Other Questions

Hospitals Funding

Alan Kelly


32. Deputy Alan Kelly asked the Minister for Health his plans for Our Lady's Hospital in Cashel in view of the volume of capital investment in the facility. [4409/17]

The date 24 October will long live in the Minister's memory because it was the day he visited the, for want of a better phrase, "phantom hospital" in Cashel. By any standard, it was bizarre, and I think the Minister acknowledged that fact. The hospital being visited by the Minister for Health did not have a single patient. A huge amount of funding has been put into the hospital and that spend will come before the Committee of Public Accounts, of which I am Vice Chairman, in the coming months. However, the real issue is that we have an empty state-of-the-art hospital. Following the agreement reached between the Cashel hospital action group and the health board as a result of the 1996 High Court case, many promises were made by many predecessors of all political colours on the services this hospital would provide, but all those promises have fallen by the wayside. The hospital in Clonmel has one of the worst overcrowding situations in the country, yet up the road we have this incredible facility. Will the Minister tell us today of a plan for this hospital?

That day is etched in my mind because what I saw when Deputy Kelly showed me around was a beautiful facility that was not being fully utilised. The Deputy knows the history better than I, but Cashel Health Campus in County Tipperary, which includes Our Lady’s Hospital, provides mainly primary care services. There is a small residential facility on the site, together with other services including day and outreach services. The residential unit, which includes elderly, mental health and intellectual disability beds, is currently fully occupied.

The development of the campus as a centre for non-acute health care services arose from a decision by the former South Eastern Health Board to centralise acute hospital services for the south Tipperary area on one site in Clonmel. This took place in 2007.

This development of the Cashel campus occurred over two phases. Phase one of the construction work was completed by the HSE in 2009 at a cost of approximately €9 million, which it assures me was within budget. It focused on new residential facilities, including elderly care, mental health and intellectual disability beds, all of which are occupied.

Phase two concluded in 2011 and, according to the HSE, also came within budget. It tells me it had a budget of approximately €14.5 million. Phase two was focused on facilitating day and outreach services in the former Our Lady’s County Surgical Hospital. The Cashel primary care team is based at the campus and a range of services are provided on and from the site, including physiotherapy, occupational therapy, public health nursing, social work and disability services as well as home help co-ordination and community mental health nursing. Upgraded space for the minor injuries unit was also provided for in phase two. Other services include the south Tipperary community intervention team, of which the Deputy will be aware, which is a nurse-led service supporting both early discharge and hospital admission avoidance. There is also an ambulance station located on the campus.

That is the history, but I agree with the Deputy - I am going off script here - that there needs to be a plan to do much more at the site. This is why I instructed the HSE to come up with one. While South Tipperary General Hospital in Clonmel is under significant pressure on an almost ongoing basis, we have this fine facility in Cashel.

On spare capacity within the building, and acknowledging what is going on within it, CHO5 in conjunction with the acute hospital south west group has now developed a vision for the future of service provision in an integrated way which would be based in Our Lady's Cashel campus and, in particular, the old building. This proposal would see the use of areas for the purposes of day hospital assessment services, extended diagnostics and outreach rehabilitation services, which would work in conjunction with both community services and hospitals, provide alternative pathways, particularly for older people, and respond to the current emergency department pressures. This is where we need to get to. The proposal is still being discussed through the ongoing winter initiative weekly meetings that I chair. I believe that these developments would support the acute hospital in south Tipperary in addition to developments that should take place in Clonmel.

The Minister has gone well in excess of his time.

I apologise. I can come back with more detail on it.

Additional information not given on the floor of the House

I have been assured by the HSE that it will continue to explore and maximise the ongoing and future use of the Cashel campus and that services provided will continue to play a significant role in the provision of overall health services within the south Tipperary area. I have requested that the HSE explore what additional supports Our Lady's Hospital in Cashel can provide in alleviating pressure in South Tipperary General Hospital, including pressure on the emergency department. This work is ongoing.

I thank the Minister for his reply. There is welcome news in it given that a plan is to be put in place. However, let us get down to brass tacks. The hospital in Clonmel is under incredible pressure and the accident and emergency unit is overcrowded. It does not have enough space. In the past few weeks, the HSE turned down a request for extra nurses and staff. It turned it down, despite the proposal having been made by the HSE management and nurses together in a process that was independently chaired by Professor Jonathan Drennan.

We have heard all this before. Given commitments that there will be a vision for the two developments in Clonmel, I hope they will be part of the future capital plan the Minister will announce. Two future developments are ongoing there regarding upgrading computerised tomography, CT, facilities to bring in more trolleys and regarding a temporary accommodation facility. However, the taxpayers of Tipperary do not understand why the minor injuries unit in Cashel is not upgraded to admit more people-----

Go raibh maith agat.

-----who are critically ill. They also do not understand-----

I thank the Deputy.

-----why there cannot be some form of step-down facility-----

The Deputy will have a further opportunity.

-----in order to alleviate the pressure.

The fine people of south Tipperary are not alone in not understanding it because I do not understand it either. I did not make the decision in 2007, and neither did the Deputy, that the site at Cashel should be exclusively used for primary and social care. I am sure he wants to acknowledge, as I do, the hard work that is ongoing there. We had an opportunity to speak to the people who work there, and I acknowledge their work, but there is spare capacity in Cashel to do more. The Deputy can say correctly that people have heard this before, but what they have not heard before is that I as Minister for Health expect more to be done in Our Lady's Hospital in Cashel, that I have instructed the HSE to come up with a plan to do more and that the HSE has now come back with what I believe are the beginnings of a plan which sees the potential to do more in Cashel, particularly in day hospital, day assessment and diagnostic care and care of the elderly. This is in addition, as the Deputy said, to the additional measures that need to be taken in Clonmel, some of which are already funded in the winter initiative. As a former member of the Committee of Public Accounts, I welcome the fact that the committee will explore this issue. Regarding the industrial relations issue, while I note the Deputy's concerns, a process is ongoing through the IR mechanism and I do not wish to comment on that.

It is not completely an IR issue, it is a fact that the hospital does not have enough nurses, and the Department of Health needs to acknowledge that, as does the HSE. It is all very well to say the hospital will turn down the request for nurses, but I ask the Minister at least to engage at a level at which we will have a decision sometime soon because the place cannot take it at the moment.

I thank the Minister for his reply. When the decision was made to create the hospital as it is in Cashel, we were promised 25 geriatric assessment unit beds, 20 rehab beds, 15 nursing home convalescent beds, a palliative care unit, etc., so the Minister knows why the people are concerned and do not necessarily believe this will happen. What happens in Dundalk and Drogheda works well. The clinicians in Clonmel have a concern about going to Cashel - I understand that - but clinicians are only one part of the equation. We need to have a plan in which the people will believe, so I ask the Minister to not alone stress the importance of this matter to the HSE, which he has done, but also to publish a plan for this. I am anxious to know where the funds will come from. We need a plan, and I encourage him to publish one. Not alone that, I ask him to do us the service of meeting-----

I call the Minister.

-----me and other public representatives-----

-----with the HSE in the near future-----

I have been more than reasonable. I call the Minister to respond.

-----when this plan is published.

The answer to the last part of the Deputy's comments is that it is a very good idea and I would be delighted to do so. He can therefore take it as given that we will have that meeting of the Tipperary Oireachtas Members. I ask that we give it a few weeks to allow-----

We should meet when there is a plan.

-----the work started already to be done. I agree that there should be a published plan. I will not stand up here and suggest on the record of the Dáil that there is a funded plan for Cashel because there is not. However, there is a review, as the Deputy knows, of capital planning and there are further opportunities to include additional capital projects.

It is rather current expenditure that is required.

That is possible. Current and capital may be required. The Deputy used a very good example of a network in Dundalk and Drogheda, and there are other hospitals in this regard. The whole idea of hospital groups is that different things are done in different hospitals and different hospitals have different strengths. The decision was made in 2007 not to classify Our Lady's Hospital Cashel as a hospital but rather as a primary care unit. I believe this was a mistake and needs to be rectified, so yes, we should publish a plan for Cashel and Clonmel working together and yes, we will have a meeting of the Tipperary Oireachtas Members.

With regard to the industrial relations point, there is ongoing dialogue with the INMO regarding not just issues in Tipperary, but also wider issues ongoing-----

I hope there is a decision soon.

-----as we speak. I hope there is a decision soon too.

The hospital needs nurses.

Question No. 33 is in the name of Deputy Seán Crowe, who has nominated Deputy O'Reilly to take it, and the Ceann Comhairle has approved.

HSE Expenditure

Seán Crowe


33. Deputy Seán Crowe asked the Minister for Health the total subventions paid from the public HSE budget to general practitioners by supplement for employment of staff; and if he will make a statement on the matter. [4570/17]

The question is very simple. I ask the total subvention paid from the public purse to GPs on an itemised basis if possible. I do not expect the Minister to read out all the figures but to give us a flavour of them, if he would be so good.

If I do not have adequate information here for the Deputy, I will revert to Deputies O'Reilly and Crowe.

The development of primary care is central to the Government's objective to deliver a high-quality, integrated and cost-effective health service. The programme for Government, as Deputy O'Reilly knows, commits to this decisive shift within the health service towards primary care in order to deliver better care closer to home in communities across the country, and I recognise that general practice has a key role to play in this context.

GPs contracted under the general medical services, GMS, scheme provide services to people who hold a medical card or a GP visit card and are remunerated for these services primarily on a capitation basis, with a range of additional support payments and fees for specific items of service. In 2015, the HSE made payments of approximately €464 million to GPs for the provision of general medical services for about 2.17 million eligible people, of which €81.6 million represented contributions towards the employment of support staff. Last year, total payments to GPs under the GMS scheme were in the region of €500 million, of which €85.3 million represented contributions towards the employment of support staff.

The Government is committed to ensuring that patients throughout the country continue to have access to GP services and that general practice is sustainable in all areas into the future. I want to ensure that existing GP services are retained and that general practice remains an attractive career option for newly qualified GPs.

I am cognisant, as the Deputy and everyone else will know by this stage, of the need for a new GP services contract which will help modernise our health service and develop a strengthened primary care sector. Health service management has already progressed a number of significant measures through engagement with GP representatives. The GP contracts review process, which has recently recommenced, will seek to arrive at further measures aimed at making general practice an attractive, fulfilling and rewarding career option into the future.

The Minister talks about wanting to make general practice an attractive option for GPs. It would be marvellous if it were an attractive option for practice nurses as well. A total of €81.6 million is spent on staffing, and a further several million - more than €21.5 million, I think - is spent on fee per procedure or fee per item. Does the Minister not think it would make more sense if the HSE directly employed those practice nurses and, to the extent possible, did away with the fee per item? I recall when other health professionals were being paid on a fee-per-item basis that there was much hand-wringing from Fianna Fáil, which I believe was in Government at the time, because the fee per item was not deemed to be good value for the public purse. This is an area where fee per item is rampant. Will the Minister give some consideration to the direct employment of these practice nurses?

The short answer is "I will". I know the Deputy's views on this, and we have had an opportunity to discuss them a little before. I refer to the question as to who employs the staff within primary care as it is developed. I will be influenced by the views of the cross-party group in this regard and the report of that group. The Deputy obviously recognises, as must I, that we currently operate under a GP contract. Schedule 8 of Statutory Instrument No. 233 of 2016 makes provision for the payment of subsidies to GMS contract holders towards the cost of employing support staff, namely, practice nurses, secretaries and practice managers. The rates of these payments are calculated according to a pro rata formula, whereby there is a sliding scale based on a patient panel size of 100 to 1,200 patients. The maximum payment rates apply where a GP has a panel size of 1,200 patients or more. As I said, this is set out in Schedule 8, which I will send to the Deputy. Each patient aged 70 years or over counts as two patients when calculating a GP's panel size for the purposes of these allowance. Finally, where a GP qualifies for supports under the rural practice support framework, he or she is entitled to practice support subsidies towards the employment of a practice nurse, secretary and-or manager at the maximum applicable rate regardless of the size of the patient panel. I will reflect on the Deputy's comments.

For example, the Primary Care Reimbursement Service, PCRS, data for 2015 indicates excisions, cryotherapy and diathermy - basically, the removal of skin lesions - amounted to 156,996 procedures at a cost of nearly €4 million. Given that there will be a renegotiation of the general practitioner contract, there is substantial scope to give direct employment to practice nurses and reform the way the process is paid for. I did not agree at the time when there was hand-wringing about the fee per item but I would be inclined to agree in this case that perhaps the fee per item is not getting the best value for money. The renegotiation of the GP contract gives the Minister and his team the opportunity to examine this.

As I stated, I will reflect on the Deputy's comments and the views of the Oireachtas Committee on the Future of Healthcare because getting this right is very important in terms of the development of primary care. I had the opportunity to address the annual conference of practice nurses recently and I heard from them some concerns about anomalies. They felt colleagues in most other settings across the health service have the possibility of engaging in educational opportunities, which they do not, and I have committed to engaging with practice nurses further on that. It is an important issue. My Department will also publish shortly policy proposals on the further development of the role of the public health nurse and engage with stakeholders and consulting in regard to that as well. Getting primary care right is absolutely about a new GP contract but it also involves a range of other health care professionals. We are at an early stage of the contract renegotiation and the Health Service Executive and the Department of Health have had initial engagement on the broad range of issues with two representative bodies of GPs. It is a very substantive body of work and I expect the negotiations to take the bulk of 2017.

Long-Term Illness Scheme Coverage

Fiona O'Loughlin


34. Deputy Fiona O'Loughlin asked the Minister for Health his plans to include Crohn's disease on the list of long-term illness scheme; and if he will make a statement on the matter. [4627/17]

My question to the Minister concerns Crohn's disease and its first cousin, colitis, which is an incurable lifelong condition. There is a very strong case for that to be on the long-term illness list. We have one of the highest rates of these illnesses and it is growing. There are 450 young children with colitis, which is a matter of grave concern for us.

I thank Deputy O'Loughlin for raising this important matter. The long-term illness or LTI scheme was established under section 59(3) of the Health Act 1970 and regulations were made in 1971, 1973 and 1975 specifying the conditions covered by the LTI scheme. There are no plans to extend the list of conditions covered under the scheme. For people who are not eligible to join the LTI scheme, there are other arrangements which protect them from excessive medicine costs. Under the drug payment scheme, no individual or family pays more than €144 per month towards the cost of approved prescribed medicines. There is a commitment in the programme for Government to try to reduce that maximum monthly threshold under the drug payment scheme and it is something I would like to do in future budgets. The scheme significantly reduces the cost burden for families and individuals with ongoing expenditure on medicines. People who cannot, without undue hardship, arrange for the provision of medical services for themselves and their dependants may also be entitled to a medical card. The Deputy is well aware of the assessment process for the discretionary medical card, which can take into account medical costs incurred by an individual or a family. Additionally, people may avail of a GP visit card, which covers the cost of GP consultations.

The LTI scheme is quite old and has not seen changes in many years. It is a scheme from the 1970s, with regulations from the early part of that decade. There are other ways in which we can try to address some of these issues. The €144 per month threshold of the drug payment scheme may be something we should look at in future budgets.

I accept the list has not been updated since the 1970s and the Minister has clearly indicated there are no plans to review it. That is not realistic and it fails to address the changing medical needs of the population we have now. The Ireland of today is very different to the Ireland of the 1970s and I fail to understand why it should be the Government's policy not to look at changing the list.

A 36 year old lady contacted me approximately three weeks ago who had been diagnosed with Crohn's disease 15 years ago. She continued with her life, working full-time, but when she had a child ten years ago, her condition deteriorated vastly. I accept there are different levels of illness. This lady does not have a medical card despite having a long-term illness. She should be entitled to that. Her husband works all hours but they genuinely cannot afford the medical bills they have. The Minister mentioned the €144 threshold for the drug payment scheme, which is still quite an amount of money that is beyond many people.

This lady's two-year illness benefit concluded in December 2016. There are many people like her. I mentioned some of the figures earlier. There are 20,000 people in the country seeing an impact, with 1,000 new cases being identified every year.

I am very much aware of the plight of people with Crohn's disease in Ireland as I suffer from the illness. I can understand how debilitating it can be to so many people in this country. I understand the financial pressures for families on low and middle incomes in meeting costs of medication. I make the point to the Deputy that in considering how we can better support people with Crohn's disease, there may be better places to look than the long-term illness scheme. This view has been adopted by successive Ministers and Governments. The scheme has been in place since the 1970s and has dealt with a number of conditions, including acute leukaemia, and terms we do not use in this country any more, such as mental handicap, cerebral palsy and mental illness. It covers a range of other issues as well, such as multiple sclerosis and cystic fibrosis.

Working together and examining the cap for the drug payment scheme, which is a commitment in the programme for Government, is one way of addressing the issue. I would be happy to meet either individuals suggested by the Deputy or representative bodies to discuss the matter further.

I thank the Minister for his commitment to try to ensure that people suffering from this debilitating illness may have a better quality of life. It is very important for us to develop a national strategy to tackle Crohn's disease and colitis, as they have a devastating impact on the everyday lives of increasing numbers of people. I mentioned the 450 children in Ireland with colitis, and that represents a 90% increase in cases in children between 2002 and 2012. That is absolutely shocking. We need to have a strategy to deal with the issue.

A survey was conducted that identified the following key gaps in services to patients, which is very important. These are a lack of specialist inflammatory bowel disease nurses, lengthy waiting times for diagnostic tests and a lack of access to gastroenterology specialists and psychological services. I ask the Minister to take note of that and I wish him continued good health in dealing with the matter.

Today is Lá Fhéile Bríde and I wish a happy day to everybody.

I wish a happy St. Brigid's Day to the Deputy as well. The Deputy makes a number of very important points. This condition seems to be rising in prevalence among the population, with an impact on people at a younger age. The Deputy mentioned statistics concerning children and that huge increase is quite revealing in that regard. It is not for me to give medical advice to people but there are a number of actions people can take to help manage that condition. How we can put public information campaigns and strategies in place is something on which I would be very eager to work with the Deputy.

Some of the Deputy's points on access to diagnostics, waiting times, etc., come back to how we deal with chronic disease management and whether we can do more of it in primary care. This relates somewhat to the previous schedule about empowering GPs in primary care to help look after chronic disease management. That is instead of people not finding Crohn's disease or colitis until it is nearly too late and having seen a significant flare-up. I would be very happy to engage further with the Deputy on this and meet people to see how we can put better strategies in place.

I suggest we next take Question No. 41 in the name of Deputy O'Reilly before reverting to the others. There is only one other Member in the House with a question tabled and that is Deputy Kelleher. We can take those two questions before reverting to the others. I am sorry to inconvenience the Minister but perhaps he can find the reply to Question No. 41.

Does Deputy O'Reilly have permission to take Deputy Louise Mitchell's question?

Yes, I do have permission but I believe the Leas-Cheann Comhairle is asking if we can reverse the order of the questions. I do not mind. I am easy.

To be fair, there is only one other Member in the House and there are approximately five questions outstanding. We can take those two and then revert to the original order. Is that agreed?

Does the Leas-Cheann Comhairle want to take the next question from Deputy Kelleher?

Does the Minister have a reply to Question No. 41 with him?

What is the question on?

Question No. 41 asks about the number of elective surgeries cancelled.

Yes, I have the reply to that question.

Health Services Data

Louise O'Reilly


41. Deputy Louise O'Reilly asked the Minister for Health the number of elective surgeries cancelled in each month to January 2017 inclusive; and if he will make a statement on the matter. [4549/17]

My question is fairly self-explanatory. I do not need 30 seconds to introduce it.

I thank Deputy O'Reilly for giving me a chance to find the question and I thank the Leas-Cheann Comhairle for making sure we are all awake.

I thank Deputy O'Reilly for her question and fully acknowledge the distress and inconvenience for patients and their families when elective procedures are cancelled. Cancellation of elective procedures can occur for a variety of exceptional reasons, including because a bed or the clinical team is not available, the patient is unable to attend or because the patient may not be fit for surgery at the time.

Based on data provided by the National Treatment Purchase Fund, NTPF, collated from reports by hospitals, approximately 3,400 elective procedures, on average, are cancelled per month. In 2016 there were typically approximately 53,000 admissions to acute hospitals on a day case and inpatient basis per month.

Public hospitals need to plan, taking account of seasonal pressures and this is an area in which we need to get much better. The national emergency department escalation framework which was agreed with a number of representative bodies and management sets out procedures to be followed in hospitals during periods of high demand for emergency care to ensure that safe care is provided to all patients. The HSE intends to undertake a review of the escalation framework in the coming months to ensure its effectiveness. As the Deputy will know, part of that escalation framework is agreement that elective procedures will be cancelled.

Reducing waiting times for the longest waiting patients is one of this Government's key priorities. In December 2016, I granted approval to the NTPF to dedicate €5 million to a day case waiting list initiative with the aim of ensuring that no patient will be waiting more than 18 months for a day case procedure by 30 June 2017. In addition, the NTPF will be working closely with my Department and the HSE to agree an approach to the remaining 2017 allocation, as well as planning the approach for the significant increase in the allocation to address longest waiting times in 2018.

The HSE is also currently developing a 2017 waiting list action plan for inpatient and day case procedures and for outpatient appointments to ensure that no patient is waiting more than 15 months by the end of October for any such procedure or appointment.

Written Question No. 82 includes a tabular statement setting out details of the number of elective surgeries cancelled from January 2016 to January 2017, broken down by month.

I am sure the Minister is as aware as I am that the full capacity protocol was initiated in one particular hospital on over 80% of the days in question, with 50% being the average across our hospitals. One of the things that happens when the full capacity protocol is activated is that elective procedures are cancelled. One of the other things that happens is that the people who have had their elective surgery cancelled when the previous full capacity protocol was initiated find themselves entering the hospital by the only door open to them, namely the door of the accident and emergency department. We are caught in a cyclical trap. We have elective procedures being cancelled and the people involved have to wait and wait, often in chronic pain. One would have to feel for the bed managers because very often it falls to them to make the phone calls telling people that they will not be coming to hospital for their operations.

Traditionally, surgical day wards were used as a safety valve but that has now become more of a permanent arrangement. I do not see any plan to reduce these waiting lists.

There is a plan to reduce the waiting lists. I have outlined that plan and have also outlined the very specific target of getting the waiting times back to no longer than 15 months for outpatient, inpatient or day case appointments by the end of October. That is about as specific as I can be. The aim then is to enhance the target times further into 2018, recognising that we have €50 million allocated for waiting list initiatives in 2018 on top of the €20 million for this year. This will not all be done through the NTPF. It will involve the HSE developing its own waiting list plan - we have seen the progress it made in that regard last year - and the NTPF implementing its plan too.

As Deputy O'Reilly outlined, we have a system-wide escalation framework in place which has been agreed. The framework is aimed at making sure that when our acute hospitals experience overcrowding in their emergency departments appropriate measures are put in place. It is designed to support our hospital groups and community healthcare organisations, CHOs, in developing integrated escalation plans so that capacity and patient throughput is appropriately managed at a time of excess demand and the most acutely ill patients are seen. I take the point that it is an indication of the lack of adequate capacity. Indeed, it is the reason we need a bed capacity review, more beds and more staff within our health service. Bed capacity and recruitment are two key issues for the Department this year.

The Minister could put the bed capacity review to music and sing it at this stage. We have not seen it yet but the Minister talks about it all of the time.

It is not done yet.

The NTPF is just another sticking plaster in the Government's box of Band-Aid. It is not going to work. It has been proven not to work. I am not asking the Minister to take my word for it; Dr. Sara Burke will tell the Minister that it does not work and does not have any long-term impact. It only works in the short term. It might get the Minister a headline or two but that is about it.

It is regrettable that there is no plan to deal with this issue. There is nothing that will give people comfort while they are waiting. I spoke to a gentleman in Westmeath on Monday night who is waiting to have a hip replacement operation. I could see the pain etched into that man's face. His operation had been cancelled and he was given another date for April. He told me, however, that he has absolutely no faith that he will have his operation in April. The man can hardly walk. He is only one example of the hundreds of thousands of people right across the State who are waiting for care.

There are far too many people waiting far too long for a procedure in Ireland. We all agree on that but what are we going to do about it? Just because Deputy O'Reilly keeps saying that I do not have a plan does not actually make it true. I have a plan. I have outlined that plan. It is funded to the tune of €20 million in 2017, with a further €50 million of funding for 2018. The Deputy might disagree with the plan or might not agree with the modality of it but I do have a plan. The Deputy can keep saying that I do not have a plan to reduce waiting list times. If she says it often enough it might even stick but it is not actually true. The plan is quite specific and it is going to reduce the length of time that people like the gentleman to whom Deputy O'Reilly referred are waiting in the Irish health service. Waiting times have become far too long in the health service. I concede that this is due to a lack of ring-fenced, targeted investment in waiting list initiatives over a sustained period of time.

On the bed capacity review, the Deputy has not seen it because it is still under way. We will have a very clear ask, by the time of the mid-term capital review, in terms of how many additional beds we need in the health service. It is not as simple as-----

What are the terms of reference of the review?

I intend to brief members of the Oireachtas Committee on Health, including Deputy O'Reilly, on the review in the coming weeks and I would welcome her input.

I am sorry to interrupt but I am trying to accommodate as many Deputies as possible. We will now move to Question No. 37. Deputy O'Reilly has been nominated to take other questions and I will get back to her. Deputy Thomas Byrne is next.

Home Help Service Provision

Thomas Byrne


37. Deputy Thomas Byrne asked the Minister for Health the reason for the delay in providing home care services in County Meath. [4361/17]

I will not delay the House. The situation in County Meath and many other parts of the country is that there are a lot of people who cannot get out of hospital or who are in need of home care but the home care simply is not available. Needs are being assessed and people are being told that home care will be provided but when it comes to the crunch, they cannot access it. I have received numerous representations on this issue, as have many other Deputies and I am sure the Minister has too.

As a fellow public representative in Meath, I can confirm that this is an issue that comes across my desk on a weekly if not a daily basis and not just because of my role as Minister of State with responsibility for older people.

To put the issue into context, the overall funding for services for older people this year will be €765 million. This includes additional funding for home care services which is aimed at allowing people to continue to live in their own homes, in their communities and with their families and also at facilitating the discharge of older people from hospitals. In this context, the winter initiative plan for 2016 and 2017 has yielded a significant reduction in delayed discharges with the numbers falling from a record high of 832 in October 2014 to just 436 at the end of last year.

The HSE’s national service plan for this year provides for a target of 10.57 million home help hours to support about 49,000 people. It also includes the provision of 16,750 home care packages and 190 intensive home care packages for clients with complex needs, including clients with dementia who will be supported with co-funding from Atlantic Philanthropies under the Irish national dementia strategy.

It is fair to say that this represents a significant increase on home care in comparison to last year’s service plan, which had a target of 10.4 million hours home help and 15,450 home care packages. This year's plan will see home help hours increase by 170,000 and home care packages by 1,300.

Despite this significant level of service provision, the demand for home care continues to grow. It is important to note that the allocation of funding for home care across the system, though significant, is finite and services must be delivered within the funding available. The level of activity and associated costs must be managed in each of the nine community healthcare organisations, CHOs, in a way that ensures that those with the greatest needs are supported and that the overall expenditure on home care services by the HSE does not exceed the available funding.

County Meath, as Deputy Byrne knows, is part of CHO Area 8.

The 2017 service plan provides for 1,260,000 home help hours and 2,373 home care packages in community health care organisation area 8, including 114 home care packages which, as Deputy Byrne stated, have been allocated to support the acute hospital system as part of the winter initiative. Applications are processed and supports are allocated promptly in line with the greatest need. Where resources are not immediately available, the approved applicant's name is added to the waiting list until such time as home care hours become available.

What is the solution for people in need who are waiting for services? We all know the official line from the Health Service Executive. The Minister of State must deliver on the ground because these services are needed now. People are dying, while others are waiting or are stuck in hospital, which is the root cause of many problems. Will the Minister of State provide an answer for those people? When will they receive care?

I am aware of the difficulties being faced in County Meath, just as I am aware of the difficulties being faced by people in counties Louth, Cavan, Donegal and every other county. It is for this reason that we are developing a home care scheme which will ensure we no longer have such a level of need. Demand currently far outweighs resources and capacity and we do not have a statutory framework to ensure the levels of services provided to people in County Meath are the same as those provided to people in County Donegal or any other area. The process of developing the home care service we hope to deliver is under way. Last year, the Department issued a report through the Health Research Board which examined the position in other countries with similar frameworks or population sizes. Following the publication of the report, we will open a public consultation process to allow people from County Meath and all other counties to have their say on what a home care support system should look like.

While the strategy is being developed, people in County Meath and elsewhere are not receiving the home care service approved for them by the HSE. They do not know what is happening and they should receive an answer. I have made representations on their behalf through parliamentary questions. They badly need detailed answers.

It is important to stress that 1,260,000 home help hours and 2,373 home care packages, including 114 home care packages to allow people to be discharged from hospital, are being provided for community health care organisation area 8, of which County Meath forms a part. We now need to develop a system that will allow everyone to avail of a service that is uniform, regulated and fully funded. Until we have a statutory framework in place, we will not be able to provide such a service for anyone in County Meath or any other county. As the Minister of State with responsibility for older people, this is a priority for me. I want to ensure people in County Meath can continue to remain in their homes and receive support at home.

Questions Nos. 38 and 39 replied to with Written Answers.

National Children's Hospital Location

James Lawless


40. Deputy James Lawless asked the Minister for Health his views on the consistent objections being raised to the location of the new national children’s hospital; and if he will make a statement on the matter. [4691/17]

My question relates to the choice of location for the national children's hospital at the St. James's Hospital site. This decision provoked controversy and a number of groups have made presentations to the relevant committee and contacted Members. Public confidence in the choice of site is not being helped by the lack of a detailed response to concerns expressed about the location. It would be helpful if these concerns were robustly addressed. Perhaps the Minister will be in a position to do so today.

I thank Deputy Lawless for his question on this very important project and I accept the legitimate and strong feelings a number of people, including parents, have expressed about it.

The project to develop the new children’s hospital is an extraordinary opportunity to enhance paediatric services for children. The granting of planning permission in April 2016 for the hospital, satellite centres and related buildings was a significant and very welcome milestone for the project. Independent reviews since 2006 have reaffirmed the importance of co-location of the paediatric hospital with a major adult academic teaching hospital. The Government decision in 2012 to locate the hospital on the St. James’s Hospital campus was made in the best interests of children from a clinical perspective. St. James's Hospital has the broadest range of national specialties of all our acute hospitals and it is appropriate that the new paediatric hospital will be co-located on this site. In addition, the hospital has a strong and well-established research and education infrastructure, which makes it the hospital that best meets the criteria to enable the children’s hospital to achieve our vision of excellence in modern paediatric practice.

Objectors to the location raise concerns primarily about access to the site. I reassure parents that the plans and design for the hospital recognise the need of most families to access the hospital by car, while noting that the campus is better served by public transport than any other hospital in the country.

While I am aware that not everyone agrees with the decision on the location of the hospital, further debate will not create consensus. My priority, as I have stated previously, is to make progress on the new hospital as soon as possible in order that we can ensure children, young people and their families have the facilities they need and deserve. An entire generation of children who were expected to benefit from a brand new national children's hospital have grown up without doing so.

Two paediatric outpatient and urgent care satellite centres will be provided at Tallaght and Connolly hospitals, respectively. Each of these centres will be projected to deal with 25,000 urgent care and 15,000 outpatient attendances each year. Each centre will provide consultant led urgent care by staff at the new children's hospital, with observation beds, appropriate diagnostics and secondary outpatient services, including rapid access general paediatric clinics.

While I appreciate the points the Minister made, I am not sure if they address the concerns raised by a number of groups, including the Connolly for Kids campaign. My party leader has also written to the Minister on this matter. I ask the Minister to respond specifically to a number of concerns about the St. James's Hospital site. With regard to parking and congestion at the site, it is anticipated that there will be 10,000 arrivals and departures at the new hospital using the already congested and narrow roads surrounding the site. It is predicted that this will produce traffic chaos. Evidence from Mr. John Smith, a retired paramedic and ambulance driver who was based at St. James's Hospital for 30 years, suggests the difficulty in accessing the site will lead to avoidable deaths of children. Concerns have also been raised about staff parking, with spaces due to be provided for only eight of every 100 members of staff in a shift. The modal shift from private to public transport required for the hospital to function, as outlined, has never been achieved in any organisation in the world and is, therefore, a bridge too far.

On the question of cost, in 2012, the former Minister for Health and Children, the then Deputy James Reilly, informed the Dáil that the cost of the new paediatric hospital would be €560 million. Five years later, the cost is projected to be closer to €1 billion or almost double the original estimate. This figure does not include information technology and fit-out costs.

The co-location of a maternity hospital has also been cited as a key argument in support of the decision. When is it envisaged that a maternity hospital will be completed on the St. James's campus? Where does it sit in the picture? We need answers to those specific questions.

I note the Deputy's reference to a letter from his party leader. I understand the Fianna Fáil Party is supportive of the location selected and, like me and many others, wants us to get on with building it. I will try to answer the questions the Deputy raised. On the issue of parking, the design of the hospital has recognised the need of most parents to access the hospital by car. For this reason, 675 parking spaces have been provided for families based on current and projected future demand, and 325 parking spaces have been provided for staff. In total, 1,000 parking spaces will be provided, which is three times the number of spaces available for the three existing paediatric hospitals. The parking system will also allow families to reserve spaces ahead of arriving to the hospital and emergency drop-off spaces will also be provided.

The site chosen will not be changed because I want to move ahead and have the hospital built. With regard to the Connolly Hospital site, there is no guarantee that a planning application for the site would be successful. A report by An Bord Pleanála stated that arguments in favour of siting the hospital on a greenfield site on the M50 were flawed because they assumed unfettered access from a national primary route and on-site car parking. The report stated that transport policies did not support such a strategy and there was no guarantee in respect of congestion on the M50.

While we must move ahead and build the new national paediatric hospital, it is important to have ongoing engagement with parents on the issues the Deputy raises. We must ensure that those who are responsible for delivering the hospital convince parents of its benefits because we need the hospital. I recently visited Great Ormond Street Hospital in London. This is a fine, world class hospital with which we have great links, but it is certainly not located on a greenfield site.

I offer my apologies to Deputy Louise O'Reilly. It has been brought to my attention that she has been nominated to take a number of questions. We will revert to Question No. 35 in the name of Deputy Denise Mitchell.

I thank the Leas-Cheann Comhairle. Perhaps we can work on improving communications between the Office of the Ceann Comhairle and the Leas-Cheann Comhairle because I went to the trouble of ensuring I could take these questions.

I take responsibility.

General Medical Services Scheme

Denise Mitchell


35. Deputy Denise Mitchell asked the Minister for Health the action that will be taken by the HSE to address a now common practice whereby general practitioners are charging GMS patients for diagnostic and routine blood tests; the recourse, other than making a complaint, available to patients that have been charged by their general practitioner for blood tests when they are needed; the way a refund can be sought; the action he will take with general practitioners to overcome this issue and barriers to care; and if he will make a statement on the matter. [4560/17]

The question is self-explanatory. It refers to the practice of general practitioners charging patients covered by the general medical services, GMS, scheme for blood tests. The Minister accepted in reply to a previous question I asked that general practitioners should not charge for these tests. I am interested in hearing what precisely he proposes to do to stop this practice.

I thank Deputies Louise O'Reilly and Denise Mitchell for asking this question. There is no provision under the general practice general medical services contract for persons who hold a medical card or general practitioner visit card to be charged for routine phlebotomy services provided by their GP or a practice nurse on behalf of a GP, which are required to either assist in the diagnosis of illness or the treatment of a condition. The HSE has advised general practitioners that where a blood test forms part of the investigation or necessary treatment of a patient’s symptoms or conditions, this should be free of charge for patients who hold a medical card or GP visit card.

Notwithstanding this, I understand that in recent times some GPs have been charging GMS patients for these services. If a patient who holds a medical card or a GP visit card believes that he or she has been incorrectly charged for routine phlebotomy services by his or her GP that patient may make a complaint to the HSE local health office and it will deal with the matter in accordance with the complaints policy.

To achieve clarity on this issue, I have asked that any difference of perspective in regard to the provision of phlebotomy services be addressed in the GP contractual review process. I am pleased that initial meetings with GP representative bodies to progress this work have recently taken place and I look forward to constructive and positive further engagements. From my perspective, the rules under the existing contract are very clear - a GP should not be charging a medical card or GP visit card patient for such blood tests. The HSE's position is that in circumstances where the taking of blood is necessary to either assist in diagnosing or to monitor a diagnosed condition the GP may not charge a patient if he or she is eligible for free GMS services under the Health Act 1970. I understand this position is not accepted by GP representative bodies. To deal with GMS patient complaints regarding charges for phlebotomy services the HSE has put in place an arrangement whereby on receipt of a complaint from a patient or other representative or advocate it imposes a deduction on a GP's practice support subsidy payment and issues the patient a refund of the amount he or she has been charged by the GP for routine phlebotomy. The matter is further complicated by the fact that precise distinctions need to be made between what are deemed routine versus non-routine phlebotomy services. I do not have time to elaborate on that point but there is a difference between the two services.

The Minister said that this matter will be addressed as part of the GP contract negotiations. One wonders what is the point of the negotiations if GPs are not adhering to the current agreement. I would like to draw the attention of the Minister to the following matter. Many GP surgeries, including some in my own constituency, have put up signs advising patients that if they do not want to pay for their blood tests they can go to the hospital to have them done there. We have just spent a good deal of time discussing the pressures under which our hospitals are already operating. It strikes me that something more concrete can be done. Perhaps a message could be issued to GPs advising them that this is not an acceptable practice. We have already discussed the subventions which GPs receive on a weekly and annual basis. It should not be beyond the scope of the Department of Health to put an end to this practice once and for all.

I have already outlined what the HSE will do. In other words, if a constituent of the Deputy or of any other Deputy is charged incorrectly for a service that my Department and the HSE believe is covered under the current GMS contract he or she, or another person on his or her behalf, can make a complaint in that regard to the HSE and it will impose a deduction on the GP's practice support subsidy payment and, more importantly from the patient's perspective, will refund the amount he or she has been charged by the GP for routine phlebotomy services. There is no point pretending - there is a long history and record of disagreement on this issue between health service management and GP representative bodies. It is not for me to speak for either of them but I am aware that in their communications to their members they have asserted a different position. The best place to resolve this disagreement and difference of view is around the table through contract negotiations.

I do not accept the Deputy's view that our GPs do not honour their contracts. I believe they work extraordinarily hard in difficult circumstances. GPs need a new contract too. I have already outlined for the Deputy what the HSE will do in the interim for patients. We need to hammer out this issue as part of the contract negotiations.

It is patiently obvious that GPs are flouting the current agreement and charging for this service. The fact that there is an arrangement in place to address situations where this arises indicates that GPs are clearly flouting the current agreement. It is entirely in order, therefore, that I would question the wisdom of cutting another deal with the same people who as the Minister said are flouting the current agreement and are doing things that they are not supposed to be doing. Perhaps it would be possible to send a message from the Department of Health to GPs instructing them to take down the signs I mentioned earlier because they are causing a great deal of concern. I am concerned that there might be people visiting GP surgeries who are unable to pay for a blood test or to go to a hospital to have it done who may decide to go home rather than present to the doctor for a test that they cannot afford to pay for. The signs need to be taken down. They are not a welcome addition in GP surgeries.

It is of concern to me that people are being referred to hospital for a service that can be adequately provided in primary care and which the GMS contract enables to be provided in primary care. However, I do not want to escalate this disagreement with our GPs in the context of contract negotiations which have already commenced. My Department and the HSE have commenced the process of engaging with GP organisations. I will ask the HSE to reflect on the Deputy's views on the signs and to report back to me on the matter. As I outlined earlier, there is recourse available for patients. I am determined to ensure we have a modern fit-for-purpose contract that GPs and patients can benefit from in the interests of a decisive shift to primary care. That is my priority.

Will the Minister keep me updated on this matter?

I will communicate in writing with the Deputy on the matter.

National Treatment Purchase Fund Data

Jonathan O'Brien


36. Deputy Jonathan O'Brien asked the Minister for Health if the relaunched NTPF will provide data relating to the number, type and value of services and surgeries commissioned from the private sector; the cost and savings to the State of services and surgeries carried out by the private sector; and if he will make a statement on the matter. [4566/17]

As in the case of all my questions today, this question is self-explanatory. It relates to data from the National Treatment Purchase Fund, NTPF. The Committee on the Future of Healthcare has met a number of different organisations on this issue. It appears there is a difficulty in terms of extracting information from the private sector. The private sector not being my first choice for investment and the Minister having chosen to spend taxpayers' money in that area I am interested in hearing if he can provide the information requested.

The Deputy would be upset if we went through an entire Question Time where we agreed on everything. We had better not do that. We have a difference of opinion in regard to the NTPF. I believe it to be an effective vehicle to reduce waiting times for patients and the Deputy believes differently, as is her right.

Reducing waiting times for the longest waiting patients is one of this Government's key priorities. Consequently, budget 2017 allocated €20 million to the NTPF, rising to €55 million in 2018. All NTPF initiatives include procedures to report on the type, nature and cost of treatments commissioned, including controls to ensure quality patient treatment, value for money and efficient processes. The Committee of Public Accounts also examined this matter in the past. My Department will also implement a robust monitoring framework in this regard.

In December 2016, I granted approval to the NTPF to dedicate €5 million to a day case waiting list initiative, with the aim of ensuring that no patient will be waiting more than 18 months for a day case procedure by 30 June 2017. Around 3,000 day cases will be managed through this process and outsourcing of treatment will commence shortly.

In addition to this day case initiative, the NTPF will be working closely with my Department and the HSE to agree an approach to the remaining 2017 allocation, as well as planning the approach for the significant increase in the allocation to address longest waiting times in 2018.

The HSE is currently developing a 2017 waiting list action plan for inpatient day case procedures to ensure that no patient is waiting more than 15 months by the end of October for an inpatient day case procedure or an outpatient appointment. This plan is being developed in conjunction with the NTPF's proposal for utilisation of its remaining €10 million funding for patient treatment in 2017. A similar plan is being developed for outpatient appointments. I expect to make known the details of both plans in the coming weeks. If there is specific information that the Deputy requires I would be happy to share it with her.

The Minister is aware of my view on this matter but I will repeat it. We will never improve the public health service by investing in the private sector, regardless of how many times we do it. The Minister can cross his fingers and wish really hard but it is not going to happen. We will agree to disagree on that point.

The Minister referenced a monitoring framework. Who will monitor this initiative? As I said earlier, the Committee on the Future of Healthcare has had discussions with the ESRI and other agencies on this issue, all of which said that it is difficult to extract information from the private sector for reasons of, as they put it, "commercial sensitivity", for which I have another term, although I do not propose to repeat it here. Perhaps the Minister will outline who will be involved in the monitoring framework and if it will be required to achieve targets on behalf of the public purse. Again, I do not believe this initiative is good value for money. However, we will agree to disagree in that regard also.

I do not believe that we should invest in the private health service instead of the public health service. However, the man who is waiting for a hip operation does not care how we get his operation done. He just wants to know what I am going to do to ensure he does not have to wait longer. While we build up capacity in the public health service we will use the NTPF as a vehicle.

That is the ideological point on which we disagree. I will write to the Deputy with exact details on the monitoring framework within my Department. It is being put in place within the acute hospitals policy division of the Department.

I am not sure I agree in regard to the lack of specificity in respect of the NTPF. In my meetings with the NTPF, I noted it can tell one what one cannot always easily ascertain when one engages with a public hospital, that is, that in return for an investment of X, one secures Y amount of procedures by a certain date. I am happy to engage further with the Deputy, however, and I will write to her on it.

Written Answers are published on the Oireachtas website.