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Dáil Éireann debate -
Thursday, 22 Oct 2015

Vol. 894 No. 1

Priority Questions

Departmental Budgets

Billy Kelleher


1. Deputy Billy Kelleher asked the Minister for Health the contingency plans his Department is putting in place in the event of a health budget overrun in 2016; and if he will make a statement on the matter. [36796/15]

What contingency plans are being put in place by the Minister for Health in the event of an overrun in the health budget in 2016 and will he make a statement on the matter? This leads from the point that next year there will be different fiscal rules applicable to Departments in the context of supplementary budgets. This year the Minister for Health has a €600 million budget deficit. Other than a sum of €280 million, no additional funding was allocated to the Minister for 2016 in last week's budget. The health service will be commencing 2016 under-resourced and underfunded. What contingency plans is the Minister putting in place in view of the fact that, as we know, he will have insufficient funding for the health services in 2016?

Since my appointment as Minister for Health, I have sought to put in place a realistic budget for health and social care. Improved budgetary parameters reflecting the growing strength of the economy have enabled me to secure additional funds for health and social care in 2015 and 2016. The gross current Estimate for the health sector for 2016 is €13.175 billion, an increase of €880 million on the Revised Estimate for 2015. In addition, potential savings of €125 million will be available to reinvest in maintaining and improving health services. While I welcome the increase in funding for the health services in 2016, I do not underestimate the challenges involved in the delivery of safe and efficient health services against a backdrop of growing needs. It is essential that we continue to focus on cost containment, productivity and efficiencies as there continues to be major cost pressures on the health service due to an increase in our aging population, the incidence of chronic conditions and the cost of new and expensive medicines, treatments and technologies.

I also recognise the need to strengthen accountability and good governance across the health service. The HSE has an accountability framework which makes explicit the responsibilities of all managers to achieve the performance targets set out in each year's service plan. Where areas of underperformance are identified, the matter is escalated according to an escalation and intervention process. The HSE’s 2016 national service plan will detail how the executive intends to develop and build on the accountability framework in 2016 to further enhance and strengthen accountability arrangements next year. The HSE will also engage in internal efforts to maximise savings and opportunities for cost containment and ensure that additional measures are identified and safely implemented to mitigate any projected deficits.

My Department will continue to work closely with the HSE to ensure that the greatest degree of budgetary control is exercised. Ongoing and intensive engagement each month between officials of my Department, the Department of Public Expenditure and Reform and the HSE, in the context of regular monitoring of expenditure, will continue to be enhanced as required in 2016.

New EU fiscal rules limit the amount of Government expenditure in any year. Therefore, any overruns need to be funded by new revenue measures, or reallocating funds from elsewhere. This is likely to mean, in practice, reduced scope to allocate additional money to Departments by way of a Supplementary Estimate at year end. Accordingly, the planning and management of health expenditure will be subject to particular attention in finalising the 2016 national service plan.

Straight away, the abdication of responsibility continues, because the Minister is saying his Department will work closely with the HSE. The bottom line is that it is the Minister who will present the Estimates and who is charged with seeking enough funding for the HSE national service plan that will be published in early 2016. The bottom line, to date, is that the Minister has said one of his overarching goals was to achieve a realistic budget for the health services. There is a €600 million hole in the budget for this year. That is hardly realistic. That is a massive deficit by any stretch of the imagination. It was foretold this time last year when everybody effectively said the Minister did not have enough money to run the health services in 2015. Form would indicate that what he has been allocated this year for next year simply is not a credible starting point. Therefore, he will have huge difficulties this time next year in trying to ensure he has enough money to maintain basic health services, bearing in mind the huge pressures on the health service at the moment.

I thank the Deputy.

There are massive waiting lists, overcrowding in emergency departments and a lack of capital investment across many of our hospitals, so there are huge problems out there and the demographics on top of that. We already know we do not have enough.

I am not sure that in health there will ever be enough money to do everything one would like to do, but we have a very substantial budget and there should be enough to maintain the existing level of service and improve it in some instances. To clarify, the €600 million Supplementary Estimate this year does not fill a hole. The Minister of State, Deputy Kathleen Lynch, and I sought much of that money during the year to make particular policy decisions, including more community beds, more hospital beds, a reduction of the fair deal waiting list to four weeks, and the provision of GP care to everyone under six years and everyone over 70 years. I would not like people to be under the misapprehension that all of that is somehow an overrun. It is not. Policy decisions were made during the year, supported by Government, to do more than we had planned to do at the start of the year. In respect of the €600 million being carried over into next year, that is not all recurring expenses; some of it involves one-off payments that will not recur next year. For example, the symphysiotomy payments scheme would be part of that. Not all the €600 million has to be paid again next year.

I thank the Minister.

There is the additional €280 million and the €125 million in savings. In the budget proposal from the party opposite, it proposed an additional €380 million for health but did not make any provision for the Lansdowne Road agreement. Assuming the party opposite does not intend to renege on that, it is providing €280 million, which is pretty much the same as we have provided, so obviously it must believe it is adequate.

The difficulty with all of this is that, as we stand here today raising issues and asking Dáil questions, there is overcrowding in emergency departments across the country and massive waiting lists. The Minister has changed the targets for inpatient and outpatient appointments to 18 months. There are cancellations on a continued basis for elective surgeries. Right across the health service there is huge pressure, which is having an impact on the quality of life of patients and putting the workforce under extreme and inordinate pressure. Last year, for example, the Minister said he would have €300 million in non-Exchequer income, but he will not have that income next year. That is not continuing income; much of it was one-off funding. Irrespective of what way the Minister wishes to put it, he will have a deficit this time next year again. If not, it will mean that services will have been cut back to remain within budget. The Minister should confront that reality now and accept that the budget for 2016 is unrealistic and simply will not sustain the health services of today, which are under-resourced and under-funded.

Almost entirely, the one-off income requirements are provided for. If the Deputy wishes to add €270 million to the €600 million and to the €280 million he can. We actually managed to have the one-off payments resolved this year. If one adds up the figures, they amount to more than €1 billion. Elective surgery is cancelled more frequently than we would wish, but the cancellation rate is 1%. I pointed to the pre-budget submission from the Deputy's party which provides for an extra €380 million for health and, perhaps, knocking €100 million off that for the Lansdowne Road agreement. Is the Deputy telling me that in his party's pre-budget submission it provided inadequately for health, as the amount provided is pretty much the same as what we have provided?

No. That is scurrilous.

Why would the Deputy's party provide an inadequate amount for health? The Deputy is accusing the Government of doing pretty much exactly what his party put in its own pre-budget submission.

Dental Services

Caoimhghín Ó Caoláin


2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health the status of the preparation of the long promised new dental Bill; the reason it is taking such an inordinate length of time to produce; if he is aware of the serious concerns regarding any row-back on the registration of all key players across the dental health care team; if he will confirm that it is intended that the Dental Council will have overall registration responsibility and oversight, including the power to inspect premises; and if he will make a statement on the matter. [36809/15]

I seek to establish the current status of preparation of the new dental Bill. Why it has taken so long to prepare and present? Is the Minister aware of concerns about the registration of all the different professional roles within the overall dental health care team and the intended roles and responsibilities of the Dental Council on the enactment of the new legislation - that is, in relation to registration, responsibility and oversight, and, specifically, the power to inspect premises? These are the matters I wish to see addressed.

Work is ongoing on the preparation of a new dental Bill. It is based on a comprehensive public consultation process which informed the key policy issues that are now shaping the drafting of the Bill. The Bill will bring about significant change in fitness to practice, regulation, registration and the constitution of the Dental Council. The legislation will provide for the regulation and inspection of dental practices by the Dental Council. These proposals also ensure modernisation of the legislation regarding governance of the council, specified functions of council, education and training and continuous professional development. A regulatory impact analysis is also under way. There is no row-back on the registration of allied dental professions. It is proposed that those allied dental professions whose scope of practise has been determined by the Dental Council as being suitable for independent practice will have mandatory registration and be made subject to fitness to practice. The council will make this determination based on its assessment of the level and nature of the risk posed to patient safety.

Allied dental professions not determined by the council as being suitable for independent practice will not have mandatory registration. However, the Dental Council may introduce rules to regulate the training and education standards and to protect the titles of these professions. It will be an offence for a person to falsely present as having the approved education and training standard or to falsely use a protected title.

Over the last number of years, the Department has updated the legislation for doctors, nurses, midwives, pharmacists and 14 health and social care professionals. This has provided for greater accountability and comprehensive regulatory governance of these professions. It was a major body of legislative work. The experience of this, and of implementing these revised arrangements, will inform the Department's consideration of priorities for further legislation in the area of professional regulation. This includes the drafting of the new dental Bill during the course of 2016. Department officials are also currently committed to drafting a priority health (miscellaneous provisions) Bill. The primary purpose of this is to amend all health profession regulator Acts as a consequence of the transposition into Irish law by January 2016 of the modernised professionals qualification directive.

The Minister of State has not explained why there is such a delay in the presentation of this new legislation. The existing Dental Act 1985 is 30 years old. When the Minister of State makes the point in relation to the Dental Council and allied dental health professions and, specifically, those who an practice independently, she is failing to take on board the Dental Council's own very clear position in respect of this matter and the registration of all those who make up the dental health care team. Appearing before the Joint Committee on Health and Children on 8 October, Dr. Eamon Croke, the president of the Dental Council, said the Dental Council believes that all members of the dental health care team should undergo mandatory registration, with the Dental Council making no distinction between those who can practice independently and those in other areas of responsibility, such as dental nurses, hygienists and dental technicians.

If what the Minister of State is talking about is to proceed, it would be only dentists and clinical dental technicians who would be required to register and this is simply not enough. Can the Minister revisit this matter?

That is not what we are saying. What we are saying is that those who will be deemed fit to have an independent practice will have mandatory registration but I do think it is important. This area is as subject to change as anything else. The issue of the proportionality of regulation is being examined in the UK and Europe. The Professional Standards Authority for Health and Social Care in the UK recently published a paper rethinking regulation which emphasises the need to apply "right touch" regulation to the regulation of health and care services in the UK. It cautions about the need to be aware of what regulation can and cannot do to contain risk and that statutory registration is not always the most effective approach. We should be conscious of that happening.

The reason for the delay is that there was a wide consultation process. Oral health is not just about dentists, as the Deputy rightly points out, and there were other players in the field who needed to be consulted. That happened over a long period.

I strongly disagree. The professional regulation unit's notes relating to this matter from August 2015 refer to allied dental health professions who are not allowed to practise independently, which is everyone other than dentists, orthodontists and clinical dental technicians. It is important that the Minister of State understands that while not registering the professions, the Dental Council may introduce rules, etc. It is critically important that it is recognised that not only Dr. Croke but the entire panel which came before us, including the board members and representatives of the Dublin Dental Hospital, indicated very clearly that they want mandatory registration across the board for the very sound reason that once one registers and regulates an area, standards improve and one has authority across the board. I am asking for a re-evaluation so that not only the independent practitioners I have named but those who are the allied support professions within the overall dental health care team, including dental technicians, dental nurses, hygienists and others, are under mandatory registration. That is very important.

In respect of the powers to inspect, will the Minister of State clarify whether, after the enactment of the new legislation, the Dental Council will have the power to inspect and close illegal practices in the public interest because that has not happened heretofore?

That is the reason there will be a new dental Bill and the council will have those powers. All the other professions that have been registered up to this point have had power under the fitness to practise area and this is a significant power. In looking at all the other regulatory bodies in respect of fitness to practise, I am not sure that each registration council needs such a body on its own. We may take a look at centralising that but fitness to practise will be central to what the council will do. It will come about in most cases through complaints from the public but in other cases through the council's inspections. We need to wait and see what the Bill will propose and I have every faith in our Chief Dental Officer because she is very familiar with the area and has taken all of the issues raised by the Deputy on board.

Hospital Accommodation Provision

John Halligan


3. Deputy John Halligan asked the Minister for Health his plans to address the overcrowding in the emergency Department and wards of University Hospital Waterford during the busy winter months; the number of the recently announced 440 additional beds that will be allocated to the hospital to increase its capacity; when these beds will open; the other measures, specific to the hospital, he has planned, to address regular overcrowding therein; his plans to address the number of delayed discharges at the hospital, particularly at weekends; his views that the shortage of residential follow-on aftercare placements for elderly patients deemed by the hospital medical staff to be medically well is adding to discharges being delayed, as many of these patients cannot be looked after at home by family members, and this is having an adverse effect on the bed shortages; his further plans to address this issue; if he will provide an update in relation to the promise to provide an additional 50-bed unit in Saint Patrick's Hospital in County Waterford; when planning permission will be sought; when building work will be carried out; his views on using the private sector to ease overcrowding at University Hospital Waterford during the particularly busy times; and if he will make a statement on the matter. [36667/15]

What are the Minister's plans to address the overcrowding in the emergency department and wards of University Hospital Waterford during the busy winter months? How many of the recently announced 440 additional beds will be allocated to University Hospital Waterford to increase capacity and when will these beds will open? What measures specific to University Hospital Waterford has he planned to address regular overcrowding at the hospital? Could he provide an update relating to the promise to provide an additional 100-bed unit at St. Patrick's Hospital in County Waterford? Could he confirm when planning permission is to be sought and when building work is expected to be carried out?

Along with other acute hospitals, University Hospital Waterford has prepared a capacity plan to help address the expected increased demand for services this winter. Measures include opening additional beds as required, managing patient flow, appropriate discharges, internal surge capacity both in terms of beds and staff and prioritising diagnostics for inpatients to facilitate earlier discharge.

In addition, University Hospital Waterford and HSE community services will put a community intervention team in place by December for the Waterford region. This is a nurse-led team which works with other health professionals and services in an effort to provide a rapid response for certain patients with an acute illness episode. Such patients require short interventions, usually under 72 hours, in the community or at home such as blood monitoring, fluids or IV. The availability of the specialist team will, I expect, reduce hospital attendance and enable some patients to be discharged earlier.

University Hospital Waterford has an average of 15 delayed discharges. The hospital works closely with HSE community services so that patients are discharged as quickly as possible to appropriate accommodation. Suitable patients on the delayed discharge list are prioritised for home care packages. The hospital also works with community and ambulance services to ensure that weekend discharges are facilitated. While the additional supports provided to University Hospital Waterford do not include additional acute beds under recent proposals, 48 extra beds will be available across the South-South West Hospital Group.

The community nursing unit project at St. Patrick's Hospital is a priority project. A design review was completely recently. At this stage, it is expected that the planning application could be submitted before the end of the year.

I try not to be critical but the Government is failing to deal with the most basic need of a human being when he or she reports ill to a hospital. This is giving them the dignity of a bed in which to receive treatment. As the main hospital in the south-east region, University Hospital Waterford serves a population of about 500,000. Going on figures from the Irish Nurses and Midwives Organisation's trolley watch, its emergency department is frequently one of the most overcrowded hospitals in the country. The figures are reaching new highs. The most recent data shows a massive 278% increase in the number of patients waiting on trolleys in September. Over one weekend alone last month, the accident and emergency department reached full capacity and ambulances had to be diverted to Wexford and Kilkenny, a journey of one hour from Waterford city. I do not need to impress on the Minister the difference an hour can make when somebody is ill, be they critically ill or otherwise.

In recent weeks, the Irish Nurses and Midwives Organisation has made claims that due to the recruitment ban, patient care at Waterford has been severely compromised. I want to hear the Minister's view about what the Irish Nurses and Midwives Organisation has said and trolley watch. Does he accept that there has been a 278% increase in the number of patients waiting on beds and that patient care at the hospital is being severely compromised?

Like all emergency departments or certainly all major emergency departments, the emergency department at University Hospital Waterford experiences overcrowding and this has increased this year. Nobody is denying that. It is worth pointing out that of all the major city hospitals, Waterford performs the best in terms of overcrowding. There are eight people on trolleys in the hospital this morning, four of whom have been on trolleys for more than nine hours. This is the lowest of all the major hospitals. St. James's Hospital and St. Vincent's University Hospital are next on ten but there are other hospitals with 20 and 30. Waterford is actually a good performer in that regard. This is down to very competent and excellent staff in the emergency department, a good consultant team and good management at the hospital. This should be recognised. We are always beating people up in the health service. Where a hospital performs relatively well, it should be recognised.

There is no recruitment embargo. Obviously, hospitals cannot hire willy-nilly but the recruitment embargo was lifted quite some time ago. This is why we have nearly 4,000 more staff in the health service than we had this time last year.

The hospital group is open to any proposals to provide additional beds. It seems that what would work most effectively and quickly for Waterford hospital is the establishment of the community intervention team, which I hope the Deputy will welcome, which is a team of nurses who visit people's homes to check their bloods, give medicines and fluids, including intravenously, thereby enabling people to leave hospital sooner or avoid going there in the first instance.

The Minister's response is interesting. The nurses I met at University Hospital Waterford the day before yesterday told me that the biggest stumbling block to the opening of additional beds to ease the chronic overcrowding is the ongoing staffing crisis. According to those nurses wards are understaffed and they are unable to meet the total needs of their patients. The INMO estimates that Waterford hospital is operating at approximately 120% capacity without the appropriate nursing staff in place. Will the Minister sanction a special needs incentive to recruit nursing staff at Waterford hospital immediately? Will he sanction, as previously requested, the appointment of an additional community discharge nurse at weekends for University Hospital Waterford?

The Minister has referred to the possibility of the private sector being utilised to cope with overcrowding. Is this planned for Waterford in the winter, particularly for elderly people in the community who are frightened and need reassurance that if they present at the hospital over the winter they will not be left on a trolley or chair, in some cases for up to 16 or 17 hours, which, as I said, is undignified and unacceptable in a western country in 2015-2016?

As the Deputy well knows the sanction of staff recruitment at individual hospitals or services is not in the remit of the Minister for Health. Sanction of staff recruitment is a matter for the hospital manager, hospital group and the HSE.

They cannot recruit unless they are given additional funding.

The Deputy is well aware that I do not have the authority to hire, fire, promote or demote staff. I know there is an election coming but standing up in the Dáil Chamber and asking me to-----

That is not fair. The Minister knows as well as I do that additional funding is required for the health services. This is not an election issue.

The Minister has the floor.

I do not like cutting across the Minister.

The Deputy seems to do so quite regularly nonetheless.

The Minister should not be making inaccurate statements. He is out of touch with what is happening.

Deputy Halligan, please, the Minister has the floor.

There clearly is an election coming given the Deputy is standing up-----

The Minister is out of touch with what is happening at Waterford hospital. That is not an election issue, it is a fact.

We are moving on to the next question.

Mental Health Services Funding

Colm Keaveney


4. Deputy Colm Keaveney asked the Minister for Health the reason there was no specific 2016 funding commitment of €35 million for mental health in budget 2016 in line with the programme for Government and previous budget announcements; if the €15 million not provided in budget 2014 will also be provided in 2016; and if he will make a statement on the matter. [36797/15]

Why was no specific funding commitment for mental health announced in budget 2016? A commitment of €35 million was expected but the programme provided for last week in the debate did not outline any budget funding for mental health. Perhaps the Minister of State would comment in this regard.

In line with the programme for Government, my priority as Minister has been to modernise our mental health services and to prioritise new resources to underpin the implementation of A Vision for Change, something that should have been done when we had lots of money but was not. Despite severe financial pressures, the Government has provided additional ring-fenced mental health funding of €125 million between 2012 and end 2015. The additional €20 million provided for mental health in 2014 must be seen in the context of the overall additional ring-fenced funding for mental health since 2012. This amount was considered appropriate given the challenge in recruiting staff to new posts, which has improved since then. The overall additional ring-fenced funding since 2012 represents a significant investment, facilitating the prioritised development and reconfiguration of community mental health teams for adults, children and adolescents. The funding is also being used to enhance specialist community mental health services for older people with a mental illness and people with an intellectual disability and mental illness, forensic mental health services, enhancement of access to counselling and psychotherapy in primary care and for suicide prevention measures.

The details of the 2016 budget will be finalised with the HSE in the context of approval of its 2016 national service plan, which will also outline the total amount of funding for all services, including mental health services, in 2016. In line with the commitment in the programme for Government, an additional €35 million will be provided in 2016 to accelerate the pace of change to develop a modern, patient-centred and recovery-orientated mental health service. This means that despite serious resource pressures overall, the Government will provide funding of €160 million up to the end of 2016, which has been specifically earmarked for new developments in mental health and suicide prevention. This will enable the HSE to continue to develop and modernise our mental health services in line with the recommendations of A Vision for Change.

This question arises out of an exchange between the Minister of State, Deputy Lynch, and the Minister, Deputy Varadkar, with Dr. Sara Burke at a recent press conference at which time the Minister, Deputy Varadkar, when asked about the mental health budget said that because it had not been decided yet and there were dynamic figures, they needed to work it out. He also said that they were within the range. The Minister of State, Deputy Lynch, commented to the effect that the commitment to mental health is for €35 million every year for the lifetime of the Government. Can we take it as a given that €35 million is being provided under budget 2016? The Minister of State might when responding to that question comment on the position on the 2014 shortfall of €15 million. It is debatable whether €35 million was provided in 2012, 2013 and 2014. Let us start afresh. The Minister of State, Deputy Lynch, has given a commitment today that €35 million will be provided in 2016. Is the €15 million not provided in 2014 incorporated in the €35 million for this year?

Perhaps there is something lacking in me but I do not understand the final part of the Deputy's question. The sum of €35 million is being provided this year. The provision for 2014 was €20 million.

The Government committed to the provision of €35 million every year.

The reason only €20 million was provided in 2014 was because of the significant difficulties experienced in recruitment, not only in the mental health service area but across a range of areas. We were in the lucky position of being able to recruit because we were provided with the funding to do so and because we got sanction to breach the moratorium. Unfortunately, because the overall context of recruitment in terms of health was down, we were unable to spend the €35 million. It is as simple as that. I did not jump up and down about it, as it were, because I was aware of the difficulties being experienced in the recruitment phase. We are now having more traction in recruitment such that the €35 million allocation for this year will be spent.

It is important to point out that the focus for the next year will be on old age psychiatry, which sadly has been neglected, and counselling in primary care, which is where most people present. We need to focus our attention on what can be done to stop people having to present at the more acute services and that is what we will do. The counselling in primary care service, CIPC, which was hugely successful last year in terms of counselling for adults, will be developed for people under 18 years.

I will come back to the Minister of State for a further reply.

I thank the Minister of State for her reply. I do not blame her for the recruitment issue but somebody has to take responsibility for it. In the HSE service plan the recruitment of staff was deliberately time delayed because of cuts in mental health service budgets. The Minister of State cannot have it both ways. The difficulties in recruiting arose because somebody made a policy decision not to recruit. That is the difficulty.

The Minister of State, in responding to a question from me over the course of the summer, said that we were 2,900 staff short of the full implementation of A Vision for Change. In 2011, we had a solid commitment on ring-fenced funding on current expenditure. Is the Minister of State satisfied that over the course of the past four years, €35 million per annum was successfully secured? What has been the cumulative current expenditure impact of that with respect to the 2,900 whole-time equivalents?

I am satisfied. I can also inform the Deputy - this has not been said publicly before - that to ensure the €35 million does not get lost in the system, it remains in the Department of Health and is only spent as required. That decision was taken to ensure we retained control of the €35 million. I can confirm to the Deputy that all that money was spent in mental health.

Deputy Halligan has sent his apologies that he cannot be in the Chamber to take Question No. 5.

Question No. 5 replied to with Written Answers.