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Dáil Éireann debate -
Thursday, 6 Dec 2018

Vol. 976 No. 3

Saincheisteanna Tráthúla - Topical Issue Debate

Emergency Departments

Acting Chairman (Deputy Bernard Durkan)

The Deputy has four minutes to make his initial submission and the Minister of State has four minutes to reply.

I thank the Minister of State for coming in to address this matter, which is very topical. It concerns our accident and emergency departments and the length of our trolley queues, which are growing year on year. Compilation of the numbers started in 2013. Each year they have increased and each month of this year they have increased. It is a year-long issue now. The Department of Health today produced its winter plan for 2018 and 2019 to try to address this issue and blunt the peak that occurs between December and March every year. However, the peak is just a peak in a continuing escalation of the crisis in our hospital and emergency departments. In March of this year we had a peak of 714 trolleys. Earlier in November we had a peak of almost 600. This is clearly not just a winter problem; it is a year-round problem. There does not seem to be any improvement in it. The winter plan was produced today, 6 December, which is much too late to deal with the problem this year. It addresses issues which should be addressed the whole year around.

How are the Minister of State and his Government going to address the health service? The trolley count is purely a symptom of what is happening within our health service. The problem is not in our accident and emergency departments. It is throughout our health system. Unfortunately, however, it is manifest in the long delays in people being admitted to hospital. We have an aging population and changing demographics. Some 20,000 people reach the age of 65 every year and the population above the age of 85 is due to double in the next ten years. These are the people who occupy our hospital services and take up most of the time. Yes, it is a tribute to our hospital system that people are living into their old age. Nevertheless we have to try to deal with these acute and chronic illnesses.

We must move away from a system which directs every patient to the hospital service. It is the default position. When people get ill, they end up in our accident and emergency departments. There must be a system which prevents that. Sláintecare is a ten year plan that has still not been implemented. There will be a three year run-in period between the start of the implementation of Sláintecare and its effect on our hospital services. What is this Government going to do to address the crisis?

The bed capacity plan stated that there should be an increase of 2,600 beds over the next ten years. That is predicated on the fact that if we start to reform our health service now we will need 2,600 beds. If we do not reform our health service now we will need 7,000 or 8,000 beds. The issue is inefficiency and a need for integration. We need an electronic healthcare record and a single patient identifier. These will be the first steps in trying to bring efficiency and cost-effectiveness, which is most important, to our health service. Unless we start to do that we will continue to have the trolley numbers that we have. Our system is locked and loaded for the next three years. Unless we start to reform, this problem will continue. Unless we start now, in three years we are going to have the same problem but it will be substantially worse.

I thank Deputy Michael Harty for raising this very important issue. I also thank him for his own contribution in the broader area of health. He has made many sensible and practical proposals, particularly in recent years. I welcome the opportunity to address the issues he has raised.

The Minister for Health acknowledges the distress caused by crowded emergency departments to patients, their families and front-line staff working in very challenging conditions in hospitals throughout the country. Hospitals are increasingly operating at or above capacity, with year-round demand pressures that increase in the winter months. According to the provisional data more than 93,000 patients have been reported as waiting on trolleys across the acute hospital system to date in 2018.

This reflects the increasing demand for unscheduled care so far this year, especially among patients in the 75 and over age group. However, it is important to put the trolley figures in context. More than one million people have attended our emergency departments so far this year. From May to October 2018 there was a consistent improvement in trolley figures when compared with the same months in 2017.

The Minister for Health, Deputy Harris, has welcomed today’s publication of the HSE winter plan 2018-2019 which will run from 1 December 2018 to 31 March 2019. The Government has committed significant resources to assist the health services across the winter period and the publication of the HSE service plan outlining how those funds will be spent is to be welcomed.

The Department of Health has been working with the HSE throughout the year to ensure the most effective response to the pressures on our hospital system associated with the winter period. As part of that process, integrated winter preparedness plans have been developed by hospital groups and community healthcare organisations to meet the anticipated surge in demand for healthcare services during the winter months. The plan will run until 31 March 2019 and includes a period of focused action from 17 December to 13 January on nine key hospital sites and their associated community healthcare organisations. Improved integrated working and enhanced community supports are central to the focus period. Bed capacity and home supports are being increased over the winter period.

This is a new and innovative approach by the HSE which seeks to build on the learnings from previous winters and the success in handling major events this year. Importantly, the plan optimises the use of existing resources and provides an alternative to emergency departments for patients, including extended opening hours and expanded services at local injury units, minor injury units and key primary care centres.

A central component of the plan, which is already under way, is the provision of an additional 550 homecare packages over the winter period to help patients return home from hospital with the supports they need. The winter plan will also seek to increase capacity in the first quarter of 2019. The national service plan 2019 will identify the sites for investment and the associated number of beds as well as the agreed capacity programme for 2019.

These initiatives will increase the number of available inpatient beds in the acute hospital system to more than 11,000, a level last seen in 2009. While I accept that the coming months will be very challenging, this plan represents a system-wide response to this challenge across the health service. It will be led at national and local levels by integrated teams representing community and hospital services.

The measures outlined in the winter plan are very good in theory but will be very difficult to implement in practice. They are superimposed on an already congested system which has no spare capacity. Hospital capacity in Ireland runs at approximately 95% to 97%. It is well recognised that a hospital which runs at 85% of capacity or more works very inefficiently, so we are already in a congested system which is working inefficiently. One should not propose putting extra pressure on that system.

The winter initiative proposes reducing the number of outpatient appointments over the period from 17 December to 13 January, but that will further congest the appointments system. More than 500,000 people are waiting for an outpatient appointment but the Government's winter plan proposes extending their wait. It also proposes reducing elective admissions. Our elective admissions run in the region of 72,000 patients. Reducing elective admissions during this period will, of course, free up beds for urgent cases at the winter peak, but that will postpone the calling of patients for elective admissions and extend that waiting list. The plan refers to decreasing diagnostics within hospitals to free up those diagnostics for acute and emergency care but those diagnostic services are already at full capacity.

It proposes discharging patients early, having extra accident and emergency department consultants available and extra consultants on wards to discharge patients. The community cannot cope with the current level of discharges. Our community intervention teams and public health nurses are worked to the bone, but the Government proposes discharging more patients into a system that cannot cope.

It must be acknowledged that attendances in emergency departments are growing year on year and that the health service capacity review indicates that Ireland has among the highest acute bed occupancy rates in the developed world.

The objective of the plan is to ensure the most effective response within available resources to the winter challenges in terms of unscheduled care provision. The four-week enhanced focus period targeting nine sites of concern builds on the experience the HSE has developed in the successful management of recent major events. The winter plan seeks to increase home supports, transitional care beds, and bed capacity in acute and community settings. In addition to winter measures, €10 million will be ring-fenced in the national service plan 2019 to increase bed capacity.

I acknowledge the concerns of the Deputy regarding theory and practice and the capacity issue and reducing pressure on the system. Those are valid points. However, we must deal with urgent cases as a priority.

Taken together, these initiatives will increase the number of available inpatient beds in the acute hospital system to more than 11,000, a level last seen in 2009. Although the focus is often on new and additional measures that will be introduced, it is essential that the health system maximises the use of existing resources and facilities, including model 2 hospitals, minor injury clinics, GP out-of-hours services and primary care centres.

All Members know that the challenges we face are significant and we all want to find the right solutions. We want patient-centred, evidence-based, results-focused sustainable solutions to the challenges currently facing our health services. The winter plan published by the HSE today is a good plan which optimises the use of existing resources. It represents a system-wide response to the challenges the health system will face in the coming months and it will be led at local level by integrated teams representing community and hospital services.

Health Services Funding

Some €346 million was targeted for savings in health in 2018. For a long time, I have been asking how that figure was reached, but I cannot get an answer. It is described as a targeted savings measure. It sounds as though a lot of work went into calculating the figure. However, I have asked very senior figures in the HSE, representatives of the Department of Health and a colleague of the Minister of State, Deputy Finian McGrath, to explain the calculation of the figure and I have not received an answer. The cynic in me thinks that somebody proposed a figure of €350 million but somebody else proposed €346 million because that would make it seem as though some targets had been identified or some work had been done in that regard.

Obviously, the Minister is aware that the target was missed. Why was it set in the first place? If we are to investigate that, perhaps we should begin by examining from where the targeted savings figure came. The phrase "targeted savings measure" brings to mind targets, savings, amounts and measures but all I see is a figure which nobody can explain.

The Minister of State, his Department and the HSE would do well to heed the very wise words of the Irish Fiscal Advisory Council.

The council said the health budget should be well founded and credible. It also spoke about the budgetary process within the health service the Government presides over and described it as suffering from weak planning and weak spending controls. Therefore, in saying this, I have the backing of the council.

The figure of €346 million was a savings target given to the HSE. I have been questioning a number of people on this. The more I question and the more the lack of answers becomes more apparent, the more worried I become that the figure was plucked from the air. I spoke to one of the Minister of State's colleagues about this. The conversation is on the record on the health committee. I must say again that I sincerely hope the Government does not get the figure from the same place as the lads we all heard on the telephone call. That is how it looks to me because nobody has been able to justify to me where the figure came from. Did the Department sit down with the HSE to come up with a figure? Was it just given to the HSE as a target to be achieved? Did the HSE come to the Department with the figure? Everyone I have asked has not been able to tell me how the figure was arrived at. I sincerely hope the Minister of State can tell me how it was arrived at. If so, perhaps he might be able to give me a list of the savings targets. What was targeted? What amount was targeted? By how much did it fall short? We know the target was not reached. That has been established and acknowledged and nobody will dispute that. If the target was not reached, have we any idea why such an overly ambitious target was established given that the health service is underfunded? We know it is underfunded because we were discussing the supplementary budget at a meeting of the health committee only this week. We know the health service is underfunded, yet somebody believes savings of €346 million can be made.

I thank the Deputy for her important question. I hope we can get to the bottom of the issue.

The HSE national service plan set out in 2018 funding for health services totalling €14.556 billion. A sum of €14.411 billion was originally allocated to the HSE by the Department, with €145.9 million held back for new developments, most of which sum has since been released. The national service plan for 2018 included the establishment of a value improvement programme, VIP, which considered how to reduce the costs of delivering services without impacting negatively on either the level or quality of such services. The HSE prepares its annual service plan on the basis of a set of estimates and assumptions. In calculating the VIP target of €346 million in the 2018 plan, the HSE went through a process that considered the level of service it could currently provide with the available funding, the level of activity that could be tailored to fit the funding and what level of activity was almost entirely driven by demand.

The health service is very complex, as the Deputy knows. It is the provider of last resort, the provider of 24-7 services and a place of safety. There are a number of areas, including emergency departments in hospitals, disability, residential placements and similar areas, in which a activity of a certain level will happen even if there is not specific funding for it. I know this from disability crises. The HSE, through its planning process, determined a need for savings of about €346 million. A core national team was established to support the system in delivering the VIP, working as part of the performance improvement management unit. Despite an initial promising start, progress in identifying and advancing proposals, and actually securing the targeted savings, was slower than anticipated. Contributing factors to this were the significant operational management pressure due to the winter surge, an extensive flu season and storm emergencies, in addition to particular calls on the VIP senior team to support GDPR implementation.

The HSE is now putting in place appropriate resources across the system to ensure delivery of progress on the programme. There were three distinct themes within the overall programme. The HSE led on two themes, namely, focusing on a cost-reduction programme at service level and focusing on a corporate value programme. The service-level programme focused on cash-releasing initiatives in 2018, such as reductions in the use of agency services and conversion to full-time permanent posts, where the latter two are local and not linked to corporate-level initiatives, such as the nursing task force, and renegotiated supplies and utilities contracts. The HSE identified a €77 million savings target in this area.

In the corporate value programme, the HSE was tasked with identifying savings and cost reductions across its entire corporate operation. This might include better control of central administrative costs such as travel and better management of supplies. It was envisaged that this programme would identify savings of €119 million. A number of savings initiatives are in progress. Work is ongoing with respect to a number of corporate-level initiatives identified earlier in the year.

Additionally, within the overall VIP, the Department of Health was to work with the HSE within a shared governance and oversight framework on a strategic value programme. This would be a multi-year strategic initiative with the intention of achieving savings of €150 million in 2018 through identifying and implementing savings from productivity, improved models of care, policy implementation and delivery of service reform. To date, the most progress has occurred in VIP theme 1, which had an overall savings target of €77 million. The targeted savings were allocated over acute hospitals and community healthcare organisations, CHOs, and the HSE has indicated that the expected realisation in 2018 will be approximately €60 million, with the acute hospitals largely achieving their targets but the CHOs falling somewhat short.

VIP theme 2 savings are being assessed across all parts of the system, and this review will be reported at the end of the year. There was no progress made on VIP theme 3 in 2018, and this has contributed €150 million to the deficit in the HSE, which amount will be funded via the Supplementary Estimate. It is envisaged, however, that the groundwork undertaken during the year will support and promote the establishment of value-improvement measures in the context of 2019. I hope that goes some way towards answering the Deputy's question.

I did not think anyone could confuse me even more; fair play to the Minister of State. What he is saying in his response is that the HSE, through its planning process, determined the need for savings. Therefore, it identified the need itself. The Minister of State will appreciate that is not exactly what the HSE said to me, but that is fine. It was stated the targets were not hit because of the winter surge. That happens every year, yet it surprised those responsible. They were also surprised by the flu and the storms. Perhaps it is fair enough to have been surprised by the storms but I really do not accept the other two reasons. Having made reference to the savings for 2018 and bearing in mind it is now December, the Minister of State said the HSE is now putting in place "appropriate resources across the system to ensure delivery of progress on the programme". I am not a big fan of having to speculate to accumulate but that is essentially what is being done. Money is being put in so the delivery of progress on the programme can be ensured.

This leads me to another question, namely, the question of how much money is involved. The health service did not reach the target of €346 million for reasons I do not accept as valid but those are the reasons given. Consequently, out of some other budget, money now will be provided to the HSE to facilitate it to put in place appropriate resources across the system to ensure delivery of progress on the programme. The end of the Minister of State's reply refers to a multi-year strategic initiative. As these are targeted savings for one year, a multi-year strategic initiative presumably will have multi-annual savings stacked into it. Does the Minister of State understand why I might be a little confused?

I do. I am confused myself.

Is he in a position to shed any light on it?

I am a lover of detective novels when I get the time to read them. I think Miss Marple would struggle with this. Can the Minister of State identify the amount the Department will now put in to achieve the process that will evaluate how the Department did not achieve the savings? People might be interested in that.

The pot of gold, Minister of State.

I thank the Deputy for raising these very important questions. There are times when I get confused myself. My initial response is that the HSE said there was a need for savings, and the bottom line is that this involves a number of areas, including emergency departments in hospitals. I know from my work in the disability sector that sometimes an emergency case can go from a normal residential place of €80,000 or €90,000 up to perhaps €250,000 in a crisis. Regarding residential placements, there are certain activities for which there is no specific funding. Furthermore, the HSE has indicated to me a series of actions being undertaken to maximise the delivery of the value improvement targets while at the same time not impacting the HSE's ability to deliver on the planned activity levels set out in the national service plan, NSP, for 2018. Delivery of savings is in progress, which reflects the success of the service level initiatives undertaken. The HSE has indicated that the expected realisation in 2018 will be approximately €60 million. Work is ongoing in respect of the number of corporate level initiatives and will be reported by the end of the year. I will raise the other questions the Deputy has asked with the Minister, Deputy Harris, and try to come back to her with an accurate response.

I thank the Minister of State.

The third Topical Issue matter is in the name of Deputy Joan Collins. It is to the Minister for Employment Affairs and Social Protection and is to discuss the delay in proceeding with implementation of the Children and Families Relationships (Amendment) Act 2018. The Deputy has four minutes to make an initial statement.

The Minister is not in attendance, though. I was not informed she would not be able to make it.

The Minister is tied up.

May I move the matter to next Tuesday?

Then I request to do so because, while I mean no disrespect to the Minister of State, I wanted a reply from the Minister.

The Minister is at a European Council meeting.

Will she be back by next Tuesday?

Yes. She will be back tomorrow.

Next Tuesday, then. Is that okay?