I welcome Mr. Kevin Kelly, acting chief executive officer of the Health Service Executive, to discuss the executive's progress report. He is joined by Mr. Pat McLoughlin, national director of the National Hospitals Office, Mr. Aidan Browne, the executive's national director of primary, community and continuing care services, and Mr. Diarmuid Collins, the executive's national director of finance. I ask Mr. Kelly to comment on the HSE report.
Health Service Executive: Presentation.
I will provide an update of what has happened since we last came before the committee. The executive went live on 1 January. The deadline was tight and an industrial dispute in December brought our numbers down to three, namely, two colleagues and me. That continued into January but it is now behind us and we are up and running.
My major concern was to ensure that when we went live, system delivery was protected. We have achieved that by running a parallel system, which will continue until the end of June at the latest, where the former chief executives, now known as chief officers, are still running their areas. We are putting in place the full structure that will take over the service, which will be based in Naas.
Much of the structure is already in place. All of the national directors have been appointed and we have almost completed interviews for the associate directors, the hospital network managers and the four regional directors. We will then recruit in respect of the 32 local health positions.
There is frustration with the perceived pace of progress but this is the largest programme of change in the history of the State and we must do it step by step or the consequences for service delivery could be serious. That creates anxiety in the system and, unfortunately, we cannot deal with much of it because we must move carefully.
In parallel with putting the structures in place, my colleagues in the National Hospitals Office and in primary, community and continuing care are stressing population health. It is a long-term project but it is critical and will dominate much of what we are doing in health promotion and protection. Under shared services, we are putting together administration activities where there are potentially significant savings. Work is going on in all of those areas and my colleagues will discuss that with the committee. We are working out our thinking and our policy positions.
We have completed the national service plan, which the Tánaiste introduced in the Oireachtas last week. Our next obligation under the legislation is to prepare the corporate plan which we must present to the Tánaiste by the end of June. That is where we will flesh out, at board level, our policy going forward. We will give a clear view of how we see the world and we will debate this with the committee during the next three years.
We are focusing on value for money. I have already established a unit within my office, headed by former chief executive, Maureen Windle, to examine every area of the service and identify where we can achieve savings without affecting frontline delivery. Due to our sheer size, we now have leverage and are in discussions with many suppliers who were previously supplying on a multiple basis across the 11 health boards. By dealing with them nationally, we are using our buying power to achieve savings.
As a result of the scale of change and its implications for those involved, we are putting extra resources into how we deal with the unions, particularly under the partnership umbrella. Working in partnership is critical to achieving seamless change. Communications are an issue internally because many of the 100,000 direct and indirect employees do not have access to e-mail or the Internet. Therefore, it is still a challenge to put across what is happening.
There is a perception that this is simply about reorganisation but the reality is totally different. We must reorganise at the beginning. I have consistently stated, however, that if this is just about reorganisation, we will only achieve a minimum. We have set out three tenets by which everything must be measured. Our work over time must improve the patient-client journey, we must create a more empowered and better working environment, with less bureaucracy for staff so we can free them for frontline delivery, and we must deliver value for money for the Government. I am optimistic that we can achieve this. I am an outsider, I am new to the health service, but, from travelling around the country, I never cease to be amazed at the quality and level of best practice that exists everywhere. We want to make that best practice the lowest common denominator.
Last year we prepared a number of patient-client journeys that track the experience of individuals and families, on the primary or acute side, with the service. These journeys are fragmented and I believe that, without investing more money, we can bring about change. It will not happen overnight and will take time but I am optimistic that we will meet those three tenets. If they are not met the whole exercise will not have been worthwhile.
I am optimistic, from the work we have done to date, that, although it will take time because of the sheer scale of the work, we will be able to improve things from the patient-client and the staff points of view.
I thank Mr. Kelly for coming before the committee. We appreciate that he is very busy.
The point has been made that this is the biggest programme of change in the history of the State but it is difficult for us to see where the changes are occurring. We are informed that it is not just about management or organisational change. However, it seems to be only about that. While I accept that the three aspirations exist, there is no clear link between what is being done and realising those aspirations.
This is very much about reconfiguring the way that the health service is managed and administered. As I understand it, that is all it is about. Perhaps Mr. Kelly might give specifics about what changes have been made in terms of the patient to whom he referred whose needs must be met. What changes will be made, in terms of the executive's service plan, within the next 12 months? Perhaps there are three or four initiatives which Mr. Kelly is aware have happened or will happen.
I am somewhat surprised that all we received about the service plan was an e-mail. I thought we might have got something more concrete but that is all I received. Apart from the existing level of services outlined in the executive's service plan — which is what all service plans seem to contain — there are two other items. The first is the provision relating to services for those with disabilities, which was announced in the budget, and the second is that concerning accident and emergency services, which was announced by the Minister. The plan contains nothing other than these provisions.
The biggest change — it is an important one — that has occurred is that there is practically no accountability in the system. When children were taken from their parents in the former Northern Eastern Health Board area, there was no accountability system in place to which public representatives, community leaders or whomever could react. I would like Mr. Kelly to elaborate on that because that is a deficit in the system. I opposed the proposals in the Bill because I do not believe they go any way towards meeting that deficit. My conviction is that within ten years we will reinstate the health boards. It is, however, a personal conviction. I would like Mr. Kelly to speak about the issue of accountability.
I would also like Mr. Kelly to refer to the issue of manpower. When I visited Tralee Hospital, I discovered that there is an accident and emergency consultant there who has no senior house officers. There are only junior house officers and the consultant. One oncologist left the service in the former Southern Health Board area because of pressure of work. I have no doubt that something similar will happen in the accident and emergency departments. There is great pressure on the individual to whom I refer because he is the only accident and emergency consultant in that busy hospital. He has no registrar and he will suffer burn out. How does the executive propose to deal with this matter during the current year?
How is the executive resolving the issue of leakage of doctors in primary care from disadvantaged areas? Incentives must be put in place. The incentives are in place to attract doctors into wealthy areas. Teachers have been assigned to disadvantaged areas with additional supports. What will the executive do to address that leakage of doctors? How will it resolve the GP-only cards issue and when will it be resolved?
The accident and emergency crisis was defined by the Tánaiste as being the issue upon which she would be judged. We watched with great interest when she made the announcements in November about what she would do. The message was reinforced by spokespersons in the HSE who said to the media that if matters have improved significantly by March, it will be a judgment on the service. Matters have not improved significantly and it is now April. I have great respect for Mr. Pat McLoughlin. He is good at delivering a message but nobody believed him when he appeared on television. The only thing that has happened is that the weather has got better and the pressure has lifted slightly after the winter. Why have the measures to deal with the accident and emergency services taken so long to implement and why are they not delivering?
How will the executive produce the medical assessment units when someone like Dr. Gilsenan said in the media this morning that it will cost €17 million in Beaumont and the HSE only provided approximately €2 million to €4 million? It is difficult to know how these issues are being practically addressed. People's cynicism is quite extensive at this stage.
I will answer some of the questions and then pass over to my colleagues. In terms of the accountability issue, the Tánaiste plans to introduce legislation to deal with it. We are close to setting up the four regional offices. It is through those offices that there will be liaison and dialogue with public representatives. As to what form this will finally take, that is still being discussed. It is obviously for the Tánaiste to bring this issue to the Oireachtas.
In terms of accountability in the particular case to which the Deputy referred, that case was heard in camera in the courts. I cannot comment specifically on it but I was personally involved in terms of being briefed in detail on the background of the case. I am extremely satisfied with the professionalism with which it was dealt — the way in which all professionals in the north-east area handled that case. It is an extraordinarily sad and difficult case.
The executive lost the case.
The Deputy can consider it in terms of losing and winning. We followed the advice we received from our professionals to the effect that we had to take certain actions. The courts took a different view but if we had not followed our professional advice, I could not have come before the committee today. I was thoroughly briefed on that case. We had no option but to follow the advice of our professional people on the ground. The case was heard in camera and it is sad and tragic. The pressures the family in question is under are enormous. We are deeply sympathetic to the family and we are still in dialogue to try to find additional ways of helping them. If I came to the Deputy and said that I ignored the professional advice I was given, that would be totally unacceptable.
In terms of the position vis-à-vis accident and emergency services, Pat McLoughlin is working actively on that, particularly on the ten-point plan, but there are many other areas we are examining. I wish to make an overall point, which I am not putting forward as an excuse because it is the reality, namely, that the executive has only been in existence for three months. We must put in place the necessary structures to deliver services on a national basis. Once we have done that, and much work is being done in the background, we will be able to make an impact on delivery on the medical side in its broadest sense. That must be our sole purpose. This is not about reorganisation. There is no point in going through all this pain and effort if we are simply going to reorganise. I return to the three tenets, which guide everything we are doing. The plan will be a failure if we do not achieve those tenets. I will ask Pat McLoughlin to outline the position regarding accident and emergency services.
Mr. Pat McLoughlin
I will deal with some of the issues concerning accident and emergency services and the associated matters relating to manpower.
We inherited a system which does not have regional self-sufficiency for services. There is a high dependency on the eastern region in terms of the provision of acute services, particularly for patients from outside that region. This is markedly so in the area of oncology. Individual boards gave priorities to oncology or surgical services and we have a map of services that shows a lack of equity across the system. For example, the former Southern Health Board had two oncologists, the former South Eastern Health Board, of which I was CEO, had deliberately prioritised that service and had three oncologists but there were other services that were not as well developed as similar services in the former Southern Health Board.
We inherited a situation whereby different priorities were developed by different statutory bodies. Almost 50% of consultant manpower is based in the eastern region, despite the fact that its population is approximately one third of the population of the country. There is a huge dependency on the eastern region for services. We have begun the process of trying to map out where we should develop services outside the eastern region to ease the pressure on it and to ensure that there is equity of access and regional self-sufficiency.
In the past, Comhairle na nOspidéal would have decided the posts in particular specialties that were needed throughout the country. However, the resourcing by individual boards may not have followed that degree of prioritisation. I have asked Comhairle na nOspidéal, during the remainder of its term, to revisit the reports, examine them and advise us as to where services should be developed from the point of view of regional self-sufficiency and equity of access so that we can begin to address that issue.
With regard to manpower in accident and emergency services, I accept the point made if one considers it from the point of view of an individual hospital or consultant. However, the Government prioritised that speciality. The number of accident and emergency consultants in the hospitals has tripled since ten years ago. The Government has invested significantly in that speciality and there is an increase in manpower.
As regards the ten point plan, I never said the situation would have improved by March. I said it would be improving.
Somebody said it.
Mr. McLoughlin
We said that people would begin to see the impact after March when we had contracted for beds generally in the private system. We made it clear that, given the scale of the investment, we were obliged to go through EU procurement. We also made it clear that there would have to be standards for that care.
Following the EU procurement process, we had to check the nursing homes and ensure that their standards were in order. We began the process of signing contracts last week and we are now seeing the beds coming on stream. We are monitoring that situation to ascertain its effectiveness and we have agreed with the Tánaiste that we will keep it under review. If aspects of the plan need to be augmented by additional resources or changed, we will discuss the matter with her.
The situation with the acute medical units is that agencies would have confirmed to the Eastern Regional Health Authority that they could develop acute medical units for a certain price. When it was agreed that acute medical units would be developed, the agencies said that, following the Comhairle report, they needed to reconsider their plans and build additional facilities. We have told them that much can be done within the hospitals by examining how they are organised without necessarily building facilities. As facilities will not be built this year, we have asked them to concentrate on looking——
Ben Dunne can build them. He can have them ready within a week.
Mr. McLoughlin
I will not deal with that issue at present.
It would be no harm to deal with it.
Mr. McLoughlin
It is not possible to put temporary buildings on to hospital campuses without getting planning and fire approval.
With regard to the AMUs, we have asked the hospitals to re-examine the facilities. We will seek to provide resources for them this year but the hospitals will have to change some internal work they are carrying out. The effective AMUs throughout the country did not necessarily get many additional beds. However, they worked more effectively with GPs, gave GPs faster access to diagnostic services and re-organised and dedicated areas for elderly patients who could be directly referred by general practice. That is one of the tenets of the system.
We have monitored the data since January and it is clear that the accident and emergency service is heavily dependent on the quality of services in the community for elderly patients. It is a medical admissions issue for the elderly. I have visited accident and emergency departments and they have confirmed that. At any one time, up to 400 beds are blocked, particularly in the eastern region, with patients who could be cared for elsewhere. These include patients who are awaiting nursing home assessments, people awaiting long-term care, young chronic sick patients, those awaiting palliative care and patients who are awaiting adaptations to their home, for example, after a stroke. A variety of people make up that 400.
The priority in the plan for this year will be to try to create capacity in the community in order that we can better use the beds that are blocked. We must examine the need for sustained investment in services for the elderly as the way to deal with this effectively in the long term. There is a capacity issue and this has been acknowledged by the Government. At present, that capacity issue is probably more pronounced in the case of the care of the elderly outside of the acute hospitals than it is in terms of acute hospital beds.
We are working well with the agencies to implement the ten-point plan. We will continue to monitor it. We will conduct an assessment of whether it is working effectively and revert to the Tánaiste. We anticipate improvements occurring in the coming weeks and months but investment will be required in the longer term.
As I said at the previous meeting, over time more will be gained in the national interest by putting extra resources into the primary care sector. In time, that will take pressure off the acute sector. From the patient's point of view, it will be a better approach.
This year we have not got extra resources, apart from the special disability funds negotiated by the Tánaiste with the Government. Even without funds, however, we can see there are ways of doing things better in the primary care sector, both from the patient's and family's point of view. The GPs issue is serious, particularly in disadvantaged areas. Mr. Aidan Browne has been examining that.
Mr. Aidan Browne
One of the greatest opportunities with the unitary system is to share the learning from across the country. In some ways we have had a more than 30-year experiment in health service delivery across ten health boards. This is the first time we have had the opportunity to take the learning from the individual areas and transfer, share and manage it. That opportunity has not always been open to us.
With regard to general practitioners, in some socially disadvantaged areas there are systems that work. Sometimes they are heavily dependent on individuals. In other cases, they are incentivised. We are constrained by the current GP contract. It has many advantages and disadvantages but we have only now really begun the process of renegotiating it. We are doing so with the intent of a population health focus which should, by default, impact more than anywhere else on the socially marginalised areas.
There is no short answer. There might be short-term incentivisation schemes which can be put in place. We are exploring those at present with the GP representatives. There are many issues in that package, including the medical card, and it will take a while to tease them out. We are ready, from an administrative point of view, to deliver the GP-only cards but we are at a stalemate with the GP representative groups on how to do it and incentivise it.
The child care issue was mentioned. The HSE cannot take a child into care without the approval of the courts. The court would have heard the evidence presented in the first instance and would have granted an interim care order. The court would have shared the concerns of the HSE. The duration of the second hearing indicates that there were many serious issues involved. It was not a simplistic case of the big, bad health service taking action without due consideration. I would have asked for a report on the matter and I am satisfied that all appropriate steps were taken, regardless of the outcome.
My point is that there is no public scrutiny.
I welcome Mr. Kelly and his colleagues. Having been involved in examining the health service from the outside, I would like Mr. Kelly to deal with an issue of concern to us, that is, the level of psychiatric services or perhaps the dearth of such services. Has Mr. Kelly evaluated in-patient and community-based psychiatric services? It should be borne in mind that some recent reports, as yet unpublished, have expressed extreme concern about the delivery of psychiatric services and the level of investment in them. In 1997, 11% of the total health budget went to psychiatric services but that figure is down to 6.9% this year. One in four people will suffer from a psychiatric condition at some stage of their lives requiring medical or psychoanalytical intervention.
The true figure for suicides last year is approximately 550, although according to the statistics the figure is 444. In the 1960s, the average annual figure was 60 suicides. There has been an enormous shift in that area. More than 400 people without a psychiatric condition, but with intellectual disability, are still being treated with psychiatric patients. Adult psychiatric hospitals with patients of all age groups also cater for children as young as 13. Can Mr. Kelly give the committee his views as an outsider during his time with the psychiatric services? What approach would he see as the correct one to adopt for the future to improve that situation?
I would not disagree with anything the Deputy has said. Even in the past ten days we have had the sad case of an individual — a young boy of 17 — for whom there was no bed available in a proper facility. We have achieved it in the past 48 hours but he was in an inappropriate institution before that. There is a shortage of such places. Looking at the situation, my own sense is that many patients are being treated in environments that are inappropriate. If one looks at examples around the country where there has been much success in moving patients out into the community and treating them in a much broader way, their quality of life has improved, as has their health. That is the way forward. Part of the issue concerns funding. Mr. Aidan Browne has examined this matter closely. He has a background in this area as a psychiatric nurse. Perhaps he would like to comment.
Mr. Browne
I agree completely with the Deputy's analysis. It would not put it too strongly to say that the situation is unacceptable because our mental health services have failed to develop at the pace they otherwise might have done. The Planning for the Future report, which is now 20 years old, set out a pathway for mental health services, which was towards a community focus. We would have expected that many of the institutions would by now have closed their doors but that is not the case. As I said earlier in reply to Deputy McManus, we also find that the experiment around the country has had different outcomes. Some areas have well developed services in terms of community focus. They have reoriented their services.
Monaghan.
Mr. Browne
Monaghan is one example and it is a model that is worth examining and transposing. The advantage of the unitary system is that we now have an opportunity to challenge the mental health service where it has not moved. As Mr. Kelly said, there are definitely resource issues — there is no doubt about that. This year, the Government has prioritised €15 million in revenue and €25 million in capital spending for mental health services. The challenge for me is to ensure that the money is used in such a way as to release the opportunities to move towards a community-based service. We also have a fairly significant property base within the psychiatric sector that provides us with some opportunities to move clients.
Disability funding is also specifically targeted towards moving people out of inappropriate placements but it is a slow journey. There are many stakeholders in this environment that we have to convince to move with us. These include the various staff organisations, in some respects the clients themselves, and in some cases the local communities who must accept a different way of managing psychiatric services. I expect that we will make progress this year and increasingly so over the next few years.
I agree with Deputy Neville on the issue of suicide. I intend to prioritise significantly the management of this area within the primary community and continuing care directors. I will appoint somebody specifically to lead our suicide prevention initiatives. As the committee is probably aware, quite an amount of work is ongoing in this respect. Some 60 separate suicide prevention projects are currently being tested within the system. Our task for this year is to see what difference they are making.
I am aware that, in many instances, a large number of community groups have put their shoulders to the wheel because of their own experience of suicide. There is an opportunity for us to be much more open to sharing our resources with the community in a way that has not always happened. In many ways, we have been insular in our services and less willing to take on initiatives the community has put forward. Those matters will challenge us and, to some degree, that is really what the reform is about.
I do not want to hog the committee's time and I appreciate that others wish to contribute. Revenue is the issue where more ongoing services are required but the allocation of €15 million is absolutely disgraceful. I ask Mr. Browne to express a view on that. It is less than was spent on the equestrian centre at Punchestown last year, yet this sum is supposed to improve the delivery of mental health services. That is the figure Mr. Browne quoted and the Minister supplied the same figure too. Mr. Browne quoted the figure as if to say, "We have €15 million", but the Government might as well give nothing as give that sum. Some 70% of psychiatrists do not have available to them the services of a psychoanalyst. One can talk about communities not accepting this system but we need multi-disciplined, community-based psychiatric services — not a psychiatrist working in the community once a week. We need to have multi-disciplined psychoanalysts and occupational therapists. Mr. Browne knows what I am talking about because it is his profession. I do not have to spell it out for him but what are the chances of that happening within ten years?
Mr. Browne talked about suicide. In 1998, 86 recommendations were made but they have not been touched upon. Last week, the Minister told me he has put together a strategy group to implement the recommendations, seven years later. What are the chances of any of those 86 recommendations being implemented, apart from the suicide resource officers? That is all that was done following the 86 recommendations, yet the Minister tells us that a strategy group has been established. How can anybody have confidence that anything will be done with an allocation of just €15 million?
The Minister talked about selling off property but that will go into capital spending, whereas what is required is revenue to deliver a service, comprising psychiatrists, psychoanalysts, and the other professionals that are not currently present to deliver that service.
Mr. Browne
I am not sure how much I can comment on what the Deputy has said. It is a greater opportunity than we have had in previous years. We have an opportunity to share our knowledge and transfer it across the system. We have some revenue, limited though it may be, to release that potential.
Does Mr. Browne agree with my analysis?
Mr. Browne
I agree we have an uphill battle.
In a sense the €11.3 million, which includes the development moneys that we have for this year, is to maintain levels of services as they were last year and spend the development moneys. As I mentioned, we have started on preparing our corporate plan and are conscious of the rightful demands right across the health sector. Over the next few months we will prioritise who needs what most. When the next Estimates process arises, we hope to be involved and engaged in a fruitful process and to put forward our views as to where the money should go. The money is not infinite and we must work within the Estimates. However, we would not disagree with the Deputy because we see the situation every day.
I welcome all the delegates to the committee. The Tánaiste has informed us that her aspiration is to deliver a world class health service. I would be happy with a half decent health service. How far are we from a world class health service? In terms of the accident and emergency crisis, I think it was Mr. McLoughlin who was thrown into the lion's den on "Morning Ireland"——
He did not do too badly.
Not bad at all. CathalMacCoille went through the issue systematically regarding where we are in the ten-point plan. Will Mr. McLoughlin go through it and tell us where we are now? In terms of the capacity problem which I have always identified as the main problem, does he agree that it is not just a question of unblocking existing beds but also of providing new beds? When will we get the new beds? When will the capital programme be announced? The Tánaiste said it would be before Easter but we have not heard anything since.
I am glad the HSE delegation is here today because we can ask questions to which we sometimes cannot get answers in the House. Yesterday the HSE was quoted in the Irish Independent. It was said that the new legal limit of 0.6 to 0.8 parts per million of fluoride, which has come down from the current legal limit of 0.821 parts per million, has not been implemented. Notwithstanding the severe shortcomings of the fluoride report, does the delegation agree that it is remiss of the Government and the authorities that this has not been implemented three years later?
Will the delegation also comment on the case of Laura O'Shea, a lady from Brittas who lives quite a distance from the maternity hospital and whose previous delivery was on the side of the road. She is fearful the same will happen with her forthcoming delivery and has asked for a midwifery service. Does the delegation agree that as we begin to close more maternity units, roadside births will become more common? Is this an issue of concern? If we close more units, we will also have more inductions and more Caesarian sections. Is that healthy for mothers and society?
Members should refrain from mentioning individual cases if possible.
The matter is in the public domain.
I appreciate that but we must abide by our instructions.
I will ask Mr. Browne to deal with a number of the points made. On the matter of the capital plan, we have completed it. It has been submitted to the Tánaiste and her Department and we will have dialogue with them on it. The matter is ongoing, but complete from our end.
Mr. Browne
I will give a brief response on the issue of the individual to whom Deputy Gormley referred. We would generally classify that as a domiciliary birth or home birth service issue. The chief executive officers of the former health boards commissioned a report, probably 18 months ago, on what would be an appropriate and safe domiciliary birth service. That report came to my desk this week and is under review with a view to deciding what steps we can take. All I will say at this point is that the decisions around domiciliary births are taken on the basis of safety. My understanding in this instance is that the view of the HSE in the locality is that it would not be safe to provide a domiciliary birth service. There is an issue about access to a maternity unit within a specified period and that would not be possible in that area. Nonetheless, I understand that the HSE in the locality is aware of this particular person's problems and will attempt to address them as best it can.
What Mr. Browne is saying is that the fewer maternity units we have, the fewer the number of home births we will have. That is the logical conclusion because, as he says, if there is not a maternity unit close by, it is not safe to have a home birth. Am I right on that?
Mr. Browne
That would be part of the issue. The other issue might be about how well equipped the primary care sector would be to deal with issues that might emerge. There is not a simple solution. I may be in a better position to comment in more detail on the issue the next time we come before the committee.
On the fluoride issue, at this point we are not well enough informed to be able to give the committee informed comment on the matter. We will come back to the issue at a later stage.
We are due back on 14 May and can cover it then.
Mr. McLoughlin
On the matter of the provision of further detail on the ten-point plan, a second MRI machine is to be provided at Beaumont Hospital which will speed up access to services. It will be provided by the autumn of 2005. We are in discussions with the three hospitals with regard to the provision of the acute medical units and have asked them to reorganise services internally. We will resource that this year.
This year.
Mr. McLoughlin
Yes, this year, but the new building will not happen this year. However, we should be in a position to reorganise services which will mean that elderly patients will be assessed more quickly. Tenders are completed on the transfer of 100 high dependency patients for suitable private nursing home care. We are doing site visits this week and should be in a position to move patients to those facilities in the next two to three weeks, if the facilities are ready.
We have signed many of the contracts relating to the 500 people who require intermediate care and are now discharging patients. We are prepared to take up places as quickly as the nursing homes make them available to us. Approximately 30 patients have been discharged to date and we expect to discharge a further 40 to 50 over the next two weeks. We are dependent on the nursing homes. They indicated they could provide the care, but they must gear up and recruit staff. They are working closely with us.
With regard to the home care packages, 500 have been agreed. Some 27 patients have been discharged at this stage. These cases are where intensive home nursing and home help is provided. A further 50 patients are being prepared for those home care packages in the community.
On the matter of out-of-hours services, 150 general practitioners in the northern area of the city have agreed in principle that they will provide an out-of-hours service on the north side. This is critical for both Beaumont Hospital and the Mater Hospital. Detailed discussions are going on with those general practitioners with a view to putting the service in place.
On cleaning services and security measures, we have agreed that we need to carry out a national audit of cleaning services within our hospitals in general to determine the standards of cleanliness and to bring in national guidelines. We are about to advertise that contract in the newspapers and we intend the process to be completed over July and August. We would then have an assessment of the quality of cleanliness in all our hospitals and establish national standards. We do not have national standards in this area.
When will the national standards be introduced?
Mr. McLoughlin
Later this year. The process is moving forward and we have brought together a group that is working on those national standards. We intend that, following the audit, we will be in a position to introduce national standards. We can then audit these and ensure that they will be part of our negotiations with any provider, be they in the public, voluntary or private system, in respect of standards of cleaning.
We are involved in discussions with some public and private interests in respect of minor injuries units and other services of that nature, the provision of which would ease the pressure on accident and emergency departments. They will not affect the services for patients who need to be discharged and patients who need to be admitted to hospital. They will improve the flow of patients in accident and emergency but they will not actually impact on the patients awaiting admission.
The three critical measures to allow for the reduction in the use of trolleys are the 100 high dependency beds we are about to commission, the 500 packages of six-weeks interim care we are buying from the private sector and the 500 packages of care for around the country which are being actioned at present. That is the position.
To return to the discussions taking place regarding the minor injuries units, when will such units come into effect?
Mr. McLoughlin
It is not possible to say at this stage. Some of them are with private providers and clearly there are issues about charging and how that would operate. We have had discussions with private hospitals which indicated that they have a capacity and an ability to do this for us. We must look at each area to see how effective it would be in reducing numbers. Clearly, we do not want to invest in minor injuries units in an area that is already well resourced. Our main problem areas have been the north side in terms of access. Beaumont is under particular pressure as are the Mater and Tallaght. Significant resources have been put into St. James's Hospital with regard to the provision of additional beds and an AMU and this is having an impact. Discussions are ongoing. I will report back to the committee when those discussions are finalised.
The Deputy referred to the issue of beds. We will be commissioning an additional 200 beds this year in different parts of the country. The resources are there to commission an extra 200 beds this year and this is being done. The staff are being recruited. It should be remembered that when the Government announced that 3,000 beds were needed, that number was the requirement over ten years. People assumed this was an initial requirement. By the end of this year, 900 of those beds will be in place. The exercise being carried out in the National Hospitals Office is to determine where the next number of beds should go, particularly in light of the issue of regional self-sufficiency and equity of access. We have commenced discussions with some consultant groups about how to reorganise services in order to make it easier for patients to access them locally.
There have also been developments this year in radiotherapy services. Two additional LINAC machines will be available in Cork. One of these was commissioned in recent weeks and the second will be in place by September. A radiotherapy service has been established over Easter in the former Western Health Board region. There will be many developments this year. A new accident and emergency unit has been opened in Naas and new accident and emergency departments are up and running at the Blanchardstown and Roscommon hospitals. A new accident and emergency department is opening in Cork University Hospital next week. All of these are being opened with additional staff and facilities and better services for patients. There is an ongoing investment that is not often publicised. We hear about the trolleys but there is a lot going on in terms of developments.
Do we, therefore, have a world-class health service?
Mr. McLoughlin
No, we do not. I do not think there is a definition of that. We regard our ability to respond quickly as a good indicator. We have not reached that point yet. Patients who are deemed to be medically suitable for an acute bed should get into that bed and that is our view. Our first priority is to try to achieve this.
When we have the world-class health service, the Deputy will be embarrassed that he doubted it.
I will be delighted to have a world-class health service.
I thank the delegation for coming before the committee. I was struck by what Mr. Kelly said about 50% of the consultants being in the eastern part of the country, which has only 30% of the population. We should be careful to remember that some consultants are very specialised. There is only one micro-surgery unit for the entire island and it is in Belfast and frankly, I think that is correct. What concerns me is that consultants in areas such as rheumatology, neurology, respiratory medicine, and rehabilitative medicine are rarely requested by the former health boards to be placed in peripheral hospitals where they would be very useful.
I hope that more effort could be made in trying to appoint consultant groups rather than stand-alone consultants. Due to the fact that I am a doctor, I have received many complaints about this over the years. There is no point in employing a surgeon without taking on an anaesthetist. As a result of the fact that we are not allowed to hit patients on the head with a bottle of whiskey, we must still anaesthetise them properly. This is a consistent problem with lists for elective surgery being cancelled due to lack of anaesthetists in the appropriate hospital.
It is known when staff will reach retirement age but I have never noticed this being taken into account, in terms of avoiding time lags, when positions are advertised. Consultants require those in other medical disciplines, such as nurses, to work with them. Deputy Neville referred to psychiatry, where psychoanalysts and community psychiatric nurses are also required. One cannot simply fill positions without employing the additional staff.
A young psychiatrist told the Irish Psychiatric Association meeting I attended earlier this year about a bad experience when she was appointed in Navan. This case is in the public domain. She did not even have an office and she had no secretary, junior staff or psychiatric nurse. She surveyed 90 colleagues who had recently been appointed to positions and they also had problems. It is a total waste of money for the taxpayer to have people standing around doing nothing. When she was eventually given an office, it did not have planning permission to be a consulting room. She was brought before her employers to be told she was being disloyal to them, instead of being encouraged to highlight faults in the system that should be rectified. This is a waste of time and money.
On primary care, GPs are being badly treated at present. They were encouraged to bring forward their own plans and were to be given tax relief on improvements to their premises but this initiative was scrapped. That is very disappointing for those doctors who put money into their practices. Far more reliance is being placed on getting suppliers of private health facilities to build premises. The GPs will then be at the mercy of rent increases.
I am fascinated by the plans for the minor injuries clinics. They will all be in more affluent areas. Are there problems in St. Vincent's Hospital accident and emergency department? I do not think so. I have been to St. Vincent's as a casualty on a few occasions and it is not a problem area because it deals with Dublin 4 and south County Dublin, where people go to their GPs first. Those hospitals with the serious problems are in the socially deprived areas and I do not believe these pay-as-you-go minor injuries clinics will be set up in those areas.
People underestimating the extent of their injuries can be a major problem. If they went to the minor injury clinic they would need to be taken to an accident and emergency department. Would they go to the top of the queue there? While this might not necessarily be the case, they have a pretty good chance. This gives rise to a type of apartheid. These clinics will also take a great deal of bread and butter work away from general practitioners. Was this matter discussed with the primary care doctors? The doctor-only card should have been discussed with the medical profession initially. While on its introduction I said in the Seanad I believed it was a good idea, I hope we will not have the same problem as we had with the over-70s card, which was not discussed in advance and now doctors are paid five times as much for treating very well-off people as they are for treating poor people with medical cards. After that terrible mistake, why were the doctor-only cards not first discussed with the medical profession?
People in primary health care are trying to make efforts to come together with Caredoc and I am delighted about the scheme in north County Dublin. However, why did the Ballymun Health Centre remain unopened for two to three years after an investment of €9 million due to some turf war between the Department of Health and Children and the local health board? That was a shocking waste of money. Someone should have taken a stand and opened it as the old centre constantly needed to be closed because of problems with water leaking through the roof and it could not employ the staff needed.
The Senator should ask a question.
I have asked many questions. I want to know why these matters were not discussed. I agree that community psychiatry should be supported — I was involved when it originally started. However, we must accept that some people with psychiatric illness are so seriously ill that they need in-patient treatment. Deputy Neville is correct in pointing out that the situation for adolescents and children is deplorable. A few years ago a psychiatrist advised me she was unable to get a 12 year-old patient admitted anywhere. She was afraid the patient would do serious damage to a member of her family. When will this issue be addressed?
I will allow Mr. Kelly to respond before bringing in Deputies O'Malley and O'Connor, and Senator Browne.
I will be a model committee member by asking a direct question.
While I do not want to go into the history of the Ballymun Health Centre, I can assure the Senator that it will be open within six months. The builders are back on site. The process is under way and we are optimistic it will be complete in six to eight months. I believe it will be a top-class facility.
I agree.
Regarding consultants, as the Senator knows Comhairle has been streamlined into the HSE. I believe this will allow us to consider matters on a national basis. Mr. Pat McLoughlin is on the board of Comhairle, which is working very proactively on that area.
Mr. McLoughlin
The Senator's point is correct. It is not possible to provide just one specialist outside a region. In the past there might not have been a link between the capital budget and the revenue budget at a national strategic planning point. We will do that in the future which is why I have asked Comhairle to consider this in a more strategic way than was done in the past. I take the Senator's point about single-handed consultants; it just does not work.
I would need to clarify the matter of the minor injury clinics. I said we did not want those clinics in areas that were already well serviced which is why we are not interested in providers who offer to put minor injury units into areas that are already served. We are interested in having them in areas where they provide good support to the primary care and the acute hospital system. They raise fundamental questions about charging for medical card holders and non-medical card holders, who will staff them and the degree of assessment which is carried out, as the Senator rightly said. We do not want accident and emergency consultants or others who are in the public system being recruited by providers of minor injury clinics. They form one part of the jigsaw in the provision of care. However, we need to consider some significant issues in this regard before we approve any such units.
While we cannot roll back the clock on the matter of the medical cards for the over 70s, I have sympathy with the Senator's view. I understand that the idea for the doctor-only card came from the GPs. As I said earlier, we are ready to engage in discussions with them about issuing the cards. However, there is a fundamental issue in that they want to tie that matter into having the whole contract renegotiated, which we do not believe is appropriate at this point.
Mr. Browne
I wish to comment on the psychiatric consultant issue. I recently became aware of Dr. Denihan's report on the support system for newly appointed consultant psychiatrists. Most of the issues she points out are highly appropriate and relevant. When administrators have limited resources they need to decide which resource to put in place. Their focus has been to appoint the consultant psychiatrist as the person who drives the service. Sometimes they are not in a position to put in the rest of the resources immediately. The move towards multi-annual planning should help us to build a team over a period. In recent years we have had considerable start-stop development.
I agree with the Senator that we have a significant deficit in child psychiatry. We need to address this issue with the child psychiatric community to determine the most appropriate approach. While this might not necessarily be a residential service, we must have a residential service option available, which we are exploring. As the Senator knows, child psychiatry is a very skilled area and only the private and voluntary sector seem to be able to access the skills required.
I will take the questions of Deputies O'Malley and O'Connor, and Senator Browne together.
May we follow Senator Henry's style or are we being restricted?
I am trying to have a free flow of information. However, I am conscious that it is almost 11 a.m.
What I said was a compliment to Senator Henry.
I apologise for being late and missing the presentation. Having missed a DART train, I had to wait 20 minutes for the next one. The Tánaiste has indicated she wishes to put the patient at the centre of health services. As we are engaged in reform, it would indicate that the patient is not currently at the centre of services. Who do the witnesses believe is now at the centre of an unreformed service? What resistance are they meeting in making the transition to having the patient at the centre of the services? It is critical that we know what will cause that change. Presumably anybody involved in the health service wants to see treatment of patients at the centre of services. What is delaying the change to put the patient at the centre?
The witnesses referred to buying in beds from the private sector, which might be either the quickest or most financially efficient way to do so. Some beds were opened in the Leopardstown Park Hospital in my area. However, there is additional capacity and I am sure the hospital would be pleased to have it opened. I read statistics which I cannot remember exactly. I am reluctant therefore, to quote them. It may have been that 90% of nurses are agency nurses or that they are paid nine times more than staff nurses. That is not an efficient way to run a health service.
What can be done? I presume agency nurses are employed to the extent that they are because we have a start-stop programme. Does the HSE have a plan to stop that? Nursing staff should be permanent, if possible, and they should be paid properly, at a level higher than agency rates. We should not allow the current set of circumstances to continue. I am sure Mr. Kelly is familiar with the accuracy of what I am talking about. It is critical that we should recruit nurses to permanent positions and pay them the correct rate. Agencies should not continue to receive the additional money.
I have noticed large advertisements for positions in the HSE in the Sunday newspapers over the last six weeks. It is extraordinary when one considers that there has been a substantial increase in health service personnel and bureaucracy since the health budget started to grow in 1997. Bureaucracy, rather than the patient, seems to be at the centre of the service. Mr. Kelly has mentioned that procedures have obstructed the fast delivery of services on many occasions. I accept that there is a need for a certain amount of bureaucracy, but I would like to know whether the HSE plans to reduce the level of it. Much of the health service bureaucracy in this country seems to have been necessitated by EU procurement requirements.
There can be problems if one is trying to build something fast. I have met people who work in prefabricated facilities which are not permanent. Such facilities, which have a 20-year lifetime, are ideal for schools or nursing homes where intensive medical treatment is not needed because they can be put in place quickly. They do not interfere with long-term plans because they can be lifted and removed quickly. We should examine the provision of such quick solutions. We need to deliver beds quickly and efficiently. It seems to me that the facilities I have mentioned represent a good way of providing such beds. We need to consider how we can reduce bureaucracy and ensure that key services are delivered quickly.
Mr. Kelly argued that we can deal with the crisis in the accident and emergency service by providing for faster access to GP diagnostic services. It seems to be an obvious solution. I understand that 85% of those who attend accident and emergency units do not need to be there. I presume that the statistics have not changed. It is critical that we should provide faster access to GP diagnostic services if we are to alleviate the bottleneck in accident and emergency departments. I would like to hear more about the roll-out of the GP diagnostic services. The 85% of people who do not need to attend accident and emergency units should visit their GPs in the first instance, where they can be dealt with more speedily.
The NHS in the UK has been seen as a poor service, when considered statistically. It has been extraordinary to hear recent news reports of the improvements in that service. There have been significant reductions in waiting times, for example. We have much to learn. There is a perception that the NHS is a monolith that is not working, but it is clear that it is when one considers that approximately 94% of patients are seen within two hours. To what extent is the HSE learning from the experience of the UK?
I would like to be associated with the welcome extended to Mr. Kelly and his team. I am pleased to great all our guests, particularly Mr. Pat McLoughlin, who was a progressive and effective chief executive of the health board in the eastern region when I first became involved in 1994 with the then Eastern Health Board, which was later renamed the Eastern Regional Health Authority. I am pleased he has been appointed to such a key role. When I was the chairman of the then South-Western Area Health Board, I was involved in the development of facilities in Naas. I am glad that Mr. Kelly and his staff are continuing to provide a good service there.
Deputy McManus spoke earlier about the frustration of public representatives, particularly Dáil Deputies. I am not necessarily criticising the HSE when I make the point that politicians should be able to make representations and have an impact on the important work being done by the HSE. As Deputy McManus said, it is one of the major issues of our time. As a representative of Dublin South-West, which is a major population centre and is like many other constituencies, I receive many telephone calls each day about health issues such as medical cards, the development of services for elderly people and speech and language therapy.
There is a need for additional health centre provision in the Tallaght area. I apologise for being parochial, but if Mr. McLoughlin can mention Tallaght I should be allowed to do likewise. There is a need to fast-track the redevelopment of Millbrook Lawns Health Centre, which is a huge issue. I am sure Mr. McLoughlin recalls that the matter was on his desk and I am sure it is on somebody else's desk now.
During Private Members' business in the Dáil last night, I called on the Tánaiste to ensure that the BreastCheck programme is retained in Tallaght. The service should continue to be offered in Tallaght, which is a major population centre. Some 6,000 women have availed of the tremendous and positive service offered in Tallaght. I would be very unhappy if the service were to be moved elsewhere. I ask the committee to note that Tallaght Welfare Society, of which I am a member, has called for the retention of the BreastCheck service in Tallaght on a permanent basis.
I would like to speak about step-down facilities. Officials at Kiltipper Woods Care Centre, which is near Tallaght, recently experienced difficulties with what they categorised as "health board bureaucracy" when they tried to ensure that beds at the centre are registered. It is important that public representatives should have an opportunity to discuss such issues with the HSE.
I am very proud of Tallaght Hospital, which is seven years old, but I am concerned about the 60 people who had to stay on trolleys in the hospital last night. I am worried about the hospital's ability to continue to develop and provide a good service. I would like to emphasise my strong support for the long-running campaign for an on-site out-of-hours GP service at Tallaght Hospital. Having said that, I would like to ask——
The Deputy has adopted Senator Henry's approach to asking questions.
As a relatively new Member of the Oireachtas, I am happy to learn from the experience of other Members. The members of the committee who know me are aware that I come from a background of voluntary community work. I am concerned about the gaps in the voluntary sector. What are the HSE's plans for including the voluntary sector in its work? If I had more time I would quote from many of the various documents which have been made available to me over a long period. I refer to Shaping a Healthier Future — A Strategy for Effective Health Care in the 1990s and Quality and Fairness — A Health System for You, both of which stressed in a definite and positive manner that the voluntary sector needs to be involved in the health service. Deputies have made it clear that it is not happening, however.
I wish the Health Service Executive well. I hope its officials consider that the process of interacting with public representatives is useful. Like the voluntary sector, politicians have an important role to play as partners in the process of improving the service offered to the public.
What percentage of the health budget is spent on preventative medicine?
I dealt with Deputy O'Malley's earlier question about the patient being at the centre of the system before she arrived at this meeting. I indicated that there is no point in proceeding with the current process of reform if it is just about reorganisation, as such an approach will lead to public cynicism. The HSE has set out three tenets by which its performance can be measured. It must improve the journeys of patients and clients and the experiences of their families, create a better environment for staff and deliver value for money for the State.
As someone who visits various parts of the country every day, I believe that the system is focused on patients. That is clear when one considers the dedication, quality and commitment of those who deliver the health service. When the HSE tracked the experiences of a number of patients and clients and their families, it found that their experiences were terribly fragmented. The issue that needs to be considered is not the system's failure to focus on patients, but the bureaucratic manner in which the service is delivered. There are too many points of contact for patients. The HSE intends to ensure, for example by recruiting local health officers, that the experience of patients and clients is central to the operation of the service. It plans to reduce the number of points of contact of patients. The HSE is optimistic that it will be successful in that regard.
I agree with Deputy O'Malley that advertisements for positions in the health service were being published in many newspapers. Mr. Diarmuid Collins and Mr. John Magner of the HSE have produced strict rules about the recruitment of further administrative staff. The executive has insisted that all health service advertisements should be published together. It was unsatisfactory that different arms of the health service were advertising separately, at an enormous cost. If one examines the advertisements which are now being published, one will see that they are appearing together. We are using the Internet as much as possible as evidenced by the complaints by newspapers that they are not getting enough material from us.
Which is a good sign.
It is. Part of the problem in accident and emergency services is that some of those accessing them cannot afford to attend a general practitioner. Addressing this problem is part of the thinking behind the general practitioner only medical card which it is hoped will encourage people to return to GPs for free treatment.
We have had many meetings on all aspects of the voluntary sector and they are becoming more and more positive. Mr. Aidan Browne can report on them. I assure members that the sector is uppermost in our minds.
We will attend the committee as often as members wish to discuss representation. The Tánaiste is preparing the legislation on the way in which representation will be handled through the regions and it is hoped to introduce a Bill by the middle of the year. We are open about contact and informing the committee of exactly what we are doing.
Mr. McLoughlin
It was suggested that 80% of visits to accident and emergency units were non-urgent. While 80% of people accessing accident and emergency services do not require hospital admission, many of them are considered to require urgent attention. According to international analysis, between 42% and 55% of patients attending accident and emergency units are considered non-urgent. The greatest difficulty we face with such patients is that their presence extends the period for which people must wait for attention. They do not affect the issue of trolleys, rather the trolleys affect them as they reduce the available space in an accident and emergency department. Accident and emergency departments are designed to accommodate patients for two to three hours. If they are there for six hours or more, the running of a department is affected. Trolleys affect operations as departments were not designed to accommodate them. When we look to the public to help us to reduce the pressure on accident and emergency services, it is because staff and space are under pressure. The numbers attending do not, in general, impact on the issue of trolleys.
Mr. Browne
As Deputy O'Connor may be aware, I have some small history in the voluntary and community sector and recognise its significant value. The primary care strategy contains a significant focus on involving the community sector. We are challenged to an extent to find appropriate representation for different care groups and it is not always easy. In the first three months of the executive's existence, we have held numerous meetings with representative groups, all of which have been very constructive. One of the benchmarks of our success will be how effectively we relate to the voluntary sector and use it to develop services.
A great deal of what Deputy Fiona O'Malley said about agency nurses was correct. The use of agencies is often uneconomical and we are examining the matter very closely. Due to changes in the education system, we will face a significant nursing shortage as we move through the year. We have allocated €2 million to fund work in the area and Mr. Diarmuid Collins has been studying the economic costs of using agencies. I do not criticise the quality of agency nurses but rather the sheer cost of employing them.
A typical agency nurse costs us 90% more than a normal staff nurse. Our difficulty is the need to avoid breaching employment control ceilings by recruiting agency nurses instead to fill gaps. While the employment control ceilings are a control mechanism, they can compromise our ability to obtain value for money or lead to behaviours which do not promote it.
In administrative terms, the executive has replaced 11 health boards and 16 different statutory agencies, each of which had its own management and process teams. A shared services programme has been implemented as part of the three pillars of the structure of the unified system. The move toward shared services will permit us to concentrate on and consolidate back office transaction processing in the areas of finance, procurement and human resources to free resources for front-line services. The process will take time and negotiations with staff will have to be involved. Over time, we intend to use a unified approach to further develop front-line services.
I sought commitments on BreastCheck and the rebuilding of the Millbrook Lawns Health Centre. If my questions cannot be answered now, I would like to receive a response subsequently as the issues are very important to my community.
We need previous notice of such matters. The Deputy can raise the matters at the next meeting with the executive.
I was hoping someone would revert to me quickly. The results could be shared with the committee subsequently. I am signalling that the issues are important. I ask for positive answers.
I welcome the delegation to the committee and will be parochial in extending a special welcome to Mr. Pat McLoughlin of the former South Eastern Health Board. I commend him for the action on long-term nursing home charges, which subject he will come before us to discuss next week. It was a pity more health boards did not follow the example of the South Eastern Health Board and seek legal advice. It is a matter for discussion on a different day.
I am aware that a new chief executive has been appointed to the HSE. Can Mr. Kelly clarify the period for which he will continue to function as acting chief executive officer? Has it been agreed when the new chief executive will take over?
The board has recommended a name to the Tánaiste and it has been publicised. The Tánaiste has accepted the board's recommendation and discussions are taking place with the candidate about terms of employment and the date from which he will be available. It is unclear at this time as to how soon the individual will be available.
Are we talking about months or a year?
At most, it will be a matter of months. I presume he will begin to work on a phased basis. I hope he will get involved very soon and build up his time input over just a few months.
I am puzzled by the Hanly report. It was produced a year and a half ago at which time Ministers went out to the plinth of the House to denounce it. At protest meetings, Government backbenchers were contradicted by Ministers and the atmosphere was highly charged. However, since then, the report does not seem to have had any real impact. During today's presentation, we heard about new accident and emergency services for Cork, Naas and other places which seemed to contradict the Hanly report's aim of rationalising such services nationally. When the Tánaiste attended the committee she was asked about the status of the Hanly report. Listening to delegates from the Health Service Executive today I am even more puzzled about the matter and am none the wiser.
As far as I can judge, the Hanly report has been binned and services are being provided as normal and even enhanced in some areas. Can Mr. Kelly clarify the status of the report? Is it sitting on a shelf gathering dust like most other reports or is he bringing it to bed to read every night and going about implementing it at work the next day? I am completely confused. We have asked the Tánaiste about the report here and in the Seanad, but have been left none the wiser by her answers.
I agree with Senator Henry about the management of accident and emergency units. I toured St. Luke's Hospital in Kilkenny recently. Despite its lack of resources, which I hope the HSE will provide, the hospital has a very useful system involving co-operation with general practitioners whereby patients are directed towards primary care and encouraged to view accident and emergency services as a last resort. The hospital also has a minor injuries unit and manages its resources extremely well to ensure that there are either no patients on trolleys or extremely few. St. Luke's Hospital is an example which Dublin hospitals could examine, as much of their problems relate to internal management. The flaw of the Hanly report was that it focused on regional hospitals when it should have concentrated solely on those in Dublin. Perhaps I am wrong on that.
The Department has issued general practitioner only medical cards and is ready to begin to operate them. Is the problem a political one in that the necessary legislation has yet to be enacted?
The legislation has been enacted.
What is the delay?
We have an issue with the IMO, which wants to open up the discussion on cards to link them in with the general practitioner contract before it will give approval to its members to use them. We do not see a need for that at this time. At this point, it is not necessary to link it into the GP contract.
History appears to be repeating itself. The decision not to consult general practitioners about the extension of medical cards to those aged over 70 years caused a dispute, yet exactly the same decision has been taken again. We do not seem to have learned from past mistakes.
I am pleased Mr. Kelly raised the MRSA superbug because it is a major problem. On a recent visit to hospital my father was told by a consultant that Ireland does not have a single clean hospital. This is appalling. MRSA has become a major issue in the general election in Britain where all the political parties have combined to tackle it. It has been pointed out to me that Centra, for example, operates a system of hygiene awards and publishes lists of stores which win an award at regular intervals. Could a similar scheme be operated in hospitals? It is worrying that a hospital consultant would state there is not a single clean hospital in the country. MRSA is a major problem and must be tackled. Last year, it resulted in 1,000 deaths in England where the problem was highlighted recently by the tragic death of a newborn baby. We must focus on this issue.
I will make two brief comments on the Hanly report which I have read a number of times. With hindsight, the communication of the report left a great deal to be desired. It is a multifaceted, multi-dimensional report which needs to be implemented over a decade rather than overnight. At its heart is the requirement that nothing should be changed unless an equally good alternative is in place. This message has been lost along the way.
The current position as regards the Hanly report is that the Tánaiste and Minister for Health and Children has asked the National Hospitals Office to take it on board. Hanly II is on hold because of the current dispute with consultants around the issue of insurance cover. Although we cannot move forward with the report for that reason, the brief has been given to the Health Service Executive to take it up when we are in a position to do so.
Mr. McLoughlin
That is correct. The principles in the report are fine. It proposes additional consultant manpower, reduced reliance on junior doctors, a more structured system of training for junior doctors and greater regional self-sufficiency and capacity, an issue I discussed earlier. In the coming year, we will begin a consultation process with the profession and community on the issue of configuration. The principles are in place and, as a planning unit, we now need to examine how the report will impact on each individual area, which will differ from place to place.
On the issue of hygiene, our examination of hygiene includes consideration of the introduction of a hygiene award. We are in discussion with some accreditation bodies on the question of carrying out further audits and introducing a hygiene award system as part of a programme of environmental hygiene in hospitals arising from the current audit and the establishment of national guidelines.
As the Senator will be aware, the Health and Safety Authority has carried out a review of accident and emergency departments. The HSA is about to publish its report and I will meet the organisation next week to obtain a preview. The Health Service Executive will respond appropriately to its findings.
I am still uncertain about the Hanly report. Most people have no problem with its findings on acute service because it is acceptable to travel a certain distance to undergo surgery. The public's main problem is the accident and emergency aspect of the report, which is causing considerable unease. Will the HSE implement the report in full in the coming years or select only certain aspects of it?
The Hanly report provides for a ten year programme which requires a large number of steps to be put in place. For example, heavy investment in paramedics is required but has not yet taken place. Until this investment is made one cannot proceed with implementing the report. A set of steps must be in place to ensure that if a service is removed it is replaced by something as good, if not better. The report is complex and a lengthy timescale is envisaged for its implementation but this must take place on a step-by-step basis. The paramedic side is a glaring gap.
Mr. McLoughlin
The issue of pre-hospital care is a critical part of the report. The National Hospitals Office will carry out a reconfiguration of the national ambulance service and an examination of response times. This will be done quickly because we can change from a system with many rigidities in terms of how ambulances are ordered and dispatched, the use of crews across different regions, the number of command and control centres and so forth. We intend to introduce a programme of reform in the ambulance service and, as Mr. Kelly noted, this will be one of the pillars or building blocks for emergency care.
One must then consider how people get access to emergency care. Should we have a first responder programme in which the ambulance service is brought to them with paramedical staff or is it preferable to bring patients to a centre where they can be assessed and triaged immediately or to a major trauma centre? We must examine and configure all these issues.
The principles of the Hanly report are being implemented in consultant manpower and training and are being driven by a number of organisations. It is important, therefore, that we have a planned approach to the development of hospital services. The establishment of a national hospitals office allows us to do this. When the Minister considered the possibility of a Hanly II or the pilot projects the Health Service Executive and National Hospitals Office were not in place. We now have a mandate to plan services across the whole acute system. We will carry out this mandate but it will take time. In doing so, we will stick to the principles of the Hanly report but investment must follow.
The discussion on the Hanly report has been interesting. To pick up on Senator Browne's comments, there is an apparent reluctance to mention the report. I was relieved to hear Mr. Kelly, as the acting chief executive of the Health Service Executive, indicate that he had read the report a couple of times. It is almost as if all the work is being done. Do Mr. Kelly and Mr. McLoughlin accept that the report is the blueprint for the future? Is it the intention to implement it within ten years? Alternatively, will the HSE and National Hospitals Office make additional investment in the paramedic service and other areas, while at the same time hoping people will forget about the Hanly report in two or three years, thus allowing another plan to be produced?
The accident and emergency crisis is a major problem which is receiving considerable media attention. Although the problem is most acute in Dublin, it is not confined to the capital. Since Christmas, as many as 18 people have regularly waited on trolleys for two and three nights in Mayo General Hospital. I worry that the focus on addressing the issue appears to be on hospitals in Dublin, Cork and other cities where up to 60 people may be waiting on trolleys at any one time.
One of the measures outlined in the ten point plan for dealing with accident and emergency is the discharge of patients from acute hospitals to step-down facilities. During the Tánaiste's most recent appearance before the joint committee several weeks ago I raised the current rates of subvention, an issue that ties in to the question of how to achieve value for money for the State outlined in the presentation for which I was, regrettably, absent. In County Mayo and elsewhere in the west, a maximum dependency patient who needs to be housed in a nursing home will get a maximum of €220 plus an additional €80 if a hardship case is made to the health board, which makes €300 in total. In Dublin, on the other hand, the equivalent figure is between €500 and €600. People in County Mayo are queuing to get into State owned facilities because they are not required to pay for them, while empty beds are available in private nursing homes. Private sector provision would be more than capable of addressing at least part of the problems in accident and emergency departments. The Tánaiste stated action would be taken to make the charges more uniform. What are the plans in that regard? What specific measures are in place to deal with problems in accident and emergency departments in the west?
The GP only card was mentioned. Between 1997 and 2004 the number of medical cards in County Mayo decreased by 8,500. When I asked whether rising incomes was the reason for this reduction, I was informed that 8,300 people were deceased, which means that for many years general practitioners were paid for medical cards belonging to deceased people. Will this money be recouped from GPs? It would pay a significant proportion of the cost of the new GP only cards. What is the position in this regard?
Last night in the Dáil, Deputy O'Connor made a contribution on a Private Members' motion on the BreastCheck service, even though it is available in Tallaght. We are waiting for the programme to be extended to the west. As late as last night, the advertisement for the appointment of a design team had still not been placed in the Official Journal of the European Union, despite the fact that the extension of the service has been a major public issue since the Tánaiste's appointment as Minister for Health and Children almost six months ago. When BreastCheck was announced in Dublin in 1998 it was up and running by March 2000. Although the extension in the west was announced in March 2003, in April 2004 the advertisement has not yet been placed in the EU journal to which I referred. I would appreciate if somebody could let me know when we can expect that to happen.
The Hanly I report is an extremely good document in pointing the way forward. The intention then was to have another group look at it after the experience of the two pilot schemes which were put in place. The whole thing has been put on hold because of the row over medical insurance. When that impasse is out of the way the Hanly report will then be passed to us and we will reconvene with most of the group that was originally envisaged and will begin the process of looking at it.
I can assure the Deputy that our focus in terms of accident and emergency departments is national. We have divided it up. One individual is responsible for the east coast and somebody else is responsible for the rest of the country. Perhaps Mr. McLoughlin will talk about that.
Mr. McLoughlin
We have analysed bids received from all health agencies. We have made proposals to the Tánaiste for each area in the country. We moved more quickly in the eastern region because of the number of blocked beds. Different problems tend to apply in different parts of the country. Services for the elderly are generally better developed outside of the eastern region and different issues exist in different areas.
A range of measures are in place. Those details have come in from the western region and they have been analysed and referred on to the Tánaiste. I would expect decisions to be made rapidly. In areas like that, generally they involve extended care and home care packages. I can assure the Deputy that the focus is not just on Dublin. We are monitoring the situation.
County Mayo has had, on average, nine patients awaiting beds since the beginning of the year. It is about mid-way in terms of statistics nationally for trolley waits. It is nine patients too many. That number is unacceptable and we are working to see if we can reduce it. Our planning will be a total system planning and will not just concentrate on the east coast.
I presume contract beds will be part of that. When the Western Health Board contracted out beds it only paid €430 per bed while the cost in Cork was €650. Why is there such a discrepancy?
Mr. McLoughlin
We inherited a situation where each board was different and was a statutory body in its own right. We have also inherited a situation whereby the provision may be uneven across the country. For example, we have a high concentration of nursing home beds in the Bray area and down the east coast and we would need much more provision in the northern area. That was the reason we went for procurement on a national basis. We need to try to achieve equity of access.
Deputy Cooper-Flynn raised the issues of resourcing and subvention. There are policy issues in this regard which the Government is considering. They are not issues for us to consider at present.
The situation regarding BreastCheck is similar. The Health Service Executive, in the form of the previous health boards, has made recommendations in regard to the development of services through BreastCheck in Cork and Galway. The Tánaiste is currently examining those proposals.
Whose responsibility is it to place the advertisement?
Mr. McLoughlin
It would have to be approved by Government because a capital investment is involved. Once it is approved it is a matter for BreastCheck to action that programme throughout the country.
I cannot understand this because when the extension was announced in March 2003, provision was made for the allocation of €21 million to it. What is yet to be decided?
Mr. McLoughlin
I am not aware of the Tánaiste's position on the matter.
I am pleased we have had this discussion because it nails down the issue. The matter awaits Cabinet approval to proceed.
As Deputy Cooper-Flynn is aware, Sheelah Ryan, the chief executive of the Western Health Board is now chairperson of BreastCheck. She is passionate about it.
She is totally committed. She was chairperson of the original steering group. I was on the health board with her in 2003. At that time we were told there would be an 18-month roll-out period. One can imagine how frustrated she must be.
There has been a very fair exchange of views with no time restrictions. I thank the HSE officials for attending today to give us such an informative and comprehensive update on progress. I look forward to their returning here again.
The joint committee adjourned at 11.35 a.m. until 9.30 a.m. on Thursday, 28 April 2005.