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Dáil Éireann debate -
Tuesday, 30 Sep 2014

Vol. 852 No. 1

Other Questions

Universal Health Insurance White Paper

Billy Kelleher


74. Deputy Billy Kelleher asked the Minister for Health his views on the introduction of universal health insurance; the timeframe for its introduction; and if he will make a statement on the matter. [36531/14]

One of the central policies in the programme for Government is universal health insurance. On 2 April the Taoiseach and the then Minister for Health published a White Paper on universal health insurance. It was light on detail and unclear as to what was intended with regard to the funding model, but on taking office the Minister rode back to a certain extent from that commitment to universal health insurance. What is the timeframe for the introduction of universal health insurance? Has it been put on the long finger or dropped?

I am committed to a major agenda of health reform in line with the commitments contained in the programme for Government and our policy statement, Future Health. I want to push ahead as soon as possible with key reforms in areas such as extending GP care without fees on a phased basis, improving the management of chronic diseases, implementing key financial reforms, including the money-follows-the-patient model, and establishing hospital groups as a critical enabler of improving patient quality and efficiency. These are big milestones on the road to universal health care.

When I became Minister for Health I reviewed our progress to date and the timescales for implementing very important reforms, including universal health insurance, based on universal entitlement to a single-tier health service that is based on need and not on financial means. While I believe it will not be possible to introduce a full UHI system by 2019, as envisaged in the White Paper, I want to emphasise my commitment to implementing these reforms. In order to do this I want to examine some key elements further and then decide on the best way forward, but this should be considered as a refocusing of our reforms, not an abandonment of them.

In regard to UHI, my Department initiated a consultation process on the White Paper following its publication. An independent analysis of the submissions is under way and I expect to receive this report in the next week. I will then publish it at a later date. My Department has also initiated a major costing exercise to estimate the cost of UHI for households, employers and the Exchequer and is working closely with the ESRI and the Health Insurance Authority. Initial costings should be available in the first quarter of 2015.

The independent thematic analysis of submissions from the consultation process on the White Paper and the results of the major costing exercise on UHI will assist in charting a clear course towards the objective of creating a universal, single-tier health service.

It is clear from that reply that UHI has been parked, but can the Minister talk about universal health care? The central policy is the introduction of UHI. It is evident from the Department of Public Expenditure and Reform and others bodies, including the Health Insurance Authority and those providing cover in the marketplace, that this will increase the cost to ordinary families. It will not be progressive. Middle-income families will have to pay extraordinary sums of money for compulsory health insurance if it goes ahead as envisaged by the previous incumbent and the proposals published in the White Paper. I am beginning to wonder if this is an election ploy, because the Minister knows he is in a cul-de-sac when it comes to the funding of the health services, and that UHI will be a major financial burden on middle-income families. He is slowly trying to let this policy wither and die. It is evident from the Minister's answer that there is no commitment to UHI. Will he not do the decent thing now and say that he is parking UHI and examining other options with regard to the provision of universal health care, which is fundamentally different from UHI?

To be clear, we are not parking UHI; that is not what I said. I spoke about universal health care and universal health insurance. To me, universal health care includes a number of dimensions, for example, access to general practitioners without fees, which will be tax funded, and access to primary care.

It also includes health insurance for everyone across the hospital system, which could be extended into primary care.

A public consultation was held on the White Paper and I will have it and publish it within weeks. At the end of quarter one 2015, I will have the costings for universal health insurance and at that point, instead of speculating about it, we will know what it will cost the Exchequer, employers and individuals and then we can take the debate from there. Practical progress is happening.

I am interested to know what is Fianna Fáil's policy on universal health insurance and universal health care. I have heard Deputy Kelleher speak on the radio about how we need to make the public system better and the private system better too. It seems the Fianna Fáil remains, as it always has been, committed to a two-tier health service, which marks a great contrast between Fianna Fáil and the parties on this side of the House, which are committed to a single-tier health system, even if it takes time to make it happen..

We stated quite clearly that we were opposed to the universal health insurance model and committed to a taxation based model. The principal reason we are committed to a taxation model is that it is progressive. Those who have most and earn most pay most and contribute most to the health services in this country. The universal health insurance model was the opposite of that, which is why the Government is slowly letting it wither and die. It knows that the model will place an extraordinary burden on ordinary families. If the Government was so committed to it, one would think it would do more research prior to the election so that we would have a rough idea how much it will cost, as opposed to the opaque plan with no clear costing or policy on how to get there. That is the problem.

We have great difficulties in funding the health services but we must establish the fundamental principle of how to fund it in the first place. We still do not know the view of the Government on how it will fund the public health system today, tomorrow and into the near future other than universal health insurance at some stage. We support the concept of universality when it comes to GP access but as I said to the current Minister and the previous Minister people cannot fund universality by taking it from those who do not have. That is clearly what the Government is doing. In respect of general practitioner access, it is taking medical cards and other services from people who do not have them. The Government must get its priorities right. The vulnerable and those who need medical care the most must be the priority. Those who can afford health care can be worked into the system but not as the priority, as an election gimmick or as a way to buy votes in the coming 18 months. That seems to be the tenor of the Minister's comments. The Minister is becoming very political in looking at cohorts that may reward the Government electorally. It is the wrong thing to do.

The Deputy is quite incorrect. More people in Ireland have medical cards than ever before and more people have GP visit cards.

That is based on income, not sickness.

The discretionary medical cards that were withdrawn have been restored to those who lost discretionary medical cards and have a medical illness. What Deputy Kelleher is saying is incorrect. However, he let the cat out of the bag about the Fianna Fáil policy because he said his party was committed to universal health care and wanted it to be tax funded. How much will it cost and who will pay for it? What tax increases is Fianna Fáil proposing? Everyone else in the country is talking about the potential for tax reductions but Deputy Kelleher has indicated that Fianna Fáil policy-----

What tax increase?

The fact that Deputy Kelleher must interrupt me throughout my response indicates the extent to which he is on the run.

Will the Minister go back to the Department of Transport, Tourism and Sport?

Deputy Kelleher has announced in the House that Fianna Fáil is committed to tax-funded universal health care, which will cost several billion euro. Anyone who can add knows that. How will Fianna Fáil impose the additional several billion euro of taxes on the Irish people?

Over what limit?

Nursing Education

Seán Kyne


75. Deputy Seán Kyne asked the Minister for Health in the context of the public health nursing diploma and the corresponding two year assignments which applicants undertake, if his attention has been drawn to the requirements of applicants to forgo permanent posts in the Health Service Executive, go on a new panel and take up new posts which are mainly based in Dublin region; the way this requirement impacts negatively on persons wishing to enter or transfer to the public health nursing sector but who are based outside of Dublin, particularly in the west; and if he will make a statement on the matter. [36490/14]

The question relates to the public health nursing diploma and the two-year requirement for people who graduate from it to spend two years in the greater Dublin area. This is of concern to people in my part of the world in the west of Ireland. I have been contacted by people who are considering doing the course or had done the course. They have families and feel they must spend two years in the Dublin area at a considerable distance from their homes.

The issue raised by the Deputy was the subject of intensive conciliation at the Labour Relations Commission during the summer between the nurses' representative body, the INMO, and the HSE, given that nurses who were due to graduate would have had difficulty in obtaining posts in their preferred locations. Conciliation meetings were held on 6 and 30 June and on 22 July. The conciliation conference held on 22 July resulted in significant progress between the INMO and the HSE. Related settlement proposals were drawn up by the commission and issued to the parties on 23 July.

The settlement proposals recognise that the situation is problematic, given that the HSE has more public health nurse vacancies in the greater Dublin region than there are nurses in the 2013-14 class who wish to or are able to work in that region. The situation is further complicated by the fact that a national recruitment panel is in place since 2011 which is composed of public health nurses who are already working in Dublin and who wish to transfer to provincial locations, including the west. In 2013 a similar issue arose prior to the graduation of the 2012-13 class. The parties accepted that this class would take priority over the existing panel for nationwide vacancies. Most of that class have been accommodated in locations that suit them and the current proposals provide for the remainder being accommodated up to the end of 2014. The proposals also provide a structure for the assignment of the 2013-14 class to posts in Dublin in the first instance and for the existing national panel to be prioritised for posts becoming vacant outside of Dublin.

A significant proportion of new posts in recent years have been in the Dublin region and other urban locations, and this is likely to continue given service demands and population trends. As a consequence, the HSE is advising applicants that the 2014-15 class will be recruited on a basis that recognises the shift in demand for public health nurses when it comes to job opportunities. This information is being made available to each candidate at the start of the campaign.

I thank the Minister for his reply. I am aware of the negotiations between the INMO and the HSE. As the Minister explained, the situation is complicated by the existing panels and the demand in the greater Dublin area. However, there are people with young families who are not in a position to spend a period of time working in the Dublin area. These are existing HSE nursing staff who have participated in this diploma course. Will the members of the 2015-16 class be allowed to return to their original posts until such time as a vacancy arises in their regions? This is an issue affecting western counties such as Galway, Donegal, Kerry and Cork, as well as other counties, because nurses from those regions would be expected to work in Dublin. I ask the Minister to consider my request.

I appreciate the Deputy's interest in this matter, which he has raised with me separately on other occasions. I refer to the industrial relations issue between the HSE and the INMO, which is being dealt with by the LRC and in which I am not involved. There are also issues relating to staff deployment. In my view, one thing the Minister for Health should not do is to attempt to redeploy staff around the country. The health service has 98,000 staff and it would be quite improper for me to start relocating doctors, nurses and therapists from one part of the country to another. I have no intention of doing so.

I acknowledge that professionals in the health service will express a preference for working in a certain part of the country, but the more important consideration is that patients need health service professionals and priority must be given to patient need over the preference of professionals.

I appreciate that point. I ask if the Minister would consider making arrangements for those graduating in the next class. I will not go into the debate about the regional imbalance in the country whereby 50% of the population lives in the Leinster region and the resultant effects such as spiralling house prices. There needs to be a shift to the regions and a proper balance in the development of the country. I acknowledge the difficulties existing under the request I have outlined but I wish again to put on the record of the House the concerns of staff who want to take up these positions and who want to be part of the health service helping patients in their own locality. I refer to the big population in Galway and other urban centres in the west. These staff want a chance to treat patients in those localities.

Hospital Waiting Lists

Billy Kelleher


76. Deputy Billy Kelleher asked the Minister for Health the factors behind the big increases in inpatient, day case and outpatient waiting lists between January and July of this year; and if he will make a statement on the matter. [36529/14]

What are the factors behind the large increases in inpatient, day-case and outpatient waiting lists in the period January to July of this year? The National Treatment Purchase Fund published statistics quite recently and some of the increases these show make Zimbabwean inflation figures appear modest. In some areas there has been a 968% increase in the number of people awaiting procedures. What are the key reasons behind the increases to which I refer?

The HSE is continuing to experience a significant increase in demand for its services, which is reflected in an upward trend reported in waiting lists for July 2014. The success of the outpatient initiative run by the HSE at the end of 2013, and further validation work in 2014, resulted in the facilitation of 33,000 extra outpatient appointments in 2013 and an additional 55,883 such appointments thus far in 2014. As the Deputy can see, there has been an increase in capacity. The success of the outpatient waiting list initiative last year in reducing the waiting list from over 100,000 in March 2013 to fewer than 5,000 in December 2013 has had the consequence of driving up inpatient and day-case waiting lists as patients are referred for appropriate treatment. In addition, other pressures such as almost 30,000 new cancer diagnoses each year are placing increasing demands - of the order of 3,000-6,000 additional referral requirements - on the system each month.

Almost half of the 7,727 patients waiting over eight months for inpatient and day-case treatment are accounted for by three hospitals, namely, Beaumont, the Mater and Galway. There are several potential strategies hospitals can use when planning their resources most effectively around the delivery of the national access targets for their patients. For example, improvements in chronological scheduling, consistent validation of waiting lists and active engagement with patients to reduce "did not attend", or DNA, rates are under way in order to address outpatient waiting list. Similar measures, as well as optimisation of theatre capacity and day of surgery admission, where possible, are being employed to improve management of inpatient and day-case waiting lists. All hospitals have been asked to provide action plans to address all waiting lists by the HSE's national director of acute hospital services. These individual hospital plans will be monitored by the special delivery unit's scheduled care team.

To the end of July more than 360,000 people were on outpatient waiting lists, an increase of almost 60,000 on the figure for last year. It is obvious, therefore, that something either is or is not happening, as the case may be. There comes a point where it is no longer possible to force that level of throughput through hospitals because they simply do not have the ability to deal with it as a result of a lack of theatre capacity, consultants and front-line staff. There is also an issue with regard to an inability to transfer people from acute hospitals to step-down facilities. The latter is because the Government, the Department and the HSE have simply not provided funding for such facilities in recent years. At any given time there can be between 600 and 700 people in our hospitals who should not be there and who should instead be being looked after in community settings - with access to home care packages - or in step-down facilities. It is one thing to make statements but there is also a need to put sufficient funding in place in order to ensure that our hospitals have the necessary capacity.

Does the Minister agree that the special delivery unit appears to have run out of steam and that it also seems to be incapable of addressing outpatient and day case waiting lists? Will he take action to ensure that adequate funding is put in place, primarily in respect of step-down facilities, in order that people will be removed from acute hospital settings when they no longer need to be there?

It is important to point out that even though there has been a significant increase in the number of those waiting more than eight months or a year, 89% of patients are waiting less than 12 months for access to outpatient treatment. The target is not being fully met but we have achieved a level of 89%.

There is obviously a deficit in the context of step-down facilities, nursing homes and home-care packages. We do not offer enough home care and people here go to nursing homes sooner than they should and sooner than do their counterparts in other countries which provide much better social and home care than Ireland. Whether the funding available will be adequate is a matter for discussion in the coming weeks. As matters stand, there are approximately 700 delayed discharges across the acute hospitals. There will always be some delayed discharges - perhaps 200 to 300 - but a figure of 700 is quite remarkable.

Were those patients in step-down facilities or nursing homes, we would not have the problems we have with overcrowding in emergency departments or delays in elective procedures. This is a major problem and it will cost a good deal of money to put right. I cannot say with any certainty whether that money will be available to me next year.

I do not expect the Minister to announce the budget in the House, although he may announce it or his efforts to secure adequate funding elsewhere from time to time. What we need in terms of policy is a stated commitment to ensure we will examine the issue in the acute hospital setting and the fact that we have up to 700 patients in beds on any one night who should be elsewhere. That is not only bad for hospitals but for patients also. They should be in step-down facilities or home care settings.

What we have seen in terms of prioritising from the special delivery unit in recent times amounts to fire brigade action to address the difficulties. What we need is a sustained policy of funding home care packages to bolster the associated social and clinical supports and step-down facilities. This should be a priority. Otherwise we will be back here next year talking about an increase in the numbers on outpatient waiting lists and waiting as day cases. We need a sustained and coherent strategy covering several years.

I quite agree with the Deputy. That there are 700 mostly elderly patients awaiting discharge in hospitals is not only bad for the health service but it is also bad for those individuals because they are more at risk of acquiring an infection in hospital and falls. It is bad all round.

It is frustrating that we have been talking about this issue for ten years. It is not something that has happened in recent weeks; it is not a sudden crisis. This is a chronic problem in the health service that has been ongoing since I was a medical student and I find it frustrating that we are still grappling with it. I will be working on the matter with the Minister of State, Deputy Kathleen Lynch, and we intend to put together an integrated plan to deal with it, starting with home care and moving all the way through the hospital system. This will have to be funded, which obviously will be a struggle.

Hospital Waiting Lists

Dara Calleary


77. Deputy Dara Calleary asked the Minister for Health if his attention has been drawn to concerns with regard to waiting times for cancer services at University Hospital Galway; and if he will make a statement on the matter. [36536/14]

There is considerable concern about the standard of service at the cancer care centre at the regional hospital in Galway. It seems there has been a deterioration, not on the part of the staff who are doing an excellent job but in the ability to access beds and chemotherapy treatment. There were reports in the media during the summer about risk control. I know that the Minister has met some of the people involved in the cancer services in the context of the new review. Will he comment on the role of University Hospital Galway in the cancer strategy programme in the next ten years?

University Hospital Galway is one of eight designated cancer centres in Ireland. Key performance indicators have been developed for referrals to cancer centres for breast, lung and prostate cancer with a view to ensuring consistent procedures and quality services for patients.

For breast cancer, the target is that 95% of patients who are deemed to be urgent cases will be offered an appointment within ten days of receipt of the referral letter and that 95% of non-urgent cases will be offered an appointment within 12 weeks. All urgent patients referred to University Hospital Galway are being seen within the ten-day target period. In August this year 86% of non-urgent patients were seen within the target timeframe. While every effort is being made to achieve the target timeframe, a significant issue arising across the cancer centres is the increasing numbers of non-urgent referrals. Some of them are deemed to be inappropriate referrals and a focus is now being put on the better overall management of the referral process.

For lung cancer, the target is that 95% of patients will be offered an appointment within ten days of receipt of the referral letter. In University Hospital Galway 60% of such referrals were seen within this very challenging timeframe in August. There have been some staffing pressures in nursing and clerical areas in University Hospital Galway in recent months and these are being addressed. Efforts are also being made to achieve an integrated team approach in the service.

For prostate cancer, the target is that 90% of patients will be offered an appointment within 20 days of receipt of the referral letter. In Galway 51% were seen within the target timescale. There has been a considerable improvement in this figure since the start of the year and service provision is being reorganised in this area to maximise throughput. A new locum consultant will start work shortly and this will have a significant impact. A permanent appointment will be advertised in the coming months.

Meanwhile, radiotherapy patients in Galway are being treated in a timely fashion and plans are in place to expand the radiation oncology facilities at the hospital to meet projected needs in the coming years.

Comprehensive cancer treatment services are available in Galway and a concerted effort is being made to address pressures on treatment capacity as they arise.

I thank the Minister. I had sought information from the HSE in respect of the number of cases presenting, but trying to get information from the executive is like throwing a ball against a haystack. The Minister introduced a ten-day turnaround for all agencies to respond to parliamentary questions in his previous Department and I encourage him to consider doing that in his new Department.

There is considerable pressure on chemotherapy clinics. Targets are being met, which is welcome, but the conditions people are being treated in are absolutely horrific. I have heard about several bad cases, including one in which a person receives chemotherapy standing up in order that the staff can keep to the schedule. People are left to wait for hours, some after travelling considerable distances to the hospital from across the region, and then they must leave Galway late at night to travel back home.

With regard to the key performance indicator for prostate cancer, which is 51% in University Hospital Galway, when does the Minister hope to have a figure to measure the improvements he has outlined? This is Blue September, and prostate cancer has become one of the greatest cancer threats. It is not acceptable that one in two cases is not being dealt with within the timeframe. When does he hope to have an updated figure in this regard?

How many of the new appointees to University Hospital Galway will be deployed in the cancer care unit? Will any of them be attached to Mayo General Hospital?

There were many detailed questions about an individual hospital. I am afraid I do not have all that information to hand. As the Deputy mentioned, I had a ten-day limit for answering parliamentary questions in my previous Department and that will be introduced in my new Department, although the timeframe will probably be 14 days, not ten. However, if parliamentary questions are not answered by the HSE, they will be followed up by my Department within that timeframe.

The figures are done monthly and reported in arrears. I have given the Deputy the August figures. It is still September and, therefore, I cannot give him this month's figures, but I imagine they will be available in October.

Will the Minister's office focus on the arrangements for the delivery of chemotherapy in University Hospital Galway? That is one area causing considerable concern and distress among patients, especially given the distances people must travel. Staff in Hawkins House do not understand the distance element, particularly where people leave Galway following their treatment at 7 p.m. or 8 p.m. and have to travel across the region.

It is a guideline of the special delivery unit that people should be given appropriate outpatient appointment times. Sometimes everyone is told to turn up at 9 a.m. or 10 a.m., and that is not acceptable. I invited all the hospital managers to meet me approximately two weeks ago and one of the issues I specifically raised with them was that hospitals should give people realistic appointment times, every 15 minutes or every half an hour, and not just have everyone arrive at the same time. None of the managers said they had a problem with that, and I will follow this up with them when I meet them again in a few months.