Ceisteanna ó Cheannairí - Leaders' Questions

The situation in our health service continues to disimprove with up to one million people on outpatient and inpatient waiting lists and severe overcrowding in our accident and emergency departments on a consistent basis. We learned today that more than 6,000 people who are waiting for elderly care services could be waiting for up to two years. These are just a number of the issues, all of which have been impacted by the chronic crisis in recruiting and retaining qualified consultants. There are 3,176 approved consultant posts in our health service but as only 2,713 have been filled, there are about 463 unfilled qualified consultant posts. Our accident and emergency departments are left without specialist qualified consultants on too regular a basis and there is a chronic shortage across the board in psychiatry across the country. There are other examples. In effect, the shortage of qualified consultants is impacting on the quality and timeliness of care for many patients throughout the country.

There is general agreement that the cuts to new entrant consultant salaries, particularly those introduced in October 2012, constitute the key factor in this chronic inability to attract and recruit consultants to the Irish health service. A cut of up to 30% was introduced in October 2012. This pay differential is a major inhibitor in terms of recruiting qualified consultants. We have an unprecedented number of unfilled permanent posts as a result of that, which is clearly undermining the quality and provision of essential care to patients across the acute hospital service.

The Public Service Pay Commission has confirmed the difficulty in recruiting consultants.

Everybody seems to have identified the pay differential between consultants recruited post 2012 and their colleagues recruited before that. The differential which can be up to 57% is the major factor. When we add the fact that we have 40% fewer consultants than the Organisation for Economic Co-operation and Development, OECD, average we see the impact on the hospital services. For example, in the Dublin Midlands Hospital Group, there are 6,500 new patients waiting to see a consultant urologist. St. James's Hospital has advertised twice and has failed to recruit a consultant. In Cork, approximately 6,000 patients are awaiting outpatient reviews for eye surgery. In a recent survey by the Irish Hospital Consultants Association, IHCA, of 300 recently appointed consultants, post-2012, 70% are seriously considering resigning from their public hospital posts unless the discrimination against them ends. Does the Taoiseach accept that we have a very serious issue in recruiting qualified consultants to the health service? Does he accept that the post-2012 pay differential is a key factor and does he accept this is having an impact on patient care adding to waiting lists and undermining overall quality and what does he propose to do about it?

The Government appreciates and understands that we have enormous challenges in our health service particularly when it comes to access, overcrowding in our emergency departments, the fact that many patients have to wait far too long to see a specialist or far too long for the operation or procedure they need.

There are other truths as well. When we ask 14,000 of our patients, as we do every year, how they rate their experience of our health service, 85% of public patients say they rate our public health service highly, that their experience is good or very good or even excellent. When it comes to patient outcomes, for example, we see big improvements in survival rates for cancer, heart attack and stroke over the past five to ten years happening because of new technology and the hard work of our front-line staff and Government investment and policies behind them. For example, on the issue of overcrowding, today 297 patients await a hospital bed. That is down 24% on this day last year and down 20% on the same day two years ago. If one looks at the HSE special delivery unit, SDU, official numbers, month on month, there has been a decrease in the number of people waiting on trolleys every month since May.

Not in Tipperary.

That of course is of no comfort to anyone who is waiting but it does mean that over the summer approximately 1,000 fewer people were waiting on trolleys than was the case for the summer of last year. If we consider waiting times, yes, there are far too many people on waiting lists but the most important point is how long they wait. People now wait on average fewer than six months for an operation or procedure that they need. There are 50,000 waiting more than three months, most people wait fewer than six months for an operation or procedure. For example, at the end of July 2017, there were almost 8,000 patients waiting more than three months for cataract procedures. That number is down to 4,000. We all get lots of queries about hips and knees. The number waiting more than three months in July 2017 was 2,400. That is down to 1,717. Similarly, there were 2,600 people waiting for tonsil procedures during the summer of 2017. That is down to 1,150. We can see that the investment in the National Treatment Purchase Fund, NTPF, in particular, is reducing waiting times considerably for patients waiting for an operation or procedure. We now plan to bring that approach to outpatients as well, making sure that money actually follows the patient.

The Taoiseach should take a walk out to some of the hospitals.

The budget provides for a record level of investment in our health service, more than €17 billion next year, more than an extra €1 billion than was provided for health last year. There was a protest some weeks ago demanding an extra €1 billion for health. We have provided more than that for next year. We need more and more to make sure that money gets to the patient. That has not always been happening.

The Taoiseach might explain why he did not answer the question. I very specifically focused on the issue of recruitment and retention of qualified consultants. I pointed out that there is a crisis in recruiting consultants because of a pay differential - the discriminatory pay difference between those recruited after 2012 and those before 2012 - and the Taoiseach chose not to answer the question at all.

He did refer to improvements in cancer and heart disease. The cardiovascular strategy of the late 1990s and the cancer strategies and the centres of excellence are the bedrock or foundation stone for the different quality of care in those two sectors.

It was long before the Taoiseach arrived on the scene.

I am glad the Taoiseach outlined the impact of the National Treatment Purchase Fund. He opposed its inclusion in the confidence and supply agreement three years ago. It took us a long time to convince him and his colleagues about the merits of the National Treatment Purchase Fund and I am glad that in some areas, the numbers are reducing. Hopefully over the next year with the budget allocation that will also happen.

The Public Service Pay Commission has acknowledged the difficulty. Does the Taoiseach acknowledge the issue?

The Taoiseach to respond.

In 2005, more than half the posts advertised received between zero and two applications. That increased to 60% in 2016. In Waterford, of 40 approved-----

Go raibh maith agat.

-----consultant posts, 36 are in place, but 20 of these are filled on a non-permanent basis. In Letterkenny 12 out of 18 are non-permanent.

The Taoiseach to respond.

The Taoiseach must accept and acknowledge there is a real problem in recruiting and retaining staff-----

The Taoiseach to respond.

-----in our acute hospitals.

The Taoiseach to respond.

What does the Government intend to do about that specific and very important issue that affects the quality of care of patients?

Deputies, please. Time is a factor.

I will answer the Deputy's question with a straight answer. The Government accepts we have a problem in recruiting and retaining consultants in our public hospital system. What is being done about it? We have a three-year pay agreement, which involves pay increases and pay restoration for consultants, including two pay increases next year and an increment. We have negotiated with ICTU an arrangement for new entrants recruited after 2011-12 to equalise the pay scales. It does not do that fully for consultants, but it goes a considerable way towards that. There will be two pay increases, pay restoration, an increment, as well as special measures for new entrants, all happening next year. Those pay increases take a big chunk out of that extra €1 billion for healthcare next year. We need to ensure we do not allow all the money go into extra pay and pay rises. We also need to ensure there is money for new services, new drugs, new equipment and new buildings.

We accept the Public Service Pay Commission report, which I have read as have the Ministers for Health and Public Expenditure and Reform. The best thing we can do now is to engage with the IMO and the IHCA on what can be done to improve the situation. We also need to bear in mind some realities. We probably need a new approach. We have more doctors working in our health service than ever before, but we are not seeing that matched in an increase in activity in-----

We have too many non-permanent people.

Go raibh maith agat.

-----the number of outpatient appointments-----

We have too many specialists.

Go raibh maith agat.

-----happening and the number of procedures being done.

Go raibh maith agat.

They could be unqualified doctors.

Unfortunately there is no direct link between spending-----

I call Deputy McDonald, who has three minutes

-----and staffing on the one hand, and outcome and activity on the other.

That is because we have too many who are unqualified.

We must observe the clock.

We potentially need a new approach that links pay to outcomes, as is the case, for example, in the NHS and other systems.

If we want four minutes for questions, let them change the Standing Orders. Taoiseach-----

We also need to be realistic that there are hospitals that get applications and those that do not.

There must be some respect for the Chair.

Before I ask my question, I extend our sympathy to the family of the former Deputy, Seymour Crawford, who I understand is being laid to rest today. I offer sympathy to the Taoiseach and his party colleagues. Ar dheis Dé go raibh a anam dílis.

This morning, Care Alliance Ireland published a report on the provision and shortcomings of public provision of home care. Its findings are stark and they highlight a shocking reality facing thousands of our most vulnerable citizens in need of care and support.

The report finds that more than 6,000 people are on waiting lists for home-care packages, a finding that was also communicated to my party colleague, An Teachta O'Reilly, in which the HSE acknowledged to her that the number of people waiting for home-care support stands at 6,118. The report states that people are waiting for up to two years in some cases for home-care support and that the average waiting time in one HSE area is six to nine months.

The report also estimates that there is an 18% gap across the board between the number of care hours being provided and those required. In one HSE area only 60% of hours requested are being provided. The figures are absolutely shocking. They are shocking because services have been cut and they remain underfunded.

The report finds that there was a reduction in services between 2009 and 2012 and, most acutely, between 2011 and 2012, under a Fine Gael and Labour Government when there was a reduction of 1.5 million home-care hours.

Despite the service remaining underfunded, no additional resources were allocated for home care supports in next year's budget. That illustrates a complete disregard for the value of home care. As the Taoiseach will be aware, it is one of the most important services provided within the public system. Care delivered in the home is the preferred form of care for most people and their families, particularly older people. The vast majority of older citizens want to live independently and comfortably in their own home for as long as possible. Home care packages are also vital for many with a disability or in medical need.

Providing these packages makes absolute sense socially, but also economically. It saves the State money and frees up resources. Failure to provide adequate care through these packages leaves people stuck in hospitals or forced into residential facilities when they could return home. This has a knock-on effect, contributing to the trolley and waiting list crises in our hospitals as beds are occupied by those who want to, and who are ready to, return home but who are prevented from doing so.

The HSE has said home support services must be delivered within the funding available. The logical solution is to make more funding available. Will the Taoiseach revisit his allocation of funding to provide for additional home care packages next year? Will he, in line with the report's recommendations, move quickly to delivering a fairer, better home care support service?

I thank the Deputy for her words of condolence to the family, friends, constituents and party of Seymour Crawford, who is being buried this afternoon in Monaghan. I had the opportunity to visit the house yesterday. Many of us served with Seymour for a period. He truly was a wonderful public representative, a gentle giant and a good friend to many of us. There will be an opportunity at a later date to pay tribute to him in a more substantial way.

With regard to home care, the Government, HSE and health policy very much favour it. It enables older people, but not just older people, to get out of hospital much quicker. In many cases, good home care means they never have to go to hospital at all. It also means people who need it, particularly elderly citizens, are able to spend much more time in their homes before they have to go into long-term residential care.

The Deputy referred to 2011 and 2012. I have no doubt she is correct in what she said in that regard but, of course, it is not 2011 or 2012; it is now 2018. There has been a considerable increase in resources and funding for home care during the past three years. In 2015, for example, the budget for home care was €306 million. This year it is €420 million, representing an increase of more than 30% in the past three years alone. An additional €1 billion will be provided for health services next year. That has not yet been allocated. I am certain some of it will be allocated for extra home help and home care packages. We need to make sure, however, that the €1 billion gets to the patients. We need to come together as a House and make sure it does not get lost in red tape and in meeting pay demands and other demands. We must make sure it goes to the patients and is allocated for extra home help and home care packages, new medicines, new services and new equipment. The big challenge we face collectively in this House over the next couple of months is making sure the €1 billion, or as much of it as possible, gets to the patients, which means better care for them, including extra home help and extra home care packages.

In 2018, the HSE service plan provided for 17 million home help hours. This allocation provided home help to 50,500 people. We acknowledge absolutely that there will be a need for additional resources next year; that is planned. We acknowledge that there are inconsistencies in waiting times from one region to the next. In some places, the waiting time is as little as 24 days while, in others, it is six to nine months, on average. It is, of course, a policy dilemma. When one allows for regional autonomy, there will be regional variation, but we need to bear that in mind.

In line with the Sláintecare plan and the Sláintecare implementation strategy, we plan to develop a statutory scheme for home care, very much using the fair deal model. People can now apply to the scheme for long-term care. If they qualify for it, they will get long-term care in approximately four weeks but, because we do not have a statutory scheme of that kind for home care, some people may get home care within 24 days while others may have to wait for six to nine months. We believe we now need to establish a statutory scheme for home care that is not the same as the fair deal scheme but that works on that model, which has proven to be a success.

Before the Deputy responds, I wish to say ar lámh deis Dé atá anam Seymour Crawford.

All of us are agreed on the necessity of home care packages, not only their social necessity but also their economic common sense. That is not a matter of controversy. The report is very clear and the figures are not wrong. The 1.5 million hours cut from the system have not been fully replaced and there is a 16% deficit in the hours required. The report also proposes how that might be funded, saying that somewhere north of an additional €100 million must be dedicated to the service. Will the Taoiseach do that? I am sure he is familiar with this through his constituency work. I have constituents who have a home care package that amounts to half an hour per day. This is for people who are sick or have serious disabilities. One would barely have one's coat off and the kettle switched on in half an hour. It is a derisory allocation.

The system has been starved of resources and the past damage has been done. Now, the repair work must start. Rather than make vague assertions, will the Taoiseach dedicate the resources necessary to meet and close that 16% gap in service provision?

The HSE service plan for 2019 is only currently being drafted and is not finalised. As Head of the Government, I want to ensure that the extra €1 billion of taxpayers' money we are putting into the health service next year, or at least as much of it as possible, gets to the patients. That means additional home care packages, new medicine, new equipment and new buildings. I would welcome Sinn Féin's ideas as to how that €1 billion should be broken down and spent. It is not good enough for a serious Opposition party, certainly not one that wishes to be in government, to come here every week demanding more funding for all forms of health care and it all adding up to €2 billion or €3 billion. There is only so much that can be dedicated to the health service next year. There is an extra €1 billion, which is a big increase. I hope the Deputy shares my desire that priority be given to patients and that the money goes to patient care and additionality, not to paying more for the same. More of the same is not the solution for our health service. There has been an increase in spending on home care from €306 million in 2015 to €420 million, a massive increase of €120 million in three years. We are not seeing the results of that for patients. That is why we need a new system and a new way of providing home care. We believe a statutory scheme is the way to go, in line with Sláintecare, not just more of the same.

My question arises from direct contact with people who have suffered at the hands of the State and religious organisations and who, unfortunately, are being traumatised again by the State, particularly through their contact with Caranua. Significantly, I pose this question on the same day that we await the Taoiseach's decision on the mother and baby home in Tuam. I sincerely hope he will decide on a full excavation and exhumation of the site with a view to maximum information being made available. This is also the day we have learned, quite incredibly, that the Government has changed the application process for compensation for women who worked in Magdalen laundries. It now requires them to specify the number of weekly hours worked, completely disregarding the spirit and content of the Quirke report.

Similarly, there is the case of Caranua and the rationale and content of its purpose. It was established to provide support to people who experienced abuse in institutions as children. In 2013, the chairwoman said there should be smooth and uncomplicated access to the fund. The chief executive officer, CEO, said it was about putting survivors at the heart of the process. It was always a defined group with a defined amount of money. It was meant to be rolled out transparently and with minimum bureaucracy. Unfortunately, nothing could be further from the truth. It is a classic example of the institution becoming more important than the people it was set up to serve.

Survivors have confirmed that its mode of delivery has added to their abuse.

Rather than rolling out a fair and transparent system based on a comprehensive plan the applicants have, at best, been subjected to an ad hoc, haphazard and unprofessional system which has succeeded in traumatising them again. People have come to Deputies at the end of their tether. Among the issues raised are the constant changing of personnel, no timely response on the phones, no timely response to letters and no giving of information relating to rights, especially the right of appeal. In essence, there has been a recreation for the applicants of the abuse suffered in institutions. Caranua is certainly misnamed. Rather than being a new friend, it is the old friend, the seanchara, with an arbitrary use of power, which is perfectly encapsulated in the way in which the arbitrary limit of €15,000 was brought in. This was retrospective and left applicants in limbo with no knowledge as to their rights. We now have an appeals system and I pay tribute to the appeals officers who have highlighted the concerns. One appeals officer is working with a significant backlog. Having recognised the need for it, will the Taoiseach confirm that he will immediately put in an additional appeals officer? Will he examine what is happening on the ground and take a hands-on approach to stop injustice being repeated when it is unnecessary?

On the mother and baby home in Tuam, the Minister for Children and Youth Affairs, Deputy Katherine Zappone, will make a statement at 3 p.m. It is fair to say that the she has put an enormous amount of work into studying this matter over the past two years. The Cabinet accepted her recommendations today. I would like to give the Minister the opportunity to outline her recommendations in detail at 3 p.m. when she is able to do so.

With regard to the Magdalen redress scheme, the Government's intention is to comply with and implement the Ombudsman's recommendations on the scheme, which is to extend the scheme to a wider group of women who did not live in the Magdalen laundries but who worked in them and lived in adjacent institutions. In doing so, we operate as a Government in good faith, accepting the Ombudsman's recommendations and trying to implement them. The scheme is, however, based on the amount of time a woman spent in the institution and the number of hours she worked there, so it is necessary to ask that question. This is the way the scheme works; it is linked to the amount of time spent in the institution and the number of hours worked there. This is how the financial award is calculated, which is the fairest way to do it.

Caranua as a body has, at this stage, allocated over €100 million to people who needed additional practical supports, often advice and counselling and in some cases assistance to modify their homes and with their healthcare. Many of the people who received some of that €100 million have put it to good use and it has helped them in their lives. I absolutely appreciate, as with any system or application process, that it can be difficult. It can be frustrating to fill in forms and it can be difficult to answer questions. Sometimes people do not get the answer they want. This is why we have an appeals mechanism.

I will have to give consideration to the issue around an additional appeals officer. I do not know whether that is necessary, but I will certainly speak to the Minister for Education and Skills, Deputy McHugh, about that. If the Deputy knows of individual cases of people who have had a bad experience of Caranua, perhaps she could pass them on to the Minister or to me and we will try to check them out. As is always the case with any application system, there will be people who are satisfied with how it worked and with the award they received, and there will also be people who are very dissatisfied. This is why we have an appeals system for them.

I welcome the Taoiseach's open attitude, but this is way beyond complaints. There has been a large number of appeals, 66% of which have been upheld in one way or another. That figure speaks volumes. Second, the administration of this scheme has become abusive in itself. This issue has been raised by me, by my colleagues last week in the Chamber in a Topical Issue debate, and by various Members through parliamentary questions. A Private Members' motion also highlighted the difficulties on the ground. It is not a matter of certain individuals being frustrated. The system is unjust, arbitrary and unfair and it recreates the abuse that was suffered when these applicants were children in the institutions.

The need for an appeals officer has been clearly set out by the appeals officer's report, which gives the number of appeals. In one year 87 appeals were received in the period and 140 were carried over. There has been a carry-over of 34 into this year, along with other appeals. The most basic requirement at this stage is to have a second appeals officer so that people bringing appeals can be dealt with with dignity.

Second, on the right to know that one can appeal, the Taoiseach should at the very least ensure that information is crystal clear. For the third year in a row the appeals officer says that it is not clear.

Once again, it is important that we remind ourselves of the purpose of Caranua. It was established to provide practical and financial support to survivors of residential institutions. It has already provided support in the region of €100 million to survivors and former residents of those institutions to help them with their lives. It is certainly not designed to abuse anyone; it is designed to help them. It has helped a lot of people, many of whom I have met in the course of my work.

On the Deputy's two specific asks, I will speak to the Minister, Deputy McHugh, about this. I absolutely agree that if people are not informed that they have a right of appeal, they should be. That would seem to me to be elementary. When it comes to any application procedure people should be made aware of the option or right to appeal. I will follow up on that. I cannot, here on the floor of the Chamber, say whether a second appeals officer is necessary but I will certainly examine the issue.

There is growing concern about the proposed new national maternity hospital. That concern is based on two issues: the question of ownership and the question of ethos. On ownership, most people simply cannot fathom why the State would even contemplate gifting a valuable asset worth more than €300 million to a private entity. That must stop. Does the Taoiseach agree?

There is also grave concern, especially among women, about the fact that it is proposed to transfer ownership of the new national maternity hospital - and it will be called the National Maternity Hospital - to a private religious entity, the St. Vincent's Healthcare Group. It is wholly inappropriate that this should be the case in this day and age. The fear, which is very well founded, is that women will be denied access to the full range of healthcare services provided for under the law. We know that religious orders have a special place in the Constitution. Under Article 44, a religious order can control what it owns. When the Supreme Court has been asked to interpret this part of the Constitution it has always supported the right of the order to protect its own ethos. We know that when it comes down to deciding the ethos of Elm Park the Constitution will have to prevail and the order will win out.

The Mulvey report was a brokered deal done behind closed doors between two private institutions, St. Vincent's and Holles Street, with no reference at all to the public interest but the Minister, Deputy Harris, continues to blindly maintain that the Mulvey report can provide a solution. What is the status of this report now? Surely it is redundant.

In May 2017, the Minister for Health asked for a month to get to grips with the crisis facing him. He has now had 17 months and he has not managed to square this circle because it is simply not possible. Can the Taoiseach now give an undertaking that the new national maternity hospital will be taken into public ownership as a condition of public funding; that the more than €300 million which has been earmarked for the new build will be conditional on this change in ownership; and that the new national maternity hospital will be governed by a new secular charter which is fit for the 21st century?

The Government is committed to the national maternity hospital relocation project. We want to see it go to tender, if not this year certainly next year and we want to see it go to construction next year. It involves the development of a new maternity hospital on the campus of St. Vincent's at Elm Park and also improvements to that hospital. The new hospital will be funded by the State and is included in Project Ireland 2040. The hospital will have full operational and clinical independence. We intend that it should apply the medical ethics of our State and our Republic and not those of any religious order. The development will represent a flagship project of the national maternity strategy and will constitute the largest single investment ever made in maternity services in Ireland. However, it is essential that the legal and governance arrangements associated with this very significant State investment are robust. Considerable work is under way and has been undertaken to develop a legal framework for this project to protect the public's significant investment in the new hospital. This legal framework will also underpin the operational and clinical independence of the new hospital from St. Vincent's. Once finalised - and it has not been finalised yet - the proposals will be subject to consideration by the Government, the national maternity hospital itself and St. Vincent's Healthcare Group. I assure the House that patient care in the new hospital will be delivered without religious, ethnic or other distinction and that any medical procedure which is in accordance with the laws of the land will be carried out there.

It should also be said that the model of stand-alone maternity hospitals is not the norm internationally. Government policy is to co-locate all remaining maternity hospitals with adult acute services to provide the best clinical outcomes. This has already been done in Cork, for example, so we want to have it done in Limerick as well with the relocation of St. Munchin's to the University Hospital Limerick site at Dooradoyle, the Rotunda to Connolly Hospital, Blanchardstown and the Coombe to St. James's Hospital where it will be trilocated with the national children's hospital that is now under construction.

With respect, I put it to the Taoiseach that he is not in a position to give the guarantee he gave here today. It is simply not possible under the law as it stands to give that guarantee. This is not about protecting an investment; it is about ownership. When it comes to ownership, the Constitution will always trump any agreement that has been done between the Government and a private religious entity. It is somewhat ironic that the Minister for Health recently set up a group to examine the strange relationship between voluntary hospitals - especially those that are religious based - and the State and to make recommendations for how that relationship can be renegotiated in the future. It is ironic that he looks as if he is about to take steps to repeat the mistakes of the past without having regard to any lessons learned.

In light of what the Taoiseach has said today, I am asking if he will give an undertaking that any draft agreement that is proposed to be done with St. Vincent's Hospital in respect of the national maternity hospital will be brought before the House before it is signed off on by Government. People simply cannot believe, on the evidence of the Constitution and the laws we know of, that what the Taoiseach is proposing is actually possible.

As it is still a matter under discussion involving the Department of Health, the national maternity hospital and St. Vincent's Healthcare Group, I am not in a position to give commitments until we know what the outcome will be. We have a good precedent in the national children's hospital, which I was involved in and which the Minister, Deputy Harris, has also been involved in. We took Our Lady's Children's Hospital, Crumlin, which is a voluntary religious associated hospital-----

It is a different situation.

-----Temple Street Children's University Hospital, which had an association with a religious body in the Mater Hospital, and the National Children's Hospital in Tallaght, which had an association with the Church of Ireland, and have taken them together and put them on a site that is publicly owned and which will be under a statutory board. We have a good example already of how we have taken three hospitals that had a voluntary religious ethos and put them together on one site with a statutory board. This is a matter that is not yet resolved but if the Deputy can see what we have done with the children's hospital, it is the kind of outcome we will be looking to achieve with regard to the national maternity hospital.

We have quite a number of voluntary hospitals in Ireland. A lot of our hospices are run by voluntary bodies which are often associated with religious bodies. We should not make an automatic assumption that it is always a bad thing because there is a long history and tradition of care there and many people have a very high regard for some of those hospitals.