Vol. 864 No. 2
6. Deputy Ruth Coppinger asked the Minister for Health the total legal costs incurred by the Health Service Executive and the State in the case of a person (details supplied) in December 2014; and the total medical costs, including staffing, drug and technological costs incurred by the HSE and hospitals in the case [2387/15]
I want to ask about the cost to the HSE or State in general arising from legal and medical fees in the tragic case of a clinically dead pregnant woman who was kept on life support for 23 days against the wishes of her family and next of kin. What has been the cost of this horrific case arising from the eighth amendment and involving the taking of unwanted intervention at a time when a health crisis was escalating in the State?
I wish once again to convey my sympathies to the family of the woman at the centre of this case.
As the House will know, this case concerned a woman who was brain dead, pregnant and on life support for a number of weeks in a hospital in the State. An application was brought to the High Court by the woman’s family to withdraw somatic life support. Clinicians decided not to do so for fear of legal repercussions arising from Article 40.3.3° of the Constitution. The case was heard in the High Court on 23 and 24 December 2014 by a panel of three judges. The family, the HSE, the interest of the unborn and the mother were all represented, and medical evidence from consultants in intensive care and obstetrics was heard. On 26 December the court issued its judgment authorising the withdrawal of ongoing somatic support.
The HSE has advised me that it is unable to provide the full legal and medical costs relating to this case at the current time. As is normal, legal fees arising from court actions take some time to be submitted and settled. In any event, it is not usual as a general rule to provide cost details at individual level in respect of specific patients as both technical and privacy issues arise in making and providing such calculations. While it will be possible at a certain point to calculate the legal costs, it may not be possible to calculate the medical costs. No additional staff were employed as a result of the case. While an ICU bed was used, it would have been used in any case, albeit by somebody else.
I expect to receive further information from the HSE on this case as part of my consideration of the High Court judgment and its implications as I wish to ascertain what lessons may need to be learned from this extremely sad and unfortunate case. As I mentioned previously, I fully believe clinicians should be able to make challenging ethical decisions in consultation with their patients and their families, as appropriate, on the basis of best clinical practice rather than on foot of legal advice or under the fear of prosecution.
I ask that the privacy of this family be respected and that it be given the appropriate time and space to grieve its loss.
I also conveyed my sympathies to the family when I raised this issue in the Dáil. I believe it was the only time it was raised. Nobody has mentioned the names of those in question, and nobody knows their names; that is fine but it should not be used as a gag against public representatives raising legitimate questions.
Dr. Peter Boylan called what happened in the tragic case grotesque and experimental. The Minister should be asking for a report from the doctors on why they felt it necessary to keep the lady on life support when it would seem, according to any information I have looked up, that no 15-week foetus has survived under these circumstances anywhere in the world. The ICU consultant involved said we were dealing with a corpse and could not believe what was going on. It would seem that we have the money to keep women as incubators but we do not have the money for nurses or beds. Can the Minister explain to people suffering from rare, life-limiting and life-threatening conditions why they cannot get medication - relevant cases have been highlighted in recent days - although money is being spent in circumstances such as those described?
The Minister of State from the Labour Party, Deputy Kathleen Lynch, is shaking her head. Fine Gael introduced the eighth amendment in 1983. The Labour Party is sitting on its hands even though it disagrees with it. It is apologising saying it is in a coalition in an election year and that it will suspend its belief in women's rights for the duration. If I were the Minister of State, I would not be shaking her head.
I disagree with the Deputy's behaviour. She should show a little respect.
We have embarrassed ourselves again in front of the world with this case. How many more of these cases are we to have?
Nobody is trying to gag Deputy Coppinger. With the greatest of respect, I do not believe she is the kind of person who would or could be gagged. She need have no fear about that.
An issue of privacy and decency arises and the family has asked for privacy and for its confidentiality to be respected. We should endeavour to do that to the greatest extent possible. All of this was heard in open court and the doctors gave their reasons and answered the questions. They gave reasons as to why they were not willing to end somatic life support without legal advice and cover. The answers to the Deputy's questions exist already. All these matters were aired in open court. The legal costs are not yet known. It takes time before legal costs are agreed, as the Deputy knows. The medical costs probably cannot be calculated and it may well be the case that there were no additional costs. As I pointed out, the ICU bed would have been used anyway, and the staff involved were employed in any case. There were no additional staff employed.
It is legitimate to ask how much was spent by the State in defending what is now an absolutely disgraceful and medieval law, which has proven that women are considered to be incubators. High Court cases cost a lot of money; I know that. Having legal representation supplied to the both the unborn and deceased woman was bizarre. The Minister is unable to provide information now. Will there be a time when he can?
People watched in horror as the case arose over Christmas. There was considerable comment in social media. It was asked why this was happening when there was a trolley crisis and bed crisis escalating in hospitals. The case brought home to people that this is an invasion of privacy, based on the eighth amendment, in respect of families' decisions. I acknowledge that the Minister admitted it is the eighth amendment and Article 40.3.3° that compelled doctors to take their course of action.
On the matter of gagging, people on this side of the House have spent their entire lives fighting for social progress but people on the other side of the House have not. Questions and issues such as those in question need to be raised. The Minister should accept that.
I am no expert on legal costs but understand bills are usually submitted and are all adjudicated upon by the Taxing Master or a similar entity. I cannot tell the Deputy when the costs will be known.
The HSE did not defend this case. On behalf of the hospital, it actually supported the proposal that life support be ended. The Deputy may take a look at the study herself. All the issues in question were aired in open court.
7. Deputy Alan Farrell asked the Minister for Health if he will provide an update on the efficiency of the process by which discretionary medical cards are assessed and granted; if he will provide information on the average waiting time between receipt of an application and a decision being made; and if he will make a statement on the matter. [2340/15]
I wish the Minister, Deputy Leo Varadkar, a belated happy birthday. As someone who had the honour of being elected with him in 2004, I have known for a long time, to my great regret, that he is about 13 months younger than me.
My question concerns the efficiency of the discretionary medical card process, with which we have had great difficulty in recent months and years. I am asking the Minister to provide an update on its efficiency and the current position on waiting lists.
Under the Health Act 1970, as amended, eligibility for health services is based primarily on residency and means. The Deputy will be aware of the publication of the report of the expert panel on medical need for medical card eligibility and the medical card process review in November 2014. A key recommendation of the expert panel was that a person’s means should remain the main qualifier for a medical card. Discretion continues to be an integral part of the medical card assessment process. All applications are assessed under the relevant legislation and the HSE's national assessment guidelines. However, to build on the conclusions of the two reports, a suite of actions have been identified to improve the operation of the medical card system, particularly for people with significant medical needs. A detailed programme of reform has been drawn up by the HSE with short, medium and long-term actions to be addressed in the period 2015 to 2016. The HSE has appointed a senior manager, at assistant national director level, with specific responsibility for primary care schemes and eligibility, to lead the reform.
I can advise the Deputy that the temporary reinstatement of discretionary medical cards that were previously removed, pending full implementation of actions to improve the operation of the system, remains in place. Holders of discretionary medical cards are no longer included in random reviews and a discretionary medical card issued on the basis of a terminal illness will not be reviewed and end dates are no longer included in the medical card.
The HSE has ensured a more integrated and sensitive processing of applications, involving a greater exchange of information between the central assessment office and the local health offices on people’s medical circumstances and needs. The HSE is taking steps to establish a clinical advisory group to develop a methodology and guidance for the assessment of applications involving significant medical conditions so as to take account of the burden involved and the needs arising from the condition and to ensure appropriate services are provided for those who need them.
The number of medical cards held on the basis of discretion having been exercised by the HSE has increased from approximately 50,300 on 1 January 2014 to approximately 76,700 on 1 January 2015. The Deputy can see, therefore, that the process is working.
I thank the Minister of State for her response and appreciate, in particular, the last nugget of information which obviously is pertinent. I commend the Minister and the Minister of State, given that, if I am not mistaken, this is the first time in seven years that the Department of Health's budget will actually be increased. It is also welcome that discretionary medical cards will not be reviewed for individuals who are terminally ill. That is a far more humanitarian way of approaching these issues. The last thing a family member wants when coping with potential grief is to have to deal with reams of paperwork from the Department of Health.
Given the difficulties with the medical card system in recent years, culminating in the report published in November 2014, I am pleased that we have seen some movement on the issue. However, a number of such cases have come through my office in recent months. While I am positively disposed to what the Minister of State said, the information with which I have been provided somewhat belies what has happened in individual cases. I appreciate, however, that what has happened in individual cases is not the best way of ascertaining how the whole system operates. Nonetheless, more could be done and I would like to see the Minister of State undertaking a review of the process in the coming months. That would give us an opportunity to debate the matter which I am sure Opposition health spokespersons would welcome.
The review of the system, both within the Department and the HSE, is virtually continuous. Because of the difficulties that arose with medical cards the matter is constantly being reviewed, re-evaluated and tweaked. There are difficulties concerning medical cards because they no longer technically just give access to a GP or medical services in an acute hospital. Their expansion sometimes causes difficulty. We are examining what additional services are provided and whether it should all come within the ambit of the Department of Health. That is all being examined, but the discretion promised in both reviews by the Government has continued. The Deputy can see from the last piece of information I have provided that clearly the process is working. The humanity and compassion that need to come into play when someone receives a diagnosis, which each and every one of us hopes we will never have to get, must be shown within the system. It is difficult to include this in legislation, but it does need to be provided for.
I thank the Minister of State for her comments. I will be brief and do not require a further response. The approach being taken to medical cards should, for instance, include continuing medical card cover for those seeking employment. That would give them peace of mind when they re-entered the workforce. These changes are being welcomed by the general public. While it is a separate issue to that of the discretionary medical card, it is worth mentioning.
As the Deputy does not need a reply, we will make some progress.
8. Deputy Richard Boyd Barrett asked the Minister for Health his plans to deal with the growing crisis in hospital accident and emergency departments across the country; and if he will make a statement on the matter. [2382/15]
In recent weeks we have witnessed an unprecedented crisis in accident and emergency departments. At its height, 600 patients were on trolleys in hospitals. When the Minister was questioned about this issue last week, he boasted that the position had improved and that the numbers on trolleys had dropped again since that horrendous peak figure had been reached. I note that, according to Trolley Watch today, there are 431 patients on trolleys. How long will we lurch from crisis to crisis? When will the Minister get a handle on the issue?
The Government regards trolley waits of over nine hours as unacceptable. I acknowledge the difficulties the current surge in emergency department activity is causing for patients, their families and the staff who are doing their utmost to provide safe, quality care in what are very challenging circumstances. All hospitals have escalation plans to manage not only patient flow but also patient safety in a responsive, controlled and planned way that supports and ensures the delivery of optimum patient care. These plans include the opening of additional overflow areas, the reopening of closed beds, additional diagnostic scans and consultants doing additional ward rounds to improve and speed up the appropriate flow of patients through hospitals.
The Government has provided additional funding of €3 million in 2014 and €25 million in 2015 to address the issue of delayed discharges. Actions being taken include the provision of about 400 additional home care packages, additional transition beds in nursing homes, 300 additional fair deal places and an extension of community intervention teams. In addition, Mount Carmel Hospital will reopen later in the spring and provide important relief for Dublin hospitals.
Last month I convened the emergency department task force to help to develop long-term solutions to the problem of overcrowding by providing for an additional focus and momentum in dealing with challenges presented by trolley waits. Following a second meeting last week, the HSE is working on an action plan to be finalised by the end of the month to specifically address emergency department issues with a view to achieving a significant reduction in trolley waits over the course of 2015.
The number of patients on trolleys this morning is 357. They includes patients on trolleys in wards but do not include patients in day wards. Of these, 169 have been on trolleys for more than nine hours. However, we do expect the number to fall below 200 by the end of the day. As the Deputy knows, patients are not discharged overnight; therefore, the figure is always higher in the morning. As patients are discharged during the day, the numbers fall. We, therefore, expect that there will be fewer than 200 by the end of the day, but then, of course, the number will rise again overnight.
There are significant variations from Mullingar, Kilkenny, Cavan to Kerry where there is no one on a trolley to as many as 24 being on trolleys for more than nine hours in Beaumont Hospital. I will be happy to answer any further question the Deputy may have.
Clearly there is some movement as a result of the crisis that arose last week but there are, as stated by the Minister, 357 people still on trolleys today. As I mentioned, yesterday there were 431 people on trolleys, some of them in wards, resulting in there being more people in wards than there should be. I note from the RTE headlines this morning reference to the fact that 4,000 nurses have resigned in the past three years, 5,000 in total have resigned over the past number of years and warning that 1,000 more are to leave in the next year. Also, some 5,000 beds in total have been taken out of the system and 2,000 beds are currently closed.
It appears that the measures being taken are small in comparison with the scale of the problem, which gives little confidence that we are not going to continue to lurch from one crisis to another. As acknowledged by the Minister in his responses last week, the emergency measures being taken will lead to the cancellation of non-emergency surgery, which will affect waiting lists and result in other people in the health service suffering. Despite the emergency efforts to deal with the trolley crisis the situation is still out of control. Is it not time that the Minister listened to the nurses, who have now been forced to call for industrial action in the form of a work to rule early next month, that what is needed if we are to get a handle on this crisis is thousands more beds and thousands more nurses, significant extra resources and a reversal of the cuts that have been implemented?
I would point out that 4,000 nurses have not resigned. Rather, the number of nursing posts has been reduced, which is not quite the same thing. Between 2008 and 2013, the number of nursing posts reduced by approximately 5,000 but this is offset in large part by the fact that nurses work additional hours under the Haddington Road agreement and also by the graduate nursing programme. However, in 2014 the number nurses employed by the HSE increased by 500. We are now starting to increase the number of nurses working in our public health system. This is in addition to the fact that we now have record numbers of midwives and more consultants than ever before. It is important to put all of the facts in the public domain. The only thing that is better than the truth is the whole truth.
If this was a simple problem it would have been solved a long time ago. The difficulties vary from hospital to hospital. The fact that the work to rule will take place in seven hospitals and not all 28 or 40 facilities indicates that there are particular problems in some hospitals. In some hospitals difficulties arise because of late discharges, either because there is no funding available for the fair deal scheme or, as in the case of the Beaumont-Louth area, there are no nursing homes. What is required is different sets of solutions, a national approach and particular approaches in particular hospitals. That is what the emergency departmental task force is all about.
I was reading from the RTE headlines. The phrase "Lies, damned lies, and statistics" comes to mind.
And then there are headlines.
Yes. According to RTE, the figures it obtained from the HSE indicate that almost 11,000 nurses left the profession between 2010 and 2013 and 1,000 more are scheduled to retire this summer. Is the chaos in our health service the result of people being forced to work harder under the Haddington Road agreement, resulting in the huge culling of nurses from our hospitals, particularly our accident and emergency departments? Is it not the case that the reason nurses are flooding out of the system is because they are at their wits end and completely stressed because their incomes have been slashed, thousands of beds have been closed and billions of euro has been taken out of the health service? Nurses can no longer bear that because not enough resources, staff or beds are available in the system patients and staff are suffering. It is a disaster.
I am sure the Deputy is not accusing the media or the people who write the headlines of lies.
I am just quoting the statistics that are being bandied about. Is the Minister disagreeing with them?
No, I am not: I am disputing the Deputy's understanding of them. It may well be the case that 11,000 nurses have left the service in the past five years but it is also the case that 6,000 nurses have come into the system. As such, the net reduction in nurses is approximately 5,000 but this has further reduced to 4,500 because the number of nurses increased in 2014. As I said, this is partly offset by the current record number of doctors and midwives in the system, nurses working additional hours and the graduate nursing programme. The number of nursing hours done is not necessarily the same as the number of nurses employed.
There are approximately 34,000 nurses in the public health service. If 1,000 of them leave this year, that equates to approximately 3% of the overall number. A 3% turnover in staff in any organisation is not enormous. It is manageable. A particular issue, as mentioned by the Minister of State, Deputy Kathleen Lynch, is that mental health nurses can retire at 55 years of age, although they do not have to do so. We are encouraging them to stay on. Also, the HSE's latest recruitment campaign for nurses had almost 4,000 applicants. There are people who are willing to work in our services.
9. Deputy Terence Flanagan asked the Minister for Health the position regarding his plans to role out primary care centres throughout the country; and if he will make a statement on the matter. [2339/15]
I am seeking an update from the Minister on the plans for the primary care centres in 2015 and 2016 and how often they are reviewed and updated.
I thank the Deputy for tabling this question. The development of primary care centres through a combination of public and private investment is supporting the delivery of an enhanced range of multidisciplinary, locally accessible primary health care services. To date, there are 85 primary care centres in operation throughout the country, 42 of which have opened since 2011. The HSE uses three mechanisms to deliver primary care infrastructure, including direct build - by the HSE; public-private partnership, PPP; and operational lease with the private sector. There are currently 37 locations where primary care centres are under construction or at an advanced planning stage using one of these three methods of delivery.
Direct Build centres are funded through the HSE’s multi-annual capital plan, with funding provided for 16 centres in the plan. Some 14 centres are being progressed through public-private partnerships. This project is currently out to tender with three preferred bidders. Tenders are due to be returned early in 2015 and it is expected that the preferred bidder will be selected in Quarter 2, 2015. Subject to successful completion of financial and contractual arrangements, it is expected that construction work will commence before the end of 2015, with the centres expected to be completed by the first half of 2017. To date, 43 primary care centres have been delivered through the Operational Lease model. The HSE is at advanced stages with developers in 28 locations where agreements for lease have been entered into and it is currently at negotiation stage in an additional 32 locations where Letters of Intent have been issued.
In November 2014, the HSE advertised an additional 73 locations for delivery of primary care centres by Operational Lease. Friday last, 16 January, was the closing date for receipt of Expressions of Interest. The HSE will review all Expressions of Interest to determine which are suitable for more detailed consideration and progression to the next stage of the process.
I thank the Minister of State for her reply. The primary care centres are a fundamental plank of the Government's strategy to keep people out of hospitals. This question relates to the previous question in regard to trolley usage in our acute hospitals. In Beaumont Hospital, which is in my constituency, many people are being treated for COPD. Treatment of these people outside of the hospital system would result in up to 45 beds per day or 28,500 bed nights per annum being freed up. There is huge potential in regard to the introduction of the primary care centres.
Perhaps the Minister of State would provide an update on the status of the Coolock, Darndale and Edenmore primary care centres. The method of delivery of the centres, including by public private partnership or operational lease, are subject to market conditions, developers and so on. Perhaps the Minister of State would update me on how often the list in relation to primary care centres is updated in terms of viability and so on.
The enhancement of primary care centres will have a manifold impact not just for health in the community by stopping people from having to access acute care in hospitals. The second impact it will have is with the recovery of the economy and the building industry which I believe is as important for those engaged in it with regard to their general and mental health.
I do not have the information on the Deputy’s specific area but I will get it for him. Primary care provision is reviewed very often. The progress we are making in it is extraordinary and going at a rate of knots. The interest in it is incredible too. I attended one of the meet-the-buyers sessions recently and it was impossible to get in the door due to the extent of interest. It is about ensuring we have proper facilities in primary care and, equally, that we get GPs, general practitioners, to co-operate through providing their specialisms and covering certain geographical areas. There are difficulties in some areas, as Members know, but we are managing it.
I very much appreciate the Minister of State's reply and her commitment in this area. What are the figures for 2015 and 2016 for the Health Service Executive's, HSE, direct own build of primary care centres? Obviously, the delivery of primary care centres is going to take significant pressures off acute hospitals. People will want to stay in their communities rather than necessarily having to travel to hospitals. The sooner more of these primary care centres get up and running the better.
Forty two centres have been delivered since 2011 while 37 are currently under construction. Up to 43 primary care centres been delivered under the operational lease model. The HSE is at an advanced stage with developers in 28 locations where agreements for leases have been entered into. The HSE has advertised an additional 73 locations for delivery of primary care centres by operational lease. The closing date for that was 16 January 2015.
A considerable body of work has been completed. I will ensure the Deputy gets a specific reply for his area.
10. Deputy Sean Fleming asked the Minister for Health his views that the 300 extra places announced for the fair deal scheme in 2015 are sufficient to meet demand; when the review of the scheme will be complete; and if he will make a statement on the matter. [2409/15]
The budget for the nursing homes support scheme for this year is €948.8 million. The budget for 2015 reflects an increase of €10 million from the position in 2014. This €10 million increase has been allocated to the scheme as part of the initiative relating to the issue of delayed discharges and has allowed for the provision of an additional 300 long-term residential care beds. It has also reduced the time spent on the placement list from 15 weeks to 11 weeks.
My Department and the HSE are working to ensure the resources are available to deliver the best possible outcomes for older people. This will require an integrated approach across community, residential and other service areas. It is clear that even with this additional €10 million, the scheme will remain under pressure and the longer term position, therefore, needs to be carefully considered. The review of the nursing homes support scheme, as well as considering how the scheme has operated to date, is expected to identify some of the issues that will need to be considered and tested more fully into the future, including the future financing of the full range of supports for older people. Work is well advanced on this review and it is expected to be completed by the end of this quarter. As the scheme is statutory based, the implementation of recommendations arising from the review will require amendments to the Nursing Homes Support Scheme Act 2009.
I thank the Minister of State for that information. She claimed there will be a €10 million increase for the fair deal scheme which represents a 1% increase in its overall budget of €1 billion. That is insignificant. I would not even elevate it to a drop in the ocean as it will have no effect. The Minister of State stated it is intended to get the average waiting time down from 15 weeks to 11 weeks. I know many people who were on the waiting list for funding for 20 weeks. When they were finally approved for funding, they had to wait another 20 weeks before a cheque actually arrived to pay for the fair deal scheme. Despite the 1% increase in funding in 2015, we will still be 400 beds short compared to what was available in 2013. The Minister of State must address in her review the issue of the HSE's own community nursing homes.
I am also concerned that she said this review will require legislation. Will we even get to it in the life of this Government?
I always find it very difficult when people either misunderstand or choose not to listen. I am assuming the Deputy did not misunderstand but chose not to listen.
Rather like the Minister of State listened to the Minister for Agriculture, Food and the Marine, Deputy Simon Coveney, yesterday.
It is that type of talk - this €10 million is only a drop in the ocean - that got us into the position we are in today. As if €10 million did not have a significant impact for the extra 300 people who could avail of the scheme. It made a significant impact. This type of attitude towards public finances - that laissez-faire attitude that €10 million does not matter and throw in what is there - is what got us here.
We are very conscious that we must be careful about the difficulties in the provision of care for older people into the future. We are equally conscious that we do need additional resources. To be honest and straight about it, provision should have been put into the original legislation for this. I believe the fair deal scheme should be demand-led with tight access. We do not need new legislation - that is what Deputy Sean Fleming chose to misunderstand - but an amendment to existing legislation, namely the Nursing Homes Support Scheme Act 2009. The Deputy is long enough here to know that is not new legislation but an amendment to an Act.
An amendment to legislation will require a Bill to go through the House. That is new legislation in simple English. Legislation can be big or small.
Everyone welcomed the extra 300 places but there are still over 2,000 people waiting for the scheme. It is not even a drop in the ocean as far as those people are concerned. The Minister of State must address the issue of why she is seeking to privatise the scheme. We know about the differences between the Labour Party and Fine Gael, namely the latter is a privatisation party. I would have thought Labour had a bit more of the common interest and the good of the people at heart. I hope in this review the Minister of State will push for community nursing homes. We have spoken several times about Abbeyleix District Hospital and St. Brigid's Hospital in Shaen, Portlaoise, County Laois. For a small amount of money - a couple of million euro, not €10 million - 70 extra beds could be provided for the scheme which would be far cheaper than going the private route. It would also be far more economical to utilise the staff in those hospitals who are only dealing with respite care to provide services in the public community nursing home sector rather than privatising it.
It is the Government’s intention to have a combination of residences available to people in the scheme, a significant proportion of which will include the public sector. We have 129 public long-stay nursing homes residences. We cannot afford to lose any one of them whether it is at Shaen, Abbeyleix or Cork. We are in constant negotiation with HIQA, the Health Information and Quality Authority, about how that can be managed. We have made it very clear that we cannot afford to lose any of them. I am a great believer in public service and will continue to be. The public service provides a different service than that provided by the private sector. The private sector does an extraordinary job in certain circumstances but both are needed in this area. Both need to co-operate in this area too.
