bigger hospitals services that more rightly belong in the smaller ones. We are determined to do so, however. Let the large type 4 hospital deal with the tertiary and regional care issues it should be dealing with. It never made sense to me that people with varicose veins and inguinal hernias should be going to big hospitals such as Beaumont, the Mater and St. Vincent's. It is like sending a ten year old Volkswagen to the Ferrari testing centre to have it serviced. It does not make sense, although it would surely do a great job.
The Deputy mentioned Portlaoise hospital. It is not in the group in question as it is a level 3 hospital.
Notwithstanding the work of the special delivery unit, does the Minister accept the long waiting times and the overcrowding in accident and emergency departments are directly related to the fact there is, among other factors, inadequate acute hospital bed provision? Is it not the case we cannot move patients from accident and emergency departments into the wards if there is not adequate provision of beds to cater to that need? Are we not creating a continuing crisis for people, particularly in accident and emergency departments? This has its echo throughout all hospital systems. I urge the Minister, as he was a voice here over a long period of time and made the case consistently in Opposition, to recognise that, while there are other aspects to it, some of which he has named, we cannot continue to keep our heads in the sand in relation to the 2,400 acute hospital beds which, according to the INMO, are now closed. Whether he accepts that figure or the HSE's lesser figure is academic. It is the need that exists. I would join others in appealing to the Minister to accept that and address as urgent the need for the reintroduction of beds within the system and even to give us a sense of a plan or timeframe within which he will work towards this and, equally importantly, the lifting of the recruitment embargo.
There were many issues raised. We have had the emergency department crisis running for several years. There was a ten-point plan issued several years ago at the height of the Celtic tiger and it failed to address this issue. The issue here has not been moneyper se alone. It must be about reforming the way we work and the system we work in, and that is what we are about.
I want to place on the record of the House my gratitude to all those working in the front line who have done sterling work to maintain a safe service, as I stated, during the grace period and also to achieve the progress they have achieved to date.
We in this House and everybody working in the health service knows there is a great deal more to do. We know there is waste and inefficiency. We know we have a system that is a whole of itself and no one part of it can function independently of the others.
We have a considerable job of work to do in terms of sorting out primary care and ensuring the right patient is seen by the right person at the right time. There is a great deal of work consultants are doing that GPs could be doing, there is a great deal of work GPs are doing that nurses could be doing, and there is much work that nurses are doing that health care assistants are doing.
One must ask the question why it is that one model for a hospital in this country has nine nurses to each health care assistant while another has three. Why can some community nursing units only manage a ratio of one nurse to one health care assistant when the London School of Nursing recommends one nurse to 2.5 health care assistants in a community nursing unit? There is a host of stuff.
I mentioned physiotherapy in one of the other questions. This is important because it shows we can change the way we work. In Cork, they succeeded in this, and it started in the UK. They screened GP referrals to consultants for orthopaedics and found that 40% of them did not need to see the surgeon at all. The physiotherapist was able to deal with them. I am sure that applies to other areas with other specialties too. Then we have a nonsensical system where if one wants to get counselling for a patient in the public system, one must refer him or her to the psychiatric clinic. A whole host of things must change.
They must, but bed needs are still a part of it.
111Deputy Brian Stanley asked the Minister for Health if he will give a definitive position regarding the practice of some hospitals informing patients that they cannot receive treatment because they do not fall within the catchment area of the hospital [29430/12]
Under the provisions of the Health Act 1970, eligibility for public health services in Ireland is based primarily on residency and means. All persons normally resident in the State are eligible for inpatient and outpatient public hospital services, including consultant services. It is unacceptable for a patient to be informed at short notice that a hospital will not treat them because they are in the wrong catchment area, and my Department has been working with the HSE to clarify its policy in this area.
A letter issued to all hospitals on 15 May from the national directors of the HSE and the chief operating officer of the special delivery unit, SDU, setting out the position on catchment areas. With immediate effect all hospitals were instructed to refrain from any further limiting of historic catchment areas, that is, to further refusal of referrals from areas from which such referrals have been accepted since 2009. This will be retrospective to the start of this year, in most cases subject to discussion. This will apply to both new referrals and to existing patients in long-term care or treatment.
My prime objective is to ensure the safety of patients and I am pleased to say this issue was given the immediate attention it required and was dealt with in a rapid and efficient manner. I am confident the regional directors of operations, RDOs, working with the hospitals have gained their full co-operation in eradicating this issue. The SDU will continue to work with the HSE to embed improved GP referral systems which will enhance patient access to the health services.
I have seen the reply the Minister sent to my colleague, Deputy Stanley, on 6 June and I note his reply today as well. Both responses invite more questions than they answer. In the response on 6 June, the Minister speaks of "informal catchment areas", issues with the areas that are "typically cyclical" and in referring to hospitals, he referred "to what they view" as their catchment areas. In the 6 June reply, the Minister's opening line states, "any individual hospital often has a number of ‘catchment areas' reflecting the different geographic areas" depending on the procedure being sought or the particular referral type.
There is a strange situation here and it is vague and unclear. Are there hospital catchment areas officially recognised by the HSE or are there not? It must come down to simple questions. If there are, can we have a map of these catchment areas that apply across the network of acute hospital sites throughout the country. In the particular instance that gave rise to the question in the first place, and while I welcome the address, as the Minister has indicated, it was where a patient was unable to secure the procedure in the hospital within his area of domicile. He sought access to St. Vincent's Hospital in Dublin, which specialises in the procedure, but was told it would not look after him because he did not live within the catchment area.
I must call the Minister.
It is bizarre. I want to hear what the Minister is doing to have this matter addressed properly.
I made quite clear what we have done to address it. I will relieve Deputy Ó Caoláin's confusion for him on why different procedures have different catchment areas. It is simple and we alluded to it only a minute ago. There are hospitals that are local, there are hospitals that provide regional services and, therefore, the region becomes their catchment areas, and there are hospitals that have national tertiary services, the catchment area of which is the country.
What has arisen in this case is that some hospitals, with their budgetary constraints, saw that patients were not in their regular catchment area for ordinary secondary care and would not accept them when in the past they had been accepting them. We have stopped that. This will not be a problem under money-follows-the-patient, which is rolling out as we speak. We started in orthopaedics and it will roll out across all the specialties. Under that scenario, hospitals will be getting paid for each patient whom they treat. This is another really important part of getting rid of a self-serving system and turning it back into a patient-centred service.
In the his reply to the question on 6 June, the Minister went on to state that it had been "agreed in the interim that any planned and agreed changes in referrals-catchment areas should not impact on patients who are already on a waiting list in a particular hospital or are patients in long term care/treatment". That is fine in terms of those who are already there, but these are important decisions. Where are these decisions being made? Who is making determinations of changes in catchment areas? Who is the body of persons entrusted with this task? Is there any engagement with the public in terms of the raft of experiences? We have only cited one in terms of the question for written answer on 6 June.
What can the Minister advise in the current examination of all this? Is it within the HSE, are there specific catchment areas properly and officially recognised by the HSE in relation to these hospitals, and can the Minister provide us with copies of that information?
I will not be providing Deputy Ó Caoláin with copies of that information. This is a consultation process that will be predicated on safe clinical practice, but also on the principle, to which I alluded in the previous answer, around the smaller hospital framework. If we are going to have a situation where we want the larger hospitals that have that received investment to deliver the tertiary services and the regional services, such as neurosurgery and cardiac surgery, then we must advise patients that they should be going to their local hospital for the ordinary procedures, such as gall bladder, varicose veins and inguinal hernia repair.
People should attend third or fourth level hospitals only where there is serious comorbidity and risk.
All Deputies are exercised about the future of small hospitals. I want to ensure smaller hospitals have a vigorous and full workload, are performing procedures and providing services that are safe, while leaving more complex procedures to larger hospitals. I will not tolerate large hospitals trying to hold on to all their services, as has been the case in the past. They may be good at accepting new services, especially in areas such as cancer care, but they are reluctant to transfer other services to smaller hospitals. Member do not agree with that approach.
112Deputy Dessie Ellis asked the Minister for Health if he will report on the progress made on the development of the mental health unit at Beaumont Hospital, Dublin; and if he will make a statement on the matter. [29432/12]
The mental health unit on the site of Beaumont Hospital will provide acute inpatient mental health services for north Dublin to replace outdated facilities at St. Ita's Hospital, Portrane. The construction phase of the project has begun and is expected to be completed by the end of January 2013. The equipping and commissioning phase should take approximately three months following completion of the building.
I thank the Minister of State for her reply. As she will be aware, a psychiatric unit was promised at Beaumont Hospital 25 years ago when the hospital was constructed. I understand she turned the sod for the new mental health unit in January. Is she confident the January 2013 timeframe is a realisable deadline?
The Minister of State's reply is certainly welcome in terms of the construction timeframe. Will she also assure the House that, against the background of many other concerns Deputies have about existing service units, the new unit will be adequately staffed and resourced to meet the day-to-day needs of its cohort of residents and service users? Given that it will not be completed for another six or seven months, will she advise when the new unit will be put into service? What interim arrangements have been made in the north Dublin area following the decision to cease admissions to St. Ita's Hospital, Portrane? I have received many representations and expressions of concern on this matter, as has, I have no doubt, the Minister, Deputy James Reilly, who is a resident of the area and represents the Dublin North constituency. The wider population across north Dublin is concerned about local psychiatric services.
The Mental Health Commission is the mental health equivalent of the Health Information and Quality Authority. On foot of serious concerns the commission had expressed about St. Ita's Hospital, a number of residents of the facility were transferred to St. Vincent's Hospital, Fairview, as part of a temporary arrangement.
As the new mental health unit at Beaumont Hospital is an acute facility under licence from the Mental Health Commission, it must fulfil the staffing obligations laid down in the Mental Health Act. Staff levels at the unit must correspond with the level determined by the commission. We should not have any concerns in that respect.
The Government cannot ignore an instruction from the Mental Health Commission. For this reason, the project is proceeding and by the summer of 2013, it will be built, equipped and accessible to those for whom it has been specifically designed. The safeguard we have in this respect is that we must respond to demands made by the commission.
It will be at least 12 months before service users have access to the new unit. My notes indicate that the north Dublin area is under significant pressure as a result of staff shortages, the ending of admissions to St. Ita's Hospital and the retirement of psychiatric nurses. While the impact of retirements is not unique to north Dublin, they are certainly causing a particular problem in the area. On what has been described as a "temporary arrangement", does St. Vincent's Hospital in Fairview have the potential to meet projected demand in the next 12 months? It will be at least one year before the new facility opens, hiccups or snag lists that may present aside.
We discussed last December's promise to make 414 additional appointments in mental health services, for which funding has been provided. Will the Minister of State indicate what progress has been made in that regard? Will any of these appointments be designated for the new facility or, given that they are supposed to be in place before the end of the year, the north Dublin area?
The use of St. Vincent's Hospital in Fairview is a temporary arrangement and those currently residing in the hospital will be moved into the new unit in accordance with the wishes expressed during consultation with them and their families. A particular issue arises with regard to staffing in the Dublin and mid-Leinster region. Having met its targets in terms of reducing bed numbers and in its community based service, the recent exodus of nurses pushed staffing numbers in the region below a safe level. This issue is being addressed.
On the 414 additional posts, people are being recruited from panels in the other three regions and new panels will be established, where required. The appointees will be in place by the end of the summer. On the Dublin and mid-Leinster region-----
I referred specifically to north Dublin.
-----the difficulty is that we may have to convert some posts to nursing. Consultations are ongoing in this regard and agreement on the issue has not yet been reached. The matter is not being ignored and regular meetings are taking place on the issue. Having ring-fenced a significant pot of money for community mental health teams, it is important that this goes well in the first year.
113Deputy Dara Calleary asked the Minister for Health the reasons for the delay in the provision of the drug Gilenya to patients with multiple sclerosis; if his attention has been drawn to the fact that the drug has the potential to transform the lives of many who suffer from MS; and if he will make a statement on the matter. [29440/12]
609Deputy Michelle Mulherin asked the Minister for Health following the decision by the National Council for Pharma Economics on 22 September 2011 to approve the drug Fingolimod, Gilenya as a cost-effective therapy for the treatment of relapsing-remitting multiple sclerosis patients in the Irish healthcare setting, when this drug will be made available to all patients who need it; and if he will make a statement on the matter. [29211/12]
615Deputy Finian McGrath asked the Minister for Health if he will provide an update on the drug Gilewya made by a company called Novortis and which is given free to multiple sclerosis patents; if it will be on the long term illness scheme and any if he will update on this drug [29275/12]
654Deputy Alan Farrell asked the Minister for Health the time frame for when Gilenya will be available on the long term illness scheme; and if he will make a statement on the matter. [29630/12]
672Deputy Brendan Griffin asked the Minister for Health when the drug Gilenya will become available and the reason for the delay; and if he will make a statement on the matter. [29778/12]
I propose to take Questions Nos. 113, 609, 615, 654, 672 and 695 together.
The manufacturer of fingolimod, Gilenya®, has submitted an application to the Health Service Executive for the product to be reimbursed through community pharmacies under the high-tech drug scheme. The list of medicinal products provided under the scheme is reviewed on a regular basis. The application in respect of the product in question is under consideration.
The HSE has identified the potential for a significant budget impact with this product and it has, therefore, been referred to the HSE drugs group which examines how new medicines can be introduced into clinical care pathways as and when resources become available. In addition, the chief medical officer has been requested to engage with the HSE to examine the current decision making process and ensure a robust system is in place to drive decision making around medicines and evidence based prescribing. It is expected that the chief medical officer will report on this matter in the coming weeks.
I am pleased to inform Deputies that we have agreed with the pharmaceutical companies on a sum of moneys to be reimbursed to us which will allow us to open negotiations on a more comprehensive deal and release the new drugs in question.
I welcome the announcement that Gilenya will be made available to people suffering from multiple sclerosis. Clinical trials and international evidence show the drug can give quality of life to people with the condition. It is an oral-based therapy, which should decrease the cost of its provision by the HSE.
There is a broader issue at stake. The National Centre for Pharmacoeconomics assesses the impact of and the value for money provided by high-tech medicines. We have reduced dramatically the base level at which we consider a drug to be suitable in terms of improved quality of life. However, the reduction from €45,000 to €20,000 means we are playing God with more people. This cannot be allowed to continue and it will have a devastating impact on people's ability to access high quality, high-tech innovative drugs that make a difference in terms of quality of life.
As there are two other Deputies who wish to speak, I ask the Minister to be brief.
The pharmacological unit carries out a health technology assessment of a medication, but that is only part of the equation. The HSE has a group that further advises on and evaluates the matter above and beyond what the pharmacological unit has stated and the health technology assessment has shown. It is not true to say, therefore, that this alone decides whether a drug will be made available. The "Ipi" drug would never meet the health technology assessment requirements, but there were wider considerations taken into account by the group, given its impact on patients, and, therefore, it was made available.
I welcome the initial comments made by the Minister. He has said the decision will be made in a matter of weeks. Is he talking about two, three, five or six weeks?
It will be made as soon as is practicable. That is all I can say. In the case of some of these drugs, it is not as simple as making a decision today, following which it will be available immediately. There are other things that have to be done and the position is different in the case of each drug. There is a major responsibility on everybody to be involved, not just policymakers and politicians but also clinicians who prescribe these drugs and the drug companies that produce them. No matter how well the economy is doing, we have limited resources and have to prioritise in how we accommodate a new drug. Other drugs have to make room for it within the pot. This means that they have to drop in price. That is only right and proper. Clinicians need to engage, as do patient groups, as well as policymakers and politicians.
I add my voice to those who have called for this drug to be made available to multiple sclerosis sufferers. It is available in the neighbouring jurisdiction and most European countries. At last Thursday's meeting of the Oireachtas health committee the Minister rightly referred to the frustration caused in engaging with the pharmaceutical industry, particularly by its slowness to engage, bring down prices and address all of these issues. Will he elaborate on the progress he is making in making Gilenya available? Is the slowness of the industry to engage a factor in this regard? What about its reluctance to accept the critical need to reduce the high cost of medicines for all citizens?
I welcome the announcement made by the Minister. However, the pharmacoeconomics centre stated recently that €45,000 was the threshold. Who decided that it should be reduced to €20,000? This rules out a lot of high-tech drugs being made available or which it is recommended should be made available at the very least. This is a fundamental factor in the availability of high-tech and breakthrough drugs.
The decision was made within the HSE and the pharmacological unit. I will have to find out for the Deputy precisely which individuals were involved. As the drugs are being made available, nobody will suffer loss as a consequence. The last thing anybody wants to do, or the last thing anybody should do, he or she a doctor, a politician or the Minister for Health, is to play God. That is a not a place I ever want to be in. We have to have a societal answer which involves all of the people mentioned, namely, clinicians, pharmaceutical companies, politicians and members of society at large, as represented by patient groups and others. We are always going to have this issue, especially the question of how drugs are priced. Sometimes one wonders if prices are just plucked out of the air. We all understand research and development are very important and encourage those involved, as we are very mindful of the importance of the pharmaceutical industry in this country. At the same time, however, some of the prices need to be subject to scrutiny. We will be doing this. To answer Deputy Ó Caoláin's question, the drugs reference pricing Bill which will be brought forward before the summer will go a long way towards addressing this issue.
