Vol. 836 No. 3
101. Deputy Clare Daly asked the Minister for Health the oversight that exists of providers of home care packages; and his plans to ensure that patients and their families receive appropriate care and assistance in their homes. [14913/14]
106. Deputy Patrick O'Donovan asked the Minister for Health his plans to introduce minimum standards in terms of training, inspections, reporting for the provision of care to elderly persons and vulnerable adults in their own homes; if he will provide details of any legislation which he will bring forward; and if he will make a statement on the matter. [14702/14]
The question relates to the oversight or rather the lack of oversight of those who provide care in people's homes, including basic medical care and also monitoring of people. I am referring to those who are sick and elderly. It appears to be a system for which nobody is accountable. What improvements does the Minister of State intend to introduce?
I propose to take Questions Nos. 101 and 106 together.
The programme for national recovery 2011-16 commits to developing and implementing national standards for home support services, which will be subject to inspection by the Health Information and Quality Authority. Primary legislation and resources will be required for the introduction of a statutory regulation system for home care services. This is being considered in the wider context of the licensing of public and private health service providers. I would like to emphasise, however, that there are effective measures that can be applied pending statutory regulation, and the HSE already applies a high level of quality control and supervision to the services provided by external providers with HSE funding.
The HSE's procurement framework for home care services includes quality and screening requirements. Providers of home care services are monitored through service level agreements with the HSE. They are required to provide a prescribed range of information in regard to the services they provide, and are supervised through regular local operational meetings and reviews of clients' care plans. The following areas are included in this context: principles of service delivery; confidentiality; a complaints procedure; consent; staff training; governance and management; and workforce related matters. The purpose of these measures is to promote quality and safety and to ensure a more standardised approach to service provision nationally. Audits are completed and quarterly reports are requested and reviewed. Supporting this is the ongoing monitoring and review of individual clients and their care by HSE professionals, such as public health nurses.
Home care services are reviewed regularly by the HSE. In addition, the HSE has in place a complaints procedure that is available to all service users. I would like to assure the Deputies that complaints are monitored as an indicator of quality of care provided and to ensure the clients' needs continue to be supported.
From listening to the Minister of State's response, one would think the system had a mechanism in place for dealing with this. Unfortunately, in my experience, that is not the case. I would like the Minister of State to explain where we are with the legislation and the statutory improvements which I believe are necessary.
I have had two very serious cases brought to my attention recently. One involved a woman who was released from hospital with a terminal condition, whereby some facilities were provided by a HSE-funded service but others were a package she got from an organisation but which she paid for herself privately, and which was outside the scope of monitoring as a result. The woman had paid, and paid handsomely, to have somebody residing in her home at night who would be awake if she needed them. Sadly, her experience was that, in many instances, she was left calling for that home care worker but getting no response and being left in soiled bedclothes overnight, and so on. Everywhere that complaint was taken, nothing was done about it. It seems those services that are not funded by the HSE are outside the remit of regulation. I believe it is an area that needs particularly close attention.
First, as I have indicated to the House, primary legislation is required and is intended to be brought forward for the introduction of a statutory regulation system, which is, of course, the most secure and best way to address the reasonable issues the Deputy raises concerning a regulation system for home care services. The programme for Government gave that commitment. I do not for a moment want to downplay the importance of the issue the Deputy raises because it is of huge importance to individuals and their families, as the Deputy rightly said. Nonetheless, the Deputy will be aware there is quite a volume of legislation being addressed within the Department of Health at this time. We are looking at the licensing of public and private health service providers as a broad piece of work. Legislation that is needed in regard to home care and home help is being brought forward and developed in that broader context of the licensing process.
While I appreciate there is a heavy workload, the problem is the Government is more than halfway through its term. Sadly, the woman I spoke about died, and her family are left with the legacy of feeling she suffered an indignity in her last weeks and months at home. They went everywhere, already coping with their loss, to try to get an explanation as to why the service they paid for so expensively did not allow that woman to remain at home in dignity.
Only last night, I heard of another couple who have now decided to move in to a nursing home. The decider was that the man woke up last night to see a rat at the end of his bed. This is an elderly couple who have home care providers coming in to mind them.
A rat does not just appear from nowhere. The fact this was allowed to happen in a home means we urgently need regulation in this area for basic human dignity, never mind the amount of money being spent on it.
The HSE is progressing a range of measures to improve its home care provision overall, to standardise services nationally and to promote access, quality and safety. For example, there is a procurement framework for home care services with quality and, most important, screening requirements applying to services procured by the HSE from external providers. A national tender system introduced in 2012 has been extended and the HSE proposes to tender again during 2014. The national guidelines for the standardised implementation of the home care package schemes have been introduced in parallel with the procurement framework. Following recent Labour Relations Commission recommendations on annualised contracts and minimum hours for home help staff directly employed by the HSE, new contracts will be operational with effect from April 2014. In accordance with the HSE operational plan for 2014, a review of home and community care will be undertaken. This will be of interest to the Deputy. An activity and resource review is to be completed by the second quarter. Service improvement initiatives are to be progressed between the second quarter and the fourth quarter and a review of models of service delivery, including the review of existing guidelines, will also be progressed throughout this year. I take the Deputy's point but the HSE is addressing these issues in an appropriate way and the legislation will be brought forward.
I have raised this issue with the Minister of State and his colleague, the Minister of State with responsibility for disability, equality and mental health. This issue is of significant concern to me because I have seen the lack of standards, inspections and training in my constituency. This is not confined to the private sector because it might be easy to blame the private sector. We do not have minimum standards, inspection regimes and ongoing continuing professional development for people who are delivering an essential service and who represent the difference between a person taking up an acute bed in a hospital, which we do not have, or being maintained at home with their family knowing they will be adequately cared for. It is not as if we are not putting a lot of money into this. Hundreds of millions of euro are going into the private sector each year for the delivery of private home care packages for vulnerable adults and elderly people. I concur with the comments of the previous speaker. This legislation is needed as a matter of urgency before there is a "Prime Time" special on this issue. To be honest, I am shocked it has not been done up to now.
I do not know if I can put it any better than I have. I take the points raised by both Deputies. In fairness, one hears accounts of bad experiences or those that certainly have been less than satisfactory. Other accounts are relayed, perhaps not as often, where people have very good experiences. I do not think it is universally bad but the way we can reassure the public and people affected is principally to have legislation in place because that secures a system in place that this House oversees in order that the Oireachtas is clear about the basic minimum standards. The HSE understands its responsibility in respect of a procurement framework, national guidelines and the initiatives I have mentioned that are in the service plan this year, such as an activity and resource review, service improvement initiatives and a review of models of service delivery. These are all directed towards ensuring proper standards are in place and that none of the kinds of incidents that have been related by both Deputies ever recurs. The Government is committed to ensuring this is the case.
The Law Reform Commission published a draft of what could form the basis of the heads of a Bill. I ask that this be referred to the Oireachtas Committee on Health and Children by the Department of Health and that the committee begin hearings about whether this could be looked at for the second half of the Government's term of office in respect of the provision of a legislative basis for the delivery of private home care. The Minister is quite right. The experience is not universally bad. About 90% of it is probably delivered very well. However, in respect of the protection of vulnerable groups like children, people with intellectual disabilities or elderly people in nursing homes, we have seen that it takes a very difficult case for legislation to be brought in.
In advance of the broadcasting of the kind of "Prime Time" programme to which I referred, which as sure as night follows day will occur, as was the case last week with the programme on the ambulance service, we should be proactive and encourage the Oireachtas Committee on Health and Children to conduct hearings on this matter and to engage with elderly people, their families, care providers, the Department of Health, the HSE and others to determine how best to deal with this. I have a great fear this issue will be left behind.
The Deputy makes some very good points and I welcome his suggestion that the Oireachtas Committee on Health and Children would, on its own initiative, address this issue. When the legislation is brought forward by the Minister, it will be subject to pre-legislative scrutiny by the committee, but given that it may be some time off - one hopes not too far off - perhaps it is something the committee would look to address. I am aware of the report from the Law Reform Commission and I take the points made by the Deputy. I will certainly communicate them to my colleague, the Minister of State, Deputy Kathleen Lynch.
Given there is a little time left, I wish to ask a supplementary question.
The Deputy had not indicated.
I will be brief. Is the Minister of State aware that many workers in this particular area who work for companies which have contracts with the HSE for home care provision are being grossly inadequately paid? Some are on the minimum wage or barely above it. Is he also aware of the type of disgraceful contracts they are being asked to accept, whereby there is no certainty of work from week to week? They have no idea of the number of hours they may have and that, in turn, has a very negative impact on those being cared for because there is no continuity of care. They do not know who to expect. That is a very serious matter and I ask the Minister of State to take it on board and to share with us his intent to address this issue.
I am aware of the contracts issue being of difficulty. Indeed, the issue was raised in the Labour Court last year. I am not sure if the Deputy is aware that there have been recent Labour Court recommendations on annualised contracts. The Labour Relations Commission, LRC, has addressed that issue and, as I understand it, has resolved it. As a consequence of the LRC recommendation, minimum hours for home help staff directly employed by the HSE will be in place soon. New contracts have been prepared and will be operational from this month.
102. Deputy Bernard J. Durkan asked the Minister for Health the extent to which increases in private health insurance continue to be monitored with a view to identifying the extent to which costs increases annually over the past five years have been identified as being attributable to any particular issue, cause, action or procedure; if any action is contemplated which might be likely to have a stabilising effect on such insurance costs in the future; and if he will make a statement on the matter. [14826/14]
My question relates to ongoing private health insurance premium increases which are leaving the public somewhat concerned about both the rates of increase and their number. Notwithstanding community rating, which we all support, is it the case that increases in excess of the amounts required are being imposed?
I thank the Deputy for raising this issue which is of critical importance. I have consistently emphasised the need for much greater cost control in the private health insurance industry in order that premiums are affordable for as many people as possible. My Department and the Health Insurance Authority, HIA, monitor the factors that contribute to costs on an ongoing basis.
The health insurance market is challenged by factors such as an ageing population, a reduction in numbers holding private health insurance and constant pressures on claims costs. However, I am determined to address these issues and to promote a sustainable private health insurance market as we move to universal health insurance.
I appointed an independent chair to work with health insurers, the HIA and my Department to identify effective strategies for costs management. Mr. Pat McLoughlin's first report, published at the end of December, made a number of important recommendations now being pursued by insurers, the HSE and my Department. These recommendations include measures to control costs, greatly improve clinical audit, streamline claims processing, and address fraud, waste and abuse in the industry.
As recommended by Mr. McLoughlin, I am also looking favourably at the scope for introducing lifetime community rating and other measures to encourage younger people to buy health insurance. Work on the second phase of Mr. McLoughlin's report, which will deal further with the factors driving costs in health insurance, is progressing well and will be completed as soon as possible.
The Government remains committed to keeping down the cost of private health insurance in the transition to universal health insurance.
I thank the Minister for his reply and his concern in this regard. Has it emerged from an examination of the figures available to date if there is a particular reason for the increases, other than the ageing population and the drop-out of many young families from private health insurance? To what extent are the costs of services being put forward as an ongoing reason for increases in such services?
Is regard being taken of the fact that the aged population also contributed when they were young? To what extent are all other insuring bodies in this country taking a fair share of the burden?
I do not think any specific reason has been identified to date but the matter continues to be examined. I am concerned that in the past there has been a history of passing on increases to the customer. There was an acceptance, or even a resignation, that medical inflation runs at 9% yet in some years we have seen health insurance costs for consumers increase by up to 25%. That is not acceptable to me and it is why I am asking for much more robust auditing, particularly from the semi-State insurer, the VHI. On behalf of the people, I am the sole shareholder in the VHI, so I want to see a clinical audit introduced there in a far more aggressive and robust manner than has been the case to date. Anecdotally, we hear about many tests being done, the value of which could easily be questioned by a competent fellow professional.
Why are we still paying the same rate for procedures that used to take two hours but which now take 20 minutes using modern technology? A whole range of services are currently being provided in this way whose prices should be reduced dramatically.
We must also examine the appropriate skill-mix in the private health sector. Procedures are being carried out by specialists in hospitals, which attract a specialist's fee and the side-room fee, which could be carried out in primary care. Some of these procedures could be carried out by advanced nurse practitioners. All these areas need to be addressed and will be as a consequence of Mr. McLoughlin's report.
I thank the Minister for his reply. We await the report with some interest. Despite the number of insurance companies now in the market-place, we must recognise the fact that when there was only a single operator in this country there was not the same emphasis on insurance premium increases. We were told at that time that more competition would lead to lower insurance premiums but to what extent has extra competition contributed to keeping insurance premiums down?
The Deputy has raised a valid question. The whole point of having a number of insurers is to create competition in the market-place. So far, however, this has not led to the sort of changes we would like to see. The main insurer in the country is the semi-State VHI which, although it is only responsible for 57% of the market, is responsible for 80% of the payout. The VHI now has a wonderful opportunity to attack this cost base.
The number of insurers in the market is healthy. However, the Health Insurance Authority will be empowered, through legislation, to play a much greater role in regulating the market. In particular, we currently have an outrageous situation whereby there are over 256 different policies. My view is very clear: the only reason there are that many policies is to confuse the customer. There should not be more than ten different policies to allow people to compare like with like and make an informed decision. I will be encouraging the HIA to examine that.
Would the Minister agree that Mr. Pat McLoughlin's review should also take into account Government policies on premium increases, the cap on tax relief and full cost recouping for private patients in public beds? These are key issues that have inflated private health insurance costs.
In the context of asking the HIA to police the health insurance market, the Minister has many times dismissed the authority's recommendations and overruled them. He brought forward policies that the HIA said should not be introduced.
On the matter of lifetime community rating, it has been obvious for some time that the market is in terminal decline. Young people are not taking it up. That is a direct result not only of the difficulties in the labour market but of Government policy implemented in the House.
The Deputy pointed his finger down, which is where he left the economy.
Gold-plated, the suggestion was.
The Minister is giving the usual old answer - the usual old mantra.
The Fianna Fáil way is to ask a question and listen to its own answer. Good man, Barry.
It is Deputy Cowen.
Please.
Do we want to have a conversation or just the Deputy asking questions and answering them himself?
We want action. Conversations we have had a long time ago.
The Minister to reply.
As I have said in the Chamber before, there is a figure of 250,000. It is also the case that 250,000 people lost their jobs, 250,000 extra medical cards were issued and 250,000 people gave up their health insurance. I did not say they were all one and the same people, but there must have been some relationship.
I accept that the cost of private health insurance has increased. I have striven to keep it down and encouraged the VHI in that regard. As the main insurer, the VHI's increase this year has only been 3% despite the removal of some of the tax subsidy. The cost of the subsidy to the taxpayer two years ago was €400 million. It was €450 million last year and would have been €500 million this year. How much further were we to allow it to go? Pressure had to be brought to bear on that. The private inpatient charge does not reflect anything like the true cost of a bed. The private insurer will still make a profit.
I have no doubt that with improved regulation from a Health Insurance Authority with more teeth to act, allied with the national pricing office, which is now up and running on an administrative basis, we will get much better value for money for people who are insured privately.
103. Deputy Barry Cowen asked the Minister for Health his plans for a safer ambulance service; and if he will make a statement on the matter. [14875/14]
104. Deputy Clare Daly asked the Minister for Health if he will order a fully independent national capacity review of the ambulance service throughout the country [14912/14]
My question predates last week's "Prime Time" programme on the ambulance service. It was timely and reiterated many of the feelings which have been expressed on both sides of the House on the efforts of those at the coalface to deal with the lack of resources and equipment. How does the Minister intend to improve the service and make it safer? It is not safe currently notwithstanding the fantastic efforts of those at the coalface.
I thank the Deputy for his question and, in particular, for acknowledging the great work done by front-line staff in our ambulance service. Every day across the State, our paramedics attend to an average of 769 patients. The workforce includes approximately 1,700 people, including national ambulance service paramedics and the Dublin Fire Brigade ambulance service. The Government is committed to improving our ambulance service and ambulance response times. I am prioritising the ambulance service despite shrinking budgets. I will not go back into why we have shrinking budgets, Deputy Kelleher. We all know why.
Could the Minister elaborate? He might as well.
He might as well press the mantra button again.
It was the little fiscal fiasco the Deputies' Government left us to deal with. We had to get our financial sovereignty back. Those little issues are important to the ordinary man and woman in the street as they seek to get re-employed having been put out of work by the Deputies' Government.
Paddy likes to know, is it?
This year, we are spending €146.9 million on the ambulance service, which is 6% more than two years ago. This year, the ambulance fleet stands at 534 vehicles, including national ambulance service emergency ambulances, rapid response and intermediate care vehicles, motorbikes and Dublin Fire Brigade ambulances. That is 77 more than four years ago when the Deputies opposite were in government.
On your bike, Minister.
That is great if they are parked up at the manager's house.
It is 77 more, Dara.
They are all parked up at managers' houses.
There are 15,000 waiting for speech and language assessment. Answer that one.
The Deputies are all welcome to Question Time.
Last year, our ambulance service responded to 280,776 emergency calls, which was almost 14,000 more calls than in the previous year.
Everything is grand.
Despite the steepest health cutbacks in the history of the State, we are spending more money and attending to more patients and, crucially, more life threatening emergency calls in under 19 minutes than in previous years.
While we are making progress, I acknowledge that we have more work to do. Nobody should wait on the side of the road with a loved one in their hour of need, fearful of whether an ambulance will arrive in time. I am determined to make further progress in order that all our citizens have access to the efficient, modern ambulance service that they deserve, regardless of where they live.
This year, to drive improvements in response times, the national service plan sets a new target of having 80% of life threatening calls responded to within 19 minutes. Last year's target was between 68% and 70%. It should come as no surprise to learn that a target was not in place when the Government took office. To achieve this year's target I am continuing to prioritise ambulance services, despite shrinking budgets. Additional funding of €3.6 million and an additional 43 staff have been provided.
We are also making better use of our ambulance fleet. We are increasing non-emergency vehicles to transport patients between hospitals, thus allowing our ambulances to focus on life threatening emergencies. Last year, 25 intermediate care vehicles were added to the fleet and this year the intermediate care service will take on more work and more staff will join the service. On-call working is also being eliminated to improve response times. This means paramedics no longer respond from their homes during a shift but are based in their vehicles or bases, ready to be dispatched on emergency calls. We are rationalising control rooms in one resilient national system in line with best practice. This process will be completed next year.
I am putting the ambulance service under the spotlight as never before, with three separate reviews under way. The aim of these reviews is clear - to improve our ambulance service. The Health Information and Quality Authority has brought forward a planned review of the national ambulance service, which has now begun. The review will examine how we assess the performance of our service and it is anticipated that it will recommend taking response times and patient outcomes into account. The review will be completed by the end of the year.
That is approximately as long as it takes some ambulances to arrive.
The outcome for the patient is more important than the time required for the ambulance to arrive.
There is a correlation between the ambulance response time and the patient's outcome.
Deputy Calleary appears to hold the view that the operation can be a success, even if the patient dies.
Additional information not given on the floor of the House
An independent capacity analysis of the national ambulance service conducted by the UK Association of Ambulance Chief Executives will be completed this autumn. This will compare resources to demand and activity levels nationwide.
The Health Service Executive and Dublin City Council commissioned a joint review of the Dublin Fire Brigade emergency service to determine the best model for emergency care provision in Dublin. The final report of the review is expected this summer. It would be premature to speculate on what effect the outcome of the review may have on any future arrangements between the HSE and Dublin Fire Brigade.
Having listened to the Minister, I am fearful that the position may be graver than I had thought. Is the Minister prepared to acknowledge that one third of those in life threatening circumstances waited too long for an ambulance to arrive last year? Is the gravity of the situation such that he is prepared to wait until the end of the year for a review on foot of which he will decide what action to take? Will he give a commitment to expedite matters by having an independent review and assessment carried out and a report presented to the House within one month? Will he acknowledge that he must make the ambulance service safer, resource it properly and facilitate those on the coalface who are doing a job in difficult circumstances?
People will not listen when the Minister cites statistics to show he is addressing the problem. He has not done anything to make the job of ambulance service staff easier. Despite many Deputies on all sides and ambulance service staff and their representatives highlighting problems in the service, it took RTE to broadcast a programme on the issue last week before the Minister acknowledged the difficulties in the ambulance service. I have not seen the Government take any action to address the issue. Perhaps the Minister will acknowledge the severity of the problem by strengthening the position of those who have been given the authority to carry out the review. The report should be furnished sooner than the end of the year.
The Minister's denial of the problem is frightening and runs counter to the direct experience of citizens and the facts unearthed by the "Prime Time" programme broadcast last week. The issue I raise predates the "Prime Time" programme and must be viewed in the context of the leaked document on the future of the Dublin ambulance service as well as rumours that responsibility for the service is to be removed from the fire brigade. Before any decision is taken on the Dublin ambulance service, an examination of the national ambulance service must be undertaken. Despite response times in Dublin being much better than elsewhere in the country, it is proposed to replace the current model operating in Dublin with the dysfunctional model being operated elsewhere. I support the call made by SIPTU and others to scrap the review being carried out by the Health Service Executive and Dublin City Council and replace it with a full independent national capacity review of the ambulance service. Such a review is critical.
To respond to Deputy Cowen, who clearly does not want to listen, I believe people will listen. As I stated, nobody denies that the ambulance service needs to improve and that reviews are required to inform such improvement. I look forward to the Health Information and Quality Authority report. All Deputies will acknowledge that HIQA is an independent regulator and has always acted independently. I have no reason to believe it will act differently in this instance.
To respond to Deputy Daly's comments on the ambulance service provided by Dublin Fire Brigade, I ask her and others not to prejudge the outcome of the review. Let us await the report and have the debate at that point.
