I welcome members to the meeting. I welcome the Minister and her officials and Professor Drumm and his officials. There is a time limit on the meeting because the Minister must leave at 12.10 p.m., while Professor Drumm must leave by 12.30 p.m. That gives us three hours. I will invite the Minister to make her opening statement, following which Professor Drumm will make his. I then propose to invite the front bench spokespersons to ask questions, for which they will have five minutes. I will also allow spokespersons to ask two supplementary questions. Then I will invite members to put questions. They will have three minutes and will also be entitled to ask two supplementary questions. As we approach 11.45 a.m. I will invite spokespersons to wrap up the meeting and will ask the Minister to respond. There will then be 20 more minutes for Professor Drumm to reply.
Health Issues: Discussion with Minister for Health and Children and HSE.
As Chairman of the Committee of Public Accounts I must leave in five minutes. It is regrettable that these two important meetings clash. Our usual schedule involves meeting on a Tuesday and I think we should stick to that in the future. I have said so in private and now say so in public.
I will make every effort to keep to the usual schedule in the future. If the meeting had been held on Tuesday, however, the issue we are discussing today would not have been on the agenda. It is important we take account of such things.
Perhaps the report was released yesterday because of the meeting today.
That is not the case. I take the Deputy's point, however, and I promise to try to work towards keeping to a regular schedule. Other members have indicated a similar clash, and Deputy Ó Caoláin must also leave at some stage. There may be a vote or two in the Houses during our meeting. If there is, we will attend the vote and come straight back. We should be businesslike and remember that, if we speak for too long, we deprive somebody else of the chance to speak. I ask the Minister to make her opening statement.
I have circulated details of some of my comments, which I will not repeat as Deputies and Senators on the joint committee can read them for themselves. However, I am happy to take questions on the opening statement. Given the events of the past 24 hours I know the committee will be anxious to concentrate on issues around cancer care and the failings identified at the Midland Regional Hospital in Portlaoise. I will dwell on that in my opening comments and will take questions accordingly.
As the committee is aware, yesterday we published four reports. One was authored by Ms Ann Doherty, acting head of the National Hospitals Office, and one was by Mr. John Fitzgerald on events in Portlaoise. Ms Ann Doherty's report was requested by the Secretary General of the Department of Health and Children, on my and Professor Drumm's behalf. It dealt with the circumstances which led to the suspension of breast radiology services at the Midland Regional Hospital last August. The second report, which I asked the chairman of the HSE to commission, was on how the events at Portlaoise were handled by the HSE from August to November last year. The HSE published Dr. Ann O'Doherty's report, which was a clinical review of mammograms over a particular period at the Midland Regional Hospital, and a report by Mr. John Bulfin on ultrasounds. If members have questions on those they will be taken by Professor Drumm.
As I did yesterday, I extend an apology to the nine women whose diagnosis of breast cancer was delayed as a result of the service that was provided at the Midland Regional Hospital. All these matters caused great anxiety to many thousands of women who, thankfully, in the end were not adversely affected. In particular, in the review of ultrasounds no cancer was diagnosed and I am very happy that this was the case.
Many lessons have to be learned from the experience. The first, which is very clear from Ms Doherty's report, is that the configuration of services in the Midland Regional Hospital led to unavoidable consequences. No matter what clinical expertise might have been available, as we heard this morning from Dr. Ann O'Doherty, it is only when cancer services, and breast cancer services in particular, are organised around high volumes with multidisciplinary teams that one gets good outcomes. Even then, as we heard, there seems to be an error rate of approximately 1% in such centres around the world.
The first lesson for all of us is to ensure we organise services on the basis of evidence and excellence and that is what we are doing. It is what Professor Tom Keane has been charged to do in the cancer control programme. In a few moments I will deal with the progress he has made over a short period. The second lesson is that there were failings of management, governance and communications and those are documented in Mr. John Fitzgerald's report.
On responsibility and accountability, I take responsibility as Minister for Health and Children. Responsibility falls on the Minister, the management of the HSE and the board of the HSE. The first duty of accountability is to establish what happened. We now know what happened but we did not know until yesterday. The second is to identify what steps we can take to fix the problems and we have done that. The third is to make sure that, having identified what steps we need to take, they are put into effect.
I have asked the board of the HSE to ensure we have a protocol for dealing with serious incidents. I want an interim protocol to be put in place before a final protocol can be adopted. In adopting a protocol we want patients and patient representatives to be consulted. I want to make sure there is a single person at the HSE responsible for ensuring the protocol is implemented, though that is not to say that same person will be responsible for carrying out reviews and inquiries into serious incidents. He or she will, however, be responsible for making sure such reviews and inquiries are carried out in accordance with the protocol. I also want to make sure the risk assessment subgroup of the board of the HSE is fully involved in these matters until such time as the protocols are fully implemented.
I have also asked the chairman of the HSE to see if there are wider issues from which we can learn relating to what happened at the Midland Regional Hospital. The HSE is a new organisation, having been in existence for three years, and many want to undermine it. For 20 years Deputies on all sides of this House have called for the establishment of a single unified organisation to deliver health services in Ireland. When the legislation was going through the House the establishment of the HSE was not opposed, at least by the main Opposition parties of the time.
That is not true.
Allow the Minister to continue. There will be a chance to ask questions in a few minutes.
There were issues relating to the speed with which we implemented the legislation and the fact that we did not facilitate politicians in being members of the board of the HSE. I can quote from the main spokespersons of the parties opposite as evidence for what I say. People felt the creation of a unified delivery system in Ireland was long overdue. We had a population of 4.3 million and, were we starting from a greenfield site, we would not have established 11 boards with individual responsibility. Most fair-minded people, including many from the parties opposite, felt that was the case. Some 20 years ago, Mr. Ivan Yates, as Fine Gael spokesperson on health, called for such a body to be established.
The HSE employs over 100,000 people and it is responsible for the delivery of health services. The CEO, as Accounting Officer, is accountable to the Oireachtas and the board of the HSE is accountable to me. I strongly believe we have the capacity within the management of the HSE to make sure the problems identified can be put right. On cancer care in particular, I do not believe we would ever have embraced the cancer control programme as we have if we did not have a single unified organisation. We would not be in a position to have eight designated centres in the country because some boards, such as the Midland Health Board, did not have a centre at all. None of the health boards would have been prepared to forgo a specialist centre in its own area.
I will speak about progress on the establishment of the centres, particularly for breast cancer. We will have ten centres by the end of this year, while we have 16 at the moment. Until recently, we had over 30 locations where breast surgery was performed while, nationally, we have 2,500 new cases per year. Professor Keane has allocated €5.8 million to the eight centres to build up capacity and has met many of the clinicians involved in cancer care. Huge clinical leadership is emerging, which is very encouraging because to succeed we need clinical leadership with political support.
Professor Keane has also agreed with the Irish College of General Practitioners on a new method of referring patients for breast diagnosis and wants to see a common referral system. He has made the point to me, as he has at this committee and publicly, that the method through which patients are referred determines the speed at which patients are seen. We want to make sure there is a common referral pattern. We have approximately 2,500 new breast cancers per year and 2,500 GPs. I do not suggest the incidence is an average of one per GP but they are the figures. Accordingly, many general practitioners do not see huge volumes of patients with breast cancer so it is important we have common referral based on best practice internationally, and Professor Keane is working to make that a reality. The system will apply not just in cases of breast cancer but to all referrals, as far as is possible, so that urgent cases are separated from what might broadly be referred to as routine cases. The intention is that urgent cases will be seen within a two-week framework. Professor Keane has also agreed new transport arrangements involving the Irish Cancer Society. Cancer societies in Canada and elsewhere are involved with the State in providing appropriate transport for patients that require it, particularly to centres of excellence.
That is a summary of the progress that has been made in a relatively short time, Professor Keane having only arrived in this country at the end of November. Today is not about process or procedure but about patients. They have to be our real concern in respect of all the issues, such as how we organise services in a way that delivers the best outcomes for patients. If patients face the possibility of cancer they want to know they can go to the best place and get the best treatment in as speedy a fashion as possible. That is the assurance we want to give to cancer patients whether they are in Donegal, Portlaoise or Dublin. We wish to ensure that they will have access to the same clinical excellence, to multidisciplinary teams, that they will have their diagnosis and surgery in the eight centres and much of the follow-up treatment can be in the smaller hospitals, as we know, under protocols that will be devised at the specialist centres.
They are my opening comments in regard to the issues that arose yesterday as far as the reports and the cancer services are concerned. I am happy to take questions on this or on any of the other issues members may wish to raise.
Before I invite Professor Drumm to speak I wish to acknowledge the presence of Deputies Enright and Charlie Flanagan from the Laoighis-Offaly constituency. I invite Professor Drumm to make his opening statement.
Professor Brendan Drumm
I thank the Chairman for the invitation to attend today. The Chairman, through the committee secretariat, has indicated a range of issues he wishes to raise with us today. I intend to give a brief update on two of the key issues raised but I am happy, as are my colleagues, to take any questions members may have on other issues. We will endeavour to answer all of the questions.
The first issue with which I will begin is the review of breast care services at the Midland Regional Hospital, Portlaoise. The HSE yesterday published the clinical review of mammography services at the Midland Regional Hospital, Portlaoise, for the period November 2003 to August 2007 which was completed by Dr. Ann O'Doherty. The outcome of the clinical review of breast ultrasound services at the hospital was also published. Breast imaging services were stopped at the hospital in August 2007.
The HSE wishes to again apologise to the nine patients whose diagnosis was delayed. Eight of the cases were delayed as a result of the original diagnosis in Portlaoise hospital, not nine. One case was correctly diagnosed at Portlaoise hospital and that diagnosis was rescinded at an expert centre. I say that in fairness to the diagnostic people at Portlaoise. The HSE also expresses regret for the upset caused to all the other patients who were the subject of the clinical review. The HSE will write to these women in the next few days offering them an opportunity to express their views about the process if they wish. A dedicated HSE advice line is in place for anybody with concerns relating to breast care services. The number for the advice line is 1800 252041 and is available on Thursday and Friday of this week from 9 a.m. to 5.30 p.m.
Dr. O'Doherty's report concluded that best practice in breast imaging services was not adhered to at Portlaoise hospital. This included the way images were processed and the absence of triple assessment and diagnostic multidisciplinary team meetings. As a result the safety, quality and standards of many aspects of the service fell well below achievable best breast imaging practice and this resulted in a significant and avoidable delay in the diagnosis of breast cancer.
Dr. O'Doherty stated that there was no evidence base to determine an acceptable misdiagnosis rate in highly symptomatic breast cancer services; although it is well recognised that even in the centres operating to the highest standards some women with breast cancer will have a delayed diagnosis. She went on to say that the false negative or misdiagnosis rate in this review on aggregate falls within the false negative rates published within similar reviews.
I did not hear Dr. O'Doherty on the radio this morning but there was an attempt to portray her views as being contrary to what I outlined. From what I know of her views they are absolutely consistent with our views in regard to this issue. There is no discrepancy between us. In accepting the recommendations of Dr. O'Doherty's report, the HSE is appealing to all health care professionals involved in providing cancer services to redouble their efforts to transfer cancer services to the eight centres of excellence announced last year as quickly as possible.
The HSE also published yesterday the clinical review of breast ultrasound tests carried out at Portlaoise hospital which did not reveal any case of a missed or delayed diagnosis. The National Hospitals Office will transfer full responsibility for all symptomatic breast cancer services to the national cancer control programme, NCCP, by the end of March 2008. In keeping with this plan the national cancer control programme has recently completed a detailed review of the resource requirements to create capacity for the progressive transfer of all symptomatic breast cancer services to the eight designated cancer centres with the objective of completing 60% transfer by the end of 2008 and 90% by the end of 2009. The resource requirement review was based on the national quality assurance standards for symptomatic breast disease services and resulted in additional funding to the eight centres from the NCCP, of €5.8 million for the implementation of the programme.
In addition to the discontinuation of breast cancer services at 13 hospitals announced in September 2007, the transfer of any remaining breast cancer services from the Midland Regional Hospital will be complete by the end of March 2008. Breast cancer services have also transferred from Clonmel to Waterford, from Connolly Hospital to Beaumont, and from Mullingar to the Mater Hospital. It is anticipated that breast cancer services from Drogheda, Tralee, Wexford and Kilkenny will transfer over the next six months, with Sligo and Castlebar transferring towards the end of the year. Final dates for these transfers will depend on confirmation that the necessary capacity is in place in the designated centres. As already announced, patients in non-designated centres will continue to receive chemotherapy and supportive care locally, as they do at present.
The second issue I wish to address relates to the cost of medicines. The HSE plans to reduce the wholesale price of drugs took effect on 1 March. Up to this point the HSE had been paying up to 18% of the medicine costs for this wholesale service, which is twice the European cost. There is no reason Irish people should pay more for their medicines than our neighbours. In turn, there is no reason the HSE should pay millions extra of taxpayers' money for the medicines it buys for its patients. The wholesalers agreed in submissions to the HSE that 7% is a fair price for wholesale services.
The HSE offered an interim pharmacy contract to address any possible impact the new wholesale rates would have on pharmacies which involved a higher flat fee of not less than €5 per prescribed item. This is an increase of 50% on the current fee payments as it compares to a current fee of €3.27 per item. This would directly benefit those pharmacies with greater numbers of medical card patients. This is a voluntary offer. The existing contract remains in place, with existing professional payments, for all pharmacies who choose to retain it.
On 18 February 2008, to ensure that this current interim fee is fair and reasonable and appropriately validated, the Minister for Health and Children and the HSE agreed that it should also be assessed and recommended by the same independent body which will price a new pharmacy contract. While this independent body is determining its recommendation, the provisional flat dispensing fee of €5 per item will still be on offer to pharmacies. The HSE appeals to pharmacies not to use vulnerable patients in its dispute but rather to engage with the independent body established to price the new pharmacy contract and have its concerns addressed there.
I am aware that I have not covered all of the issues raised by the Chairman but by taking this approach it will leave more time available to the committee to ask specific questions.
I thank Professor Drumm. Before we commence with the opening statements from party spokespersons I wish to refer to an apology from Deputy Flynn who cannot be here this morning. She asked me to convey her apologies. She is anxious that we raise the issue of breast cancer services with the Minister, Deputy Harney, and with Professor Drumm, especially in the light of the recent reports. She hopes to meet them at some future date to discuss her concerns.
I invite Deputy Reilly to begin his opening statement. I ask members to try to stay within the time limit. I do not want to have to ring a bell. I wish to ensure that every member has a chance to make his or her point. Deputy Reilly has five minutes. Professor Drumm and the Minister will then respond after which Deputy Reilly can ask one or two supplementary questions.
I will attempt to stay well within the time. I do not intend to make a detailed statement. I would prefer to get more information. I agree with the Minister, today is about patients, but it is also about how process and procedure can affect or, in this case, afflict patients. Notwithstanding what the Minister said about the HSE, this would not have happened in the health board era, bad and all as it was. There was a CEO at the top of the system and he or she knew his or her neck would be on the line and he or she would have taken action long before it got to the stage it did.
In regard to the HSE, over which the Minister has stood and under whose stewardship it was formed following the passage of legislation, it started from a very peculiar place. Having spoken with an international mergers expert the Minister has merged 11 companies into one. She started from a position where nobody was to lose a job, nobody was to move jobs and there still is not a permanent pay job person. This probably explains what everybody now knows is the dsyfunctionality of the HSE which everybody has witnessed and people have commented on, including city councils and Circuit Court judges.
Does the Minister believe it was reasonable not to interview Dr. Moodley? Does the Minister believe it was reasonable to put her on administrative leave when three separate individuals within the health service advised against it? May I ask a question which has not been answered in any of the reports, namely, who decided to wait for a cohort of cases? Who made the decision to leave files belonging to women who may or may not have had cancer? Thankfully, none of them had cancer. Who made that decision, because that is one of the blackest aspects that has come out of this? I sympathise with the women who have cancer, having been reassured that they did not have it.
Will the Minister outline why the agreed resources were not put in place for this designated centre which, in modern parlance, would have been a centre of excellence? Why was no pathologist appointed? Why was no radiologist with a special interest in mammography appointed? Why was no clinical team leader appointed? Why was no modern equipment, such as a mammogram machine, put in place?
This centre had no chance from the outset. How can we be sure something similar will not happen again? There is still no accountability or transparency. The report states that attendance at meetings was varied, that systems management and communications all failed. What else is the HSE about except those things? It is an absolute failure of the HSE at all levels.
The John Fitzgerald report states there is an issue around the advisers. It also states that: "At a meeting on 13 September a discussion was held on both the mammogram and ultrasound elements of the review, both of which were described in the minutes of that meeting". His report further states:
In relation to communication between the HSE and the Department, I would have some concerns about the quality of this process. This was partly due to the multiplicity of communication channels in operation involving different people within the HSE, and different people within the Department and/or advisers to the Minister.
The Travers report which the former Minister for Health and Children, Deputy Micheál Martin, commissioned states, in page 80:
They should probe, in an insightful and effective way, areas of policy implementation, operations and administrative difficulty...Ministers should insist on full and periodic briefings on key issues of policy and operational performance.
In the House I asked the Minister if there were other letters from Mr. Naughton to her office or to her predecessor? She said there was not and that she was not aware of any but if I knew of any I was to give her details. It has come to my notice that there was a letter from Dr. Naughton to the Minister's predecessor, Deputy Martin. My understanding is that it was handed to the three investigators. As further evidence of that, on the last page of Dr. Ann O'Doherty's report she refers to Dr. Naughton. She states that this correspondence has been emphatic in showing that he consistently and repeatedly wrote to senior health board officials, Ministers for Health and the Department of Health. I would like the Minister to comment on that and to inform the committee whether or not she has that letter, or if any of her investigators have it. I ask also that a copy of that letter be made available to us.
As I pointed out in the past, I believe Dr. Peter Naughton's letter of 2005 was the one that highlighted all of this. If action had been taken then, these women would not have had to endure such suffering.
What is Professor Drumm's response to Dr. Ann O'Doherty's assertion this morning that, far from being acceptable, the error rate at 6% was six times the norm? That is what she said on "Morning Ireland" this morning and we all heard it.
She said--
Deputy Reilly has the floor.
The HSE has described its financial position this year as challenging. Can Professor Drumm confirm if the allocation of funding for the HSE in 2008 is sufficient to maintain the levels of service provided in 2007? Will he confirm if additional cutbacks are to be announced in the coming week and, if so, will he please provide details today? Will he confirm if the cutbacks mentioned in the internal HSE memo, leaked in January, are official HSE policy and are to be implemented?
I wish to ask Professor Drumm two questions in regard to pharmacists. He has made it very clear, and so has the Minister in the House, that the issue is with the wholesale margin and the wholesalers. Why are pharmacists being punished for the perceived sins of the wholesalers?
Yesterday I asked the Minister about the consultants' contract. Can Professor Drumm outline what stage it is at? When can we expect new consultants to be appointed? Specifically, can he explain how he could promise to appoint 100 consultants to hospitals that performed well when it has since become clear that there was funding only for 20?
I invite the Minister and Professor Drumm to respond and, as stated, Deputy Reilly can follow up with two supplementaries.
I am not going to dwell at any great length on whether the establishment of the HSE was right or wrong. I have made my point and my comments. I genuinely and strongly believe, as many people do, that in a country with 4.3 million people, a unified health system is appropriate for a whole host of reasons as follows: appropriate cancer care; good outcomes for patients; how services are organised; uniformity of provision of services; consistency in relation to how standards are enforced; and so on. The HSE was a merger of not just 11 health boards. Many other organisations were also submerged into the HSE.
In regard to the ratio of staff or administrative management staff, I have said before on the record, and I repeat, it was decided on day one that there would not be a redundancy programme. I remember the debate. I have quotes here of what I was being asked and if people would lose their jobs. There was a huge IR issue around this merger. That is not to say that now that the HSE is three years in being, if it is the view of Professor Drumm and the HSE management, and particularly when the new HR director is appointed, that there are staff surplus to requirements in some areas and shortages in other areas, it will not be addressed. We do not want to have people in positions for the sake of it. I have an open mind. If there are too many people in certain places, it is an issue we have to be courageous enough to examine. I am more than happy to do that. We want the appropriate ratio of management administration to clinical staff. As I said before, what is support staff to one person is a bureaucrat to another. We should remember that.
I cannot comment on the people interviewed by those charged with carrying out the inquiries. That was entirely a matter for them. I did not interfere with any of the investigations. I never spoke to John Fitzgerald from the time he began his investigation. I bumped into him yesterday and except to greet each other, I did not speak about his report. I did not speak to Ann Doherty about her report. I did meet Dr. Ann O'Doherty in relation to a clinical event we held with Professor Tom Keane around 21 November in regard to cancer care but not about her report. Neither did I speak to Mr. John Bulfin. These people were charged with carrying out reports and are people of competence and integrity. I believe they carried out the duties assigned to them in the appropriate fashion.
Reference was made to the decision to suspend the doctor. I am not the employer of the doctor; the HSE is the employer. That is perhaps a matter for Professor Drumm and the HSE, except to say that people have strong employment rights. They have access to lawyers to vindicate those rights and, as employers, we must be careful in the manner in which we seek to interfere with those employment rights. It is not unusual, if an investigation is under way, for somebody to be put on administrative leave. It is preferable that would happen than that somebody might continue working where there could be issues. That is normal practice in employments of this kind.
Dr. Naughton wrote to me in the summer of 2005. His letter was dealt with at the highest clinical level. It was dealt with by Professor Donal Hollywood, who was the medical director at the Midland Regional Hospital at the time. Professor Hollywood engaged with Dr. Naughton in regard to that letter. Subsequent to that letter, a radiologist was appointed. An attempt was made to appoint a second radiologist. Interviews took place on two occasions but nobody was deemed suitable. A pathologist was appointed to Mullingar hospital with a specialist interest in cytology and there were also sessions in Portlaoise.
I met Dr. Naughton on many occasions. In fact, shortly after the cancer control plan was launched last September, he was one of the first surgeons I met when I opened the hospice in Portlaoise. At a very large meeting which many of the Deputies present attended he bravely said that although Portlaoise general hospital, where he is a surgeon, was not one of the designated centres, he supported the plan and would do everything he could to have it implemented. I thought at the time it was courageous of him to say this because there were many in the room whid did not agree with the plan. I have met Dr. Naughten on a number of occasions and he has never raised with me the concerns he expressed in that letter, nor has he ever said he was unhappy with the way it was responded to.
I repeat that resources required for mammography services and so on cannot be provided in over 30 hospitals. The hospital in question was designated against the best medical advice available. That is a fact but, unfortunately, the political system went along with it. To be frank, it would never come up to the plate because it was dealing with only 50 cancers a year. We knew then that unless a hospital dealt with 100 cancers, good outcomes would not be achieved. That figure has risen since to 150; standards are rising constantly. There are 250 publications worldwide on breast cancer outcomes and volumes of activity. Volume does mean better outcomes, a fact undisputed by clinicians.
In regard to briefings, on page 7 of his report Mr. Fitzgerald states:
On 21st November it became clear to all those involved in the HSE (including at corporate level) and the Department that a parallel review process for ultrasounds was still ongoing at MRHP.
According to Mr. Fitzgerald, that is when it became clear. That is a fact. When I informed the Dáil of these matters and was asked questions, I did so in good faith based on the information available to me. Mr. Fitzgerald comments in his report - it is a challenge for all of us - that the constant requirement for numbers led to many of the problems experienced. Former patients at Portlaoise who were not affected by these issues wondered if they were because they were hearing about different reviews through the media, which caused much anxiety. On patient protocols, from now on patients must be contacted first, promptly and personally before they hear about reviews through the media.
Regarding the media, I will repeat what I said yesterday. On that famous Saturday in November some of the women affected had to run the gauntlet of the media to get in to see the clinicians. Professor Hill told me at the time that that was unsatisfactory. They had to wake up to a headline that that day 95 women would learn whether they would live or die. All of us must learn lessons from the experience at Portlaoise, including me.
On patient safety, I have asked the Secretary General to involve the chief medical officer in the Department and his team in dealing with these issues. My office and those of the Ministers of State receive over 1,000 letters a week, frequently from patients or doctors complaining about something or issues raised by staff who work in the system. I have said previously that when I arrived in the Department of Health and Children I learned that people who worked in the health system liked to make known their critical views on where they worked. Perhaps that is not a bad thing but we receive over 1,000 letters a week. I have asked the Secretary General to involve the chief medical officer and his team at the earliest opportunity to ensure there is a clinical view of those letters and, as with the referrals, we can separate the serious ones where patient safety issues arise. The Secretary General is engaged in discussions on the matter.
Equally, in regard to communications with the HSE to do with reviews, we must ensure there are points of contact in the Department and clear lines of communication. That is a lesson all of us must learn.
Regarding Dr. Naughton's letter to the then Minister, Deputy Martin, when Deputy Reilly asked me about it, I asked the Department to carry out an investigation and it was unable to find any letter sent by Mr. Naughten to my predecessor. Of late I have not asked for further inquiries to be carried out but will do so in the light of what he said this morning. It was unable to find any correspondence received prior to the letter he sent to me in the summer of 2005.
I call Professor Drumm.
I put a question about the Minister's advisers.
I have just received a note from Ms Ann Doherty who says she did receive a letter as part of her inquiry. She might wish to deal with it.
And the issues of the advisers.
What is the issue with the advisers?
The report states the Minister's advisers received draft documentation in September. It further states on page 12, section 4, that there were too many lines of communication. It reads: "... in operation involving different people within the HSE, and different people within the Department and/or advisers to the Minister".
I have accepted that clear lines of communication between the Department and the HSE are important when it comes to investigations but if I am preparing to attend an event, come before this committee or answer parliamentary questions or respond to a matter on the Adjournment late at night in the House, I try to access whatever information I can.
Mr. Fitzgerald states on page 6 of the report that people became aware of the parallel ultrasound review on 21 November and that applies to advisers. An e-mail was sent, the facts of which I will give the Deputy. Europa Donna Ireland contacted one of my advisers wanting to know when the women in Portlaoise would be met. A query was put to the HSE. As part of the response, an e-mail was sent and it included a reference to a "draft for discussion". As Mr. Fitzgerald states in his report, that factually did not turn out to be what happened. Therefore, I do not attach any significance, as I said in a Dáil reply to the Deputy, to that matter. Mr. Fitzgerald makes it clear that it was on 21 November when people became aware of the parallel ultrasound review.
The point is that the message did not get through and the advice was given to the Minister's advisers instead of the Department directly. That is a fault line that must be addressed.
Will Ms Doherty clarify the issue concerning the letter? She is also with the National Hospitals Office.
Ms Ann Doherty
As part of the work of the review into the circumstances, I asked all the people I contacted to submit documentation. The Deputy is correct. Dr. Naughton, in part of his submission, submitted a letter he had sent to the then Minister, Deputy Martin, in April 2002.
With respect, Chairman, it is very serious that it was not available under the Freedom of Information Act to one of the newspapers or the Minister when she searched the file. It raises the question: did somebody interfere with the file?
The Secretary General is present. I did not personally go through all the files, nor did he, but we will investigate the matter. The search was made in good faith in the Department.
I will accept it was made in good faith but an investigation will have to be carried out into the reason it went missing from the file. That is a very serious matter.
To help us move on the Deputy might put those points when we are winding up the meeting. I invite Professor Drumm to respond.
Professor Brendan Drumm
The specific questions for me concern, first, the Dr. Ann O'Doherty comment which I have not heard this morning but which was relayed to me second hand, that there was an inevitable 1% delayed diagnosis rate in top class centres. There is no argument among us on that issue. It is the one question I have been asked since I arrived here, that we should centralise--
Would Professor Drumm repeat what he said?
Professor Brendan Drumm
I said there was no argument that one could minimise--
I refer to the comment about the figure of 1%. I did not catch it.
Professor Brendan Drumm
I am informed that she points to an inevitable 1% delayed diagnosis rate in high quality symptomatic services with triple assessments, etc. There is no argument about this. That is the reason we are trying to set up such centres. There is no argument--
That is not what Professor Drumm said.
The more members interrupt, the less progress we will make. They had their chance--
Professor Brendan Drumm
Let me be clear. If the Deputy wishes, I can give her printouts of everything I said and of everything Professor Tom Keane who made the same comments said at the press conference. It was clear that we were discussing the high risk associated with running centres. Despite the sequence of events - centre set-up, cancer centre, health board meetings, arguments, decisions taken at meetings to divide the service between Tullamore, Portlaoise and Mullingar against the advice of the cancer specialist appointed by the health board, further arguments and the inclusion of a facilitator to achieve the division - the HSE is accused of being responsible for the establishment in question. The matter might go even further back. Recently, the Journal of the National Cancer Institute showed far higher figures for false positive diagnoses. I could show the committee significantly higher figures for false negative diagnoses from studies done all over the world. Did we say this was acceptable? Absolutely not. Rather, we stated that the service should have gone long ago.
As I stressed yesterday, there are many service areas other than cancer. If I took the committee up and down trauma centres and intensive care units, it would find the same outcome unless someone decided to take and support the tough decisions on centralising services. Mortality rates in many units are too high based on the services as constructed. If everyone present is 100% behind the north east report and what will be introduced after the south and the mid-west reports are completed - it would not take Einstein to predict their contents - we should be fair and let the HSE get on with its work. Dr. O'Doherty and I are as one in our comments and any of the statements I made yesterday that members read will be 100% in alignment with this.
The problem remains, namely, if we run this centre or any centre like it in respect of cancer services or otherwise, the figures will be the same. Not for one minute has Dr. O'Doherty claimed that there will not be significant rates of error in centres run under these circumstances. When she mentioned the error rate of 1%, she was not referring to mammograms alone, but to the error rate when triple assessments are conducted. We agree with her in this regard and everything we stated yesterday is focused on achieving that error rate. I am glad to clarify the issue. If anyone can point out a statement I have made that is inconsistent in this regard, I would be pleased to address it.
Deputy Reilly referred to funding. We have consistently pointed out that there is a challenge of between €250 million and €300 million, particularly in terms of hospital sites. It may be larger depending on this year's demand-led schemes, as there was a significant growth in payments to the GMS, the primary care reimbursement service and the drugs repayment scheme at the end of last year. Some of this relates to increases in medical card issuance. For example, there would be considerable increases if the economy changed and there were many redundancies. For every redundancy, four or five people are covered by the GMS on average. This is an acceptable part of what we do and it is our responsibility to address these costs as they appear.
We have set considerable targets for cuts in areas such as supplies and travel for HSE employees, telephony and many corporate charges. As a single entity, our organisation has sought better value for money, not least in the pharmacy and other procurement areas, than was previously available when there was no centralised approach to purchasing. The question on the pharmacy issue concerned why we took action against pharmacists rather than against the wholesalers. We have determined a new wholesale margin. As I keep stating, what is occurring between pharmacists and wholesalers is for them to work out. To some extent, it is incredible that the public and the health service are involved in wholesaling. Can members imagine any other industry where a public service body has been contracted to determine how the manufacturer supplies its products to a retailer? I suspect it is a unique situation. How it started is questionable. What are we doing in a wholesale loop? Do members know of another major purchaser who is also responsible for setting up the wholesale link? I do not.
Members made many comments on the failures of the HSE, but it is interesting that pursuing reasonable value for money in terms of pharmacies is seen as and is being portrayed by many as our failure. Pharmacists' fees in 2005 amounted to €320 million and €370 million in 2007. To date in 2008, the fees have increased by 10%. In 2002, it was stated that rural pharmacies would disappear due to deregulation, but their numbers have increased significantly. In 2005, it was stated that they would disappear following the opening of the market to pharmacists qualified abroad. We will see what occurs in 2008. It would be interesting to return to this issue in one year and determine whether people would be willing to reassess the so-called demise of rural pharmacies honestly. I grew up in a rural town and have seen no evidence of pharmacies disappearing. Whether the demise of rural pharmacies is a genuine issue or is being used to challenge value for money for us and the taxpayer remains to be seen.
The IHCA is the major player in the consultants' contract, as the IMO has fewer members. The national executive of the IHCA will discuss the matter at the end of the month and put it to a vote of the IHCA's members. After it does so, I hope that a workable contract will be in place. Funding for consultants' appointments is dealt with in the same way as all other HSE expenditure. It is correct to state that the Estimates do not provide us with funding for all of the 100 plus consultants, but that is a challenge we face. It has had a positive effect and we are committed to it.
By any fair assessment, the number of people waiting on trolleys in accident and emergency units has reduced dramatically since we took over. It is easily forgotten. We can show the figures to anyone who wants to examine them. People state that the numbers at the Mater Hospital have been miscounted, but we do not run the Mater Hospital and I would be concerned if we had been given the wrong figures. Each day, our hospitals admit nearly 1,000 people and an average of 100 people wait on trolleys, a significant number of whom wait for less than six hours.
Hopefully, the consultants of the IHCA and the IMO will ratify the contract in the relatively near future.
As I have given this slot 30 minutes, people will have a chance to contribute later.
I welcome the Minister, Professor Drumm and their delegations.
I will begin with the Minister's point to the effect that, rather than being a matter of process and procedure, it is about patients. While this is the case and patients are the most important people involved, they will suffer and, in some instances, die if the process and procedure do not work. Most of my contribution will focus on process and procedure because, unless we get them right, things will not work.
I will start by addressing the question of whether the HSE is good or bad. In principle, everyone agrees that a centralised control system was necessary, but all of the decision making has been centralised, which was not supported. A proper chain of command would allow people at various levels to know their responsibilities. This is essentially what is wrong with the system and is the Minister's responsibility, not that of Professor Drumm, because she established it. There are many sideline managers, as it were, with an additional 600 people at grade 8 or above than previously, although I may be wrong. Some six new positions have been approved this year.
This goes to the heart of what the three reports have identified as being wrong. If I may, I will go into the specifics because doing so is necessary if we are to improve the situation. I am glad Ms Doherty is present because some of the specifics are in her report. In page 9 of her report she talks about structures. This refers to Portlaoise but I have no reason to believe the situation might not be similar in other hospitals. She says, with regard to roles and responsibilities,
"The review group found that there was a difference of opinion regarding these formal reporting relationships, for example, the Hospital Manager in Midland Regional Hospital Portlaoise, described his job as similar to the role of the Senior Hospital Administrator in the former Health Board structure and his understanding was that the reporting relationship of the Consultants, together with the Director of Nursing (DoN), is to the General Manager. The DoN confirmed that her post reported to the Network Manager."
Under the heading "Quality and Risk Structures", the report states, "There is no formal reporting relationship between Quality and Risk and hospital management." The report goes on to confirm that there were no medical consultants at the meeting on 28 August, when two of the major decisions were made. There were five different types of manager at it - a network manager, a general manager, a manager of strategic planning and performance management, a hospital manager and a risk manager - as well as a director of nursing and a clinical nurse specialist, which is appropriate.
There appeared to be parallel managers and people did not know to whom they were reporting. The clinical people do not appear to have had a say in any of this. I do not know if that is only true of Portlaoise but there is no reason to believe it might not be the case in other places. On one of the radio stations this morning I heard Professor Donal Hollywood talking about structures and conducting an audit. Do we know what is happening in the decision making process in various hospitals throughout the country? That appears to be crucial. If we are to learn anything from this, we must learn to have proper chains of control and management where we know who is responsible for what. In all three reports nobody is pointed out as being responsible because, genuinely, there is nobody responsible.
That is at the heart of what is wrong with the HSE. I do not blame Professor Drumm; the Minister should have put it in place properly. It is no good the Minister saying that if Professor Drumm says a number of people should be sacked, she will do it. She must take responsibility for how the organisation was set up. There is also no point in blaming the media for the distress of the women, and blaming other people for other things. The Minister must put things right; she should have established the organisation properly in the first place.
I also wish to refer to a statement from a coalition of organisations, including the Irish Cancer Society, Action Breast Cancer, Irish Patients Association, Marie Keating Foundation, Patient Focus, Reach to Recovery and Europa Donna. They say these reports demonstrate gross incompetence. However, they focus on the fact that the women concerned were not treated with the dignity and respect they deserve and were not as fully involved in the investigative process as they should have been. Dr. Ann O'Doherty said she will talk to the women today and she has explained why she did not talk directly to them previously. It was related to the patient and doctor relationship. Nevertheless, the patients have suffered mainly because of the structures.
It is interesting that Ann Doherty was able to get a copy of Professor Naughton's letter but the Minister was not. That again raises the question of how she gets the information that is required. Asking Professor Naughton for the letter might have been the way to do it, if the trawl in the Department had not yielded anything. We accept it was not possible to recruit an appropriate consultant radiologist who had the expertise in mammography, and that is included in one of the reports. However, can the Minister explain why there were no multidisciplinary teams and no triple assessment? That is the norm for a cancer centre, and this was the cancer centre for the midlands. I understand that the equipment was decommissioned. Why did nobody get an opportunity to examine it? We are told it was probably 15 years old, given the type of model, but nobody seems to know about the equipment or to have examined it.
The quality of the images is dealt with in detail in Dr. Ann O'Doherty's report. There are questions about the equipment which do not appear to have been anybody's responsibility in terms of the three reports undertaken. Why was that? I wish to refer to Professor Drumm's response regarding Dr. Ann O'Doherty. I heard her on "Morning Ireland" this morning. She said that the level of misdiagnosis was in the mid-range within inquiries into misdiagnoses, not within the mid-range in the normal diagnostic system. In other words, if one examines all the inquiries that were conducted in places where there was misdiagnosis, it was in the mid-range of those. It was not in the mid-range of the general diagnostic process. That is what I understood from her comments.
I wish to address two areas that are related. One is the waiting times for colonoscopies. It can be up to 18 months for public patients. In my region it is nine months, which is a concern. Will anything be done to address that in the next year? In reply to Deputy Reilly, Professor Drumm said he did not think the money was available to employ the extra consultants. There is a challenge of €300 million in the budget. The embargo has made the waiting times for outpatients even longer because staff have not been replaced. There is a large staffing issue with regard to waiting times. The Minister says that if we do not bring back the patients who have recovered, it will help but how much will it help? Professor Keane suggested that patients who have finished their treatments should not be brought back. That could be only of minimal help with the waiting times for colonoscopies.
My constituency is not yet included in BreastCheck. There is a misconception that because Cork and Galway now have fixed units, BreastCheck is available throughout the country. It is not. It will not be rolled out in areas that have mobile units, which is the case with Limerick and other parts of the west and south, until the end of 2009. In the meantime, I am told that even private patients in Limerick referred by general practitioners for mammographies are waiting approximately six months. Public patients must wait for up to 11 months. Barringtons was closed down due to the investigations and Professor Gupta of Limerick Regional Hospital has said that he does not have enough resources. That is one of the designated centres of excellence. Women's lives are at risk while we are in this transitional phase and we must protect them. We must also protect men's lives, which are affected by the colonoscopy difficulties. How will patients be protected in the next challenging year? Many of my other questions are technical but they are important for how we learn from what happened in Portlaoise.
I will invite the Minister and Professor Drumm to respond, after which the Deputy can ask two supplementary questions.
There were a number of questions about the Health Service Executive. If somebody really thinks that this committee could have 11 chief executive officers before it answering questions like Professor Drumm does very frequently during the year and that it would get the same level of interaction--
That happened every month, in public.
The Eastern Regional Health Authority had 50 members. It was more like a parliament than a board. If somebody can point to any error in the legislation establishing the HSE, we will fix it. However, nobody has come forward with an amendment. It is an issue of responsibility, and the first responsibility is that of the Minister. I take my responsibility seriously on these issues. For that reason I asked for reports so we could find out what happened. One cannot fix anything if one does not get the facts. A motion of no confidence in me as Minister was put down in the Dáil before we knew the facts. Now that the facts are known, I notice there will be no motion of no confidence.
Do not bet on that.
We should get the evidence, knowledge and facts, particularly in the case of health, before we make decisions. Information, audit and data should inform our decision making. What has really impressed me is the manner in which the HSE deals with audit, information and data when making decisions, supported by the Minister for Health and Children. Any Minister for Health and Children worth the job should support quality and safety in the first instance. However, we need the facts, the evidence and the information. We now have the capacity, which we never had before, to support quality and safety. Many of the things Deputy O'Sullivan spoke about happened under the health board. In 2002, when the Department approved the appointment of three consultant posts in cancer care in the midlands, the board was asked to ensure that triple assessment was undertaken at the specialist centre, to ensure that local guidelines and protocols were implemented and monitored, and to ensure audit and evaluation. The board did not do any of that but to be fair to the board, it would have been next to impossible to get a specialist in breast radiology for a hospital with 50 cases a year. From places I have visited in the past three years, I know how difficult it is to get these specialists even in large locations, but it is virtually impossible to get an international specialist here. They are sought after worldwide and we must accept that it is virtually impossible to get them in centres with small volumes.
A valid point was made concerning referral periods. Professor Keane told me, and has said publicly, that the volumes in which we recall patients to out-patients departments to see consultants after their treatment is very high in Ireland compared to other places where it is not best practice. Generally speaking, except in a minority of cases, when patients have treatment they should go back under the direction of their general practitioner. The fact that people who have had treatment are returning unnecessarily to their consultants means that consultant cannot see new patients to provide a diagnosis. Changing that system will have a big impact.
The new method of referral, which is now being discussed and agreed with the surgeons and discussed and possibly agreed with the Irish College of General Practitioners, will assist GPs in being able to refer in accordance with best international practice. It will separate urgent cases from less urgent ones. Many people who go forward for mammography do not actually need it, while many who need it cannot get it. We need to ensure that those who really require a mammogram have access to it quickly. I understand that Professor Keane is seeking to put in place a two-week referral period for urgent cases.
How will that happen with the current resources?
I am sorry to interrupt the Minister but we must suspend this sitting for a vote. We will get back as quickly as we can. I tried to secure a pairing arrangement with the Opposition but I was not allowed to do so.
In the interim, can the letter from Mr. Naughten to the Minister, Deputy Martin, be made available to the committee?
That is fine.
There may be another vote but in the interests of continuity, I propose that the Minister and I remain behind along with the spokespersons for Fine Gael and the Labour Party. Is that agreed? Agreed. Deputy Jan O'Sullivan was in possession.
The Minister was replying to me.
I also propose that the letter, to which we referred a few minutes ago, be circulated. There is not a big issue on doing so. Is that agreed? Agreed.
Deputy O'Sullivan asked the length of time it takes to get a referral for an initial diagnosis, specifically on mammography in the context of the mid-west. Many of the people referred probably do not need mammograms and many of those who do are not referred.
Surely general practitioners refer them. How can the Minister state they do not need mammograms?
Professor Keane is now working with the Irish College of General Practitioners and with the clinicians at the hospital level on a more appropriate referral route, in other words, to have consistency of referral to help general practitioners know the ones to refer and the manner in which one should refer. If there are 2,500 new breast cancers a year and 2,500 general practitioners, there would be an average of one per general practitioner and it is not an area with which general practitioners would deal on a frequent basis.
On management and governance, we approved the 12 top management posts in the HSE and I hope the HSE will be in a position to have permanent appointments in those posts as quickly as possible. I understand the HSE recently interviewed for a HR director. There have been difficulties filling some of those posts in recent years. One would hope that the permanent positions could be filled quickly and thereafter that there would be clear lines of accountability and responsibility. We must have that urgently and the wider lessons from the Portlaoise experience obviously must be taken on board. We have the people, in Professor Drumm and his team, who have the capacity to fix the problems that were identified and I have every confidence that will happen.
I hasten to add that I am not blaming the media and I exclude most media outlets from the comments I made earlier. I remember on the Saturday morning when the clinicians from Dublin, including Professor Hill and Dr. Allen, when down to Portlaoise, the women who were going to see them at the Cuisle Centre had to run the gauntlet of some media outlets trying to interview them. That evening I spoke to Professor Hill and he was upset that such was the experience of the women. That morning they had to hear from the media that 95 women that day would hear whether they would live or die, and that is not appropriate. I simply make the point that in future we want to ensure in the case of serious incidents when there are reviews and investigations when matters of this kind arise that as quickly as possible the patients are contacted, personally and directly, and that they do not learn from the media, the political system or whoever that they may or may not be such patients. Thankfully, we are speaking of more than 3,000 patients who Dr. Ann O'Doherty was able to reassure had nothing to worry about and in 600 ultrasound tests no cancer was diagnosed. That was encouraging. Notwithstanding that, even those women had to go through the anxiety, trauma and worry of whether cancer would be diagnosed, and that is a great pity.
Investigations and reviews in this area are not uncommon. There was one in Northern Ireland in recent years and there is currently one under way in France. We must have the capacity within our health system - the establishment of HIQA will greatly assist in this regard - to investigate and to inquire when issues such as this arise. I suspect in the past that would not have happened. Thankfully, because of the intervention of the director of nursing who, as Mr. John Fitzgerald stated in his report, was worried about over-diagnosis rather than under-diagnosis, these matters were investigated appropriately.
On the reports, we all have lessons to learn. We have identified what the problem was and we now must urgently put in place the solution to the problems identified in Ms Ann Doherty's report, Mr. John Fitzgerald's report and in Dr. Ann O'Doherty's report. From the end of March, I understand, breast surgery at Portlaoise will come to an end. Mammography has already come to an end there since the end of August and it will not be reinstated. That is the appropriate response to what we all know of the facts that emerged over recent months.
The Minister did not respond on the colonoscopy issue but maybe Professor Drumm will. The question of being recalled does not apply in the case of colonoscopy. If one needs a colonoscopy, one needs it. The point the Minister made in the case of mammograms would not apply to colonoscopies.
I remind members that the Minister has one hour left here with us. I am not cutting off Deputy O'Sullivan but reminding everybody here.
Professor Drumm
I will start from the bottom of the list because we have specific information on mammography in Limerick. Ms Doherty may wish to comment on that.
Ms Ann Doherty
On the symptomatic service, two to three weeks would be the timeframe for the urgent symptomatic service. Deputy O'Sullivan is correct that there is a significant waiting time for the non-symptomatic service.
Is it not urgent in the case of the non-symptomatic cases?
Ms Ann Doherty
The word the clinicians in Limerick use is "non-symptomatic". It is their view - as Deputy O'Sullivan stated - that those women would be far better served through a screening service, which is what the Deputy stated at the beginning.
I have spoken to women who have symptoms who have been told that they will have to wait for eight or nine months.
Ms Ann Doherty
I will follow it up again. I have just spoken to people in Limerick and they have told me that in symptomatic cases the timeframe is two to three weeks.
Urgent, yes; symptomatic, I am not so sure.
Ms Ann Doherty
Those were the words they used with me. I will follow it up and come back to the Deputy.
Professor Drumm
Is Deputy O'Sullivan asking particularly about waiting lists for colonoscopies in Limerick?
No. I am asking about the general figures up to 18 months.
Professor Drumm
We accept that the waiting time for endoscopy varies considerably up and down the country. For instance, the waiting time varies now from where in St. Vincent's Hospital in Dublin one can have an endoscopy provided from an accident and emergency attendance, to where there is up to a year's wait for a colonoscopy at the most extreme level in a couple of centres. The waiting time is not as long for upper endoscopy. We can probably get the specific figures for Deputy O'Sullivan.
I am not looking for figures. I am looking for something to be done about the fact that people must wait that length of time. Did we learn anything from the Ms Susie Long case?
Professor Drumm
We must set strict criteria. In terms of colonoscopy and upper endoscopy across the world, an area with which I am particularly familiar, it is a bottomless pit and we must set the criteria. We have been poor at working with the general practitioners. That is one of the things Professor Keane and the cancer control programme will do in the future. He will work with the general practitioners to set the criteria which judge the absolute priority so that we get the high-risk and medium-risk cases done with real urgency, as against the significant number where there is a low risk. We have failed to adequately separate those. We are working full time on trying to improve it. We have some centres where one can now get an endoscopy done out of an accident and emergency attendance, and we will continue to try to build on that.
On the question regarding Dr. Ann O'Doherty, I did not hear her comments but I am open to anyone referring to what I have said and finding a contradiction between our two viewpoints. Dr. Holohan heard Dr. O'Doherty's interview and perhaps he might like to comment on what was said.
Dr. Tony Holohan
Dr. O'Doherty stated this morning that the rate relating to the investigation at Portlaoise amounts to approximately 6%. She contrasted that with what would be the ideal rate in the best of centres in respect of which triple assessment, throughput and quality assurance would apply. She estimated a rate there of approximately 1%. The rate one would expect to get from a mammogram on its own as distinct from a mammogram as part of the triple assessment service would be substantially higher than 1%.
In terms of what I understand Professor Drumm of the HSE and Professor Keane to have said yesterday, it was that Dr. O'Doherty's findings are not surprising and are consistent with reviews into similar problems that had occurred. Dr. O'Doherty was directly and personally involved with one of those reviews. Those two views are consistent with each other. Dr. O'Doherty is saying that the context of the two is entirely different and this explains the difference in the rates. The 1% rate applies in the kinds of centres to which she is referring, namely, that at which she is currently employed and the type of facilities we are trying to put in place under the eight designated centres.
Professor Brendan Drumm
We accept that the multidisciplinary teams were not functioning fully. My understanding is that the pathologist and oncologist were based in Tullamore. The surgery was never centralised and was left that way as a result of a local decision between Mullingar and Portlaoise. Therefore, Mullingar hospital often needed to do breast surgery and Portlaoise hospital continued to carry out breast surgery. Radiotherapy was done in Dublin. We have no argument on that matter. It is absolutely the case.
On the investigative process, we will have an interim serious untoward incident response unit in place in a couple of weeks. This will be replaced by a permanent unit within a month. There will be challenges to be faced by everyone - the HSE, the Oireachtas and the media - in this regard because the unit will be obliged to operate on the basis that all information relating to investigations will have to be kept out of the public domain until such investigations are complete.
Members of the public will also face a challenge because a major decision will have to be made. A similar decision had to be made in other jurisdictions and was, to some degree, made in the case under discussion. The decision to which I refer relates to whether in circumstances where one is obliged to review 3,000 mammograms one informs all of the women to whom they relate that they are under review or whether one waits and then informs only those women in respect of whose mammograms a problem has been identified. That is not an easy decision to make. As a result of the process that has been undergone, it has been decided that at the beginning of a serious untoward incident investigation everyone should be informed. That is a judgment that will have to be made. It will be difficult, in many respects, to gauge what this will mean from the public's perspective because these reviews will arise from time to time. As stated earlier, one could begin conducting such reviews at many centres today in respect of various different processes that we operate.
I take the Deputy's comments on how the HSE is organised in a positive and constructive light. She identified many issues with which we will be obliged to deal. On the existing management structure, we must be careful with regard to using terms such as "temporary". Ms Laverne McGuinness and Ms Doherty were both national directors within the HSE when I took up my post. I have reassigned them to very significant roles within the organisation. However, they are not temporary directors. They are full-time directors and were merely reassigned to the roles they now hold.
I did not refer to temporary directors.
Professor Brendan Drumm
I accept that. I was talking about when we refer to the management structure.
The Deputy is absolutely right about the need for more local empowerment. She hit the nail on the head when she referred to the need for clinician empowerment.
As regards the level of confusion that can exist in the context of how our structures operate at local level - given that the HSE was established as a centralised body - we are in the middle of a process that will be completed in the next six to eight weeks and that will hopefully lead to us approaching our board with a proposal to address some of the issues to which the Deputy refers. We accept that this is the next step for the organisation's evolution. One of the major questions revolves around how clinicians can become more empowered. Professor Tom Keane and I are both clinicians and Ann Doherty comes from a nursing background. However, there is a need for more front-line clinicians to be involved in decisions regarding how our system operates.
Yesterday's events were played out in the context of there being a whole load of dysfunctional managers. It is unfair to people throughout the system - even those in the Deputy's area, where the local hospital works extraordinarily well - to describe them as being dysfunctional on foot of a specific incident that occurred. We accept our responsibilities in respect of that incident. However, what I do not accept is that there are not huge numbers of managers within our organisation and clinicians who are providing a superb service for patients on a daily basis. I will reiterate my views on that matter at every opportunity and we will move forward.
The other issue to which the Deputy referred is that relating to overall audit. I accept that the level of audit within our systems in respect of professional activity is not adequate. Matters will become much easier with the implementation of the new consultants contract because clinical directors will be appointed. One of the major roles of such directors will be to ensure that happens. I guarantee that this will present major challenges for the hospital system, particularly in terms of the workloads currently experienced in certain units and the maintenance of skills. We will take action on this matter quite rapidly when the new contract comes into play.
Does anyone know that happened with the equipment? Why was it not examined?
Professor Brendan Drumm
The equipment was--
Ms Ann Doherty
The service was discontinued and the equipment was decommissioned. That would be normal practice.
Professor Brendan Drumm
Unless the equipment is up and running, one cannot actually carry out the type of tests--
So it cannot be examined.
Professor Brendan Drumm
There is no doubt in Dr. O'Doherty's report, and from our discussions with her, that it is clear the issue does not lie with the equipment. There are issues in the context of how equipment was used, how images were processed, etc. I return to the fact that matters of this nature would be dealt with much better in a centre catering for huge numbers of people. That is the goal we must try to achieve.
I do not usually contribute and I prefer to leave it to members to do so. However, I wish to clarify a number of points in the context of what the Minister and Professor Drumm said happened in the midlands. I was a member of the Midland Health Board from 1985 to 2002. The impression being created in response to what happened at Portlaoise is that politicians drove the process which led to the three centres at Mullingar, Portlaoise and Tullamore being divided. I wish to outline the background to this matter. I do not want to apportion blame and I recognise the huge concerns for the women involved and their families.
In 1994, the then Minister, Deputy Noonan, brought forward the national cancer strategy, which I fully supported. In that strategy, Tullamore was designated as the lead centre for cancer treatment. In the months that followed, many public meetings were held in counties Laois, Offaly and Westmeath in an attempt to change that direction. I invited the political representatives, their medical counterparts and the Portlaoise Hospital action committee to meet Deputy Noonan's successor as Minister, Deputy Cowen, and Professor Jim Fennelly from the Department of Health and Children. During the debate on this matter, I was accused of selling out my county and supporting the Tullamore option as a result of my friendship with Deputy Cowen. The impression was given that Deputy Cowen informed me that I had to opt for Tullamore, which was nonsense. Two county councillors and I were the only public representatives in County Laois to support the designation of Tullamore under the national cancer strategy.
I am highlighting this matter because the impression has been put about that politicians intervened in order to vote down expert medical advice on the division of the services. I do not want to reopen old arguments. However, this matter is worth considering. When we decided at health board level to designate Tullamore as lead centre, a High Court challenge was brought. As a result, two valuable years were lost while the matter was before the courts.
I wish to establish one point. The politicians did not decide that the service should be divided between Portlaoise, Mullingar and Tullamore. It is worthwhile for the sake of clarity that politicians acted in response to the medical argument, persuasion and representations to divide up. We made it quite clear time and time again that we were not medical experts. It is not a matter of selecting one group to blame. We all share the blame for everything that happened in the midlands. It was one of the first boards to deal with the location of cancer services. It is important not to decide glibly that politicians acting under pressure divided the services over two years. There were constant faxes, messages and meetings with the medical staff in all the hospitals and they convinced the board members that Tullamore would be the lead centre. This is important to remember.
I take Professor Drumm's point. I fully support him, the HSE and the Minister. It would have made no difference if all the chief executive officers had been in place. Things are better now with one person answerable to the committee.
The sad part of these debates when issues affect local hospitals is that, naturally, local politicians come under pressure. The provision of ten specialist centres will reduce that pressure. It was not in my best interest to support Tullamore. However, those who opposed it at the time now recognise that one centre serving the entire midlands region would have been much better. For the sake of clarity, it is important to put that in the mix.
The problem was a designated centre was not funded. It was not provided with a pathologist, a radiologist, a team leader or a modern machine.
I am not dodging that. I call Deputy Blaney.
I thank the Minister, Professor Drumm and the HSE delegation for attending. It is a welcome opportunity to meet them, given the timing of their appearance following the publication of the Portlaoise report. I commend them on the manner in which they conducted their investigation. Politicians have been crying out for this type of investigation in the health service for years. They want services to take responsibility and undertake proper investigations. When the status of the nine patients was uncovered, many politicians jumped up and down and called for heads to roll and so on. Thankfully, the Minister and Professor Drumm did not bow to them and, as a result, we have reports and we know where we stand. Only now can they consider the action to be taken and they should be commended for the way they conducted the investigation. Thankfully, the nine ladies can rest assured as a result of their reports that their lives are not in danger in the short term.
I refer to the comments about the old health system. I was a member of a health board for four years and it is not fair to say chief executive officers could take decisions and they had responsibility for everything. Behind the scenes they told board members about the problems they had securing accident and emergency department funding to introduce new measures so that people would not have to lie on trolleys or have to wait between six and 36 hours for treatment. Three years ago, the issue of accident and emergency departments was the hot potato in the health system but there is no word of it today. That says a great deal about the HSE. All is not rosy in the garden and I do not expect it to be tomorrow or next year because the executive still has a great deal of work to do, but the quicker the cancer issue can be parked and everyone gets behind the cancer centres to allow those with the expertise to get on with the work, the better for everybody, particularly patients.
The Chairman referred to the proposed closure of Portlaoise hospital in the 1990s. Will the Minister or the chief executive officer inform the committee why that was proposed and why there was a U-turn on the decision? I would like an update on cancer service provision in the north west on a cross-Border basis because it is not mentioned in the reports.
The committee has had many deliberations on the pharmacy issue. We have debated the issue for hours and it centres on the wholesale price. I still not have received clarification on the HSE's agreement with wholesalers. The committee asked for a copy of the agreement and the best any member received was a telephone call. As a member of the committee, that is why I have a problem with the officials dealing with the pharmacists. I put my back behind the officials first day when I was informed by them that the HSE had an agreement. To this day, I have not received proof of such an agreement. All we have is word of mouth and nothing in writing. I would like clarification on this. I welcome the setting up of an independent body to negotiate the new contract but I would like the issue to be put to bed in the intervening six weeks for the good of all concerned.
I also welcome the work of the HSE, Professor Drumm and the Minister on the consultants' contract. That will have massive positive reverberations across the health service. Neither the Minister nor Professor Drumm commented on that but perhaps they will comment on the positives of the contract for the health service.
Referrals are an issue across the board and not only in regard to cancer services. The waiting times for patients are a major problem. Perhaps they will outline in detail what they are doing about that.
Are there plans to cover orthodontic treatment under the National Treatment Purchase Fund? If so, when will that happen?
When will the Dunne inquiry report be published?
I thank Deputy Blaney for commenting on some of the positive developments; he did not have specific questions.
With regard to why the issue arose in Portlaoise, the Chairman knows more about the background and he has explained it well so I will not go back over the reason. There is no point in going back over what we now recognise was a failed system with low volumes. Excellence cannot be achieved through low volume whether that is in Portlaoise or anywhere else in the world because it is not possible. It is equally extraordinarily difficult to recruit the specialist staff to such places and that is recognised globally.
Following the designation of the breast centre in Portlaoise on 4 November 2002, the Department approved three consultant posts. I outlined the conditions earlier. That was following the letter I have now seen that was sent to the former Minister, Deputy Martin, in April of that year.
There is significant North-South co-operation. The HSE has a service level agreement with Belfast City Hospital on radiation oncology. The take-up has not been as high as we anticipated, but some patients have been treated and others are currently being treated there. We also hope to have a satellite centre in the north west linked to Belfast City Hospital, which is a specialist centre for radiation oncology. There are ongoing discussions on that.
We have had discussions on paediatric care between the two Departments and the HSE has had discussions with its counterparts in the North. When the new national paediatric hospital is in place, we hope many of the treatments currently carried out in Birmingham, Manchester or London for children from Northern Ireland will be performed in Dublin. We are also a part of the North-South-US cancer consortium. Significant assistance has been provided to us as a result of the agreement reached as part of the follow-up to the Good Friday Agreement and huge support and expertise has been made available to us from the National Cancer Institute in the US. Recently, I established a group to consider bio-banking on a North-South basis. Therefore, there is much good North-South co-operation.
I add some further comment on children's cancers. These are organised on the basis of centres of excellence at Crumlin hospital, even though in some cases the treatment is delivered in 15 or 16 other places. The National Cancer Registry showed in 2007 that the five-year survival rate for childhood cancer in Ireland was higher than the European and US averages and was significantly higher for acute non-lymphocytic leukamia. This proves the point. I do not like to call the treatment facilities centres of excellence because every health care setting should be a centre of excellence, but when we have specialist centres to deal with high volumes we do much better. I hope that what is happening in the area of children's cancer will lead to similar experiences with other cancers.
We have spent a long time seeking to negotiate the consultant contract. It was not a question of a new contract for the sake of it, but to get the right contract that suits the needs of the public healthcare system for the future. Of particular importance to me, the Government and the HSE was the issue of access for public patients. We wanted one-for-all access to outpatient and diagnostic services and wanted to be able to control and reduce the level of private practice in our acute hospitals. These hospitals are fully funded by taxpayers and staffed by people paid by taxpayers, but in recent years there has been an increasing level of private activity in them. In one hospital in Dublin recently, half of the elective procedures were on private patients, which does not reflect the catchment of the hospital or the make-up of accident and emergency patients. The new contract that has been agreed is significant for the public healthcare system and I hope that at the end of the month the Irish Hospital Consultants Association will be in a position to recommend it to its members.
We want to move from a situation where our hospitals are dependent on 4,000 junior doctors and 2,000 consultants to one where we have 4,000 consultants and 2,000 juniors. As I said in the Dáil yesterday, as a result of the way we run our hospitals with non-consultant hospital doctors and overtime, etc., the employing of consultants will not be that much more expensive when we reduce the number of junior posts. The appointment of clinical directors with responsibility is a significant move, as are the introduction of longer working days and structured attendance at weekends. All of these changes will greatly enhance performance in our public hospitals.
The National Treatment Purchase Fund has been a great success. It is, effectively, a universal insurer. The scheme has now treated 100,000 patients and I had the pleasure the other day of presenting a bouquet of flowers to the 100,000th patient, Ms Catherine Kennedy from Clara in County Offaly. She had complex spinal surgery performed in a private hospital in Dublin which was paid for by the fund.
Deputy Niall Blaney is from Donegal. Four hospitals in the country account for 50% of the waiting lists and they are very poor referrers to the fund. One of these is Donegal and another is Tallaght. I am concerned that while there is treatment available for patients, they are not being referred for it. This is not acceptable. I have spoken at length to the administrators of the fund and to Professor Drumm on the matter. We must decide together how we can get the required treatment for the patients. They are the people who come first. There is no justification for Tallaght Hospital, for example, not referring patients to the fund when the resources and capacity exist to treat the patients. Patients do not care where they are treated, once they get the appropriate high-standard quality treatment.
With regard to orthodontic treatment, a review of dental treatment is under way and will be completed in the summer. Hopefully, it will be an innovative policy review. In the early days of the National Treatment Purchase Fund some orthodontic work was carried out. I am open to that if possible. However, the problem with orthodontic work is that it is ongoing and not a once-off procedure. The role of the fund is to provide for a procedure and a follow-up appointment. Some pioneering work has been done and appointments with clinicians were arranged for 22 outpatients. The outcome of that initiative has been significant. Over one-third of the patients did not require any follow-up treatment. Sometimes people are on the list for an outpatient appointment, but once they have had it they do not need further treatment. The fund is not geared up to provide ongoing treatment. However, in specific cases and in some regions of the country where there are particularly long waiting lists, we may be able to use the fund to deal with some issues. I intend to discuss that matter with my officials and with the fund administrators.
The Dunne inquiry went on for a number of years and cost in excess of €20 million. When the report was produced to me, the strong legal advice of the Attorney General was that it was not fit for publication. That remains the advice and I am not in a position to go against it. After receiving the Dunne inquiry report, we appointed Dr. Deirdre Madden to carry out an inquiry. She reported and we are implementing her report. She saw all the documentation to which Ms Anne Dunne had access that was part of the Dunne inquiry report. Some matters have been published as a result of freedom of information requests, but I am not in a position to publish the report, based on strong legal advice. The Dunne report was not a completed report in that sense. We know from previous inquiries and reports about the legal situations that can arise in such cases. Those adversely commented on in such reports must be given an opportunity to respond, that response must be considered and so on.
I agree with the Minister with regard to the National Treatment Purchase Fund. The Minister mentioned Donegal where there is an issue with patients not being made aware of the availability of the fund. Also, some hospitals are not as forthcoming with information or as helpful as they could be, certainly not as helpful as the national line. If there was some direct contact on the issue, matters would improve.
I want to keep the discussion moving and to ensure that every member gets the opportunity to ask questions. I ask members to allow us group some of the questions.
Before proceeding, could I hear Professor Drumm's comments on the questions already raised?
Professor Brendan Drumm
I will go through them quickly, but may need more time on the pharmacy issue. On the consultant contract, we see huge cost benefits from introducing clinical directorates. Clinicians will bring more accountability into the system, will prioritise patients more clearly and will begin to come to the frontline where the systems are managed. The introduction of an 80:20 contract in terms of public-private mix will also be a positive move. It does not mean that someone's income will be reduced, because if consultants keep public patients going through the system, they can also put more private patients through it. We believe that is possible.
This issue also links to Deputy O'Sullivan's question about waiting times. We now have detailed metrics across the hospital system that we started using last month and they will be available for the community within the next two to three months. This afternoon, I will attend a meeting on the use of those metrics. The metrics will allow us say how many outpatients are seen, how many are new and how many are follow-up patients, for each clinic and hospital across the country. We will work with the consultants on this because in some places waiting lists are much lower than in other places. We need a sense of urgency in dealing with this issue.
We also intend to focus on child and adolescent psychiatry in the community area this year. We believe patients in some parts of the country are dealt with much more effectively than in others, because of the use of people such as clinical nurse specialists. We need co-operation from every member of the team to ensure that patients are not inconvenienced by a structure that insists they can only come through one point in the team. We believe those services can be greatly enhanced. Another example which is up and running across the country is that of people with back problems all of whom must be seen by an orthopaedic surgeon. We now have structures in many places where physiotherapists, with the co-operation of the orthopaedic surgeons, see those patients in advance of the orthopaedic surgeon. The number of patients that can be removed from that list is significant. We are looking to roll out this system. Many of these waiting lists could be dealt with by using more innovation than just putting in more of the same people who are currently seeing those patients on those lists. However, I do not think we will ever solve some of them.
The pharmacy question is a serious question with regard to the wholesalers. I will ask Professor Sabra to comment. He is an expert on the issue and is more likely to provide total clarity.
Professor Kamal Sabra
With regard to the wholesalers, as explained to the committee previously and in our correspondence regarding the 64 or 68 questions to which we replied, we had a meeting with each wholesaler to clarify the issue of whether any pharmacist would be overcharged. They confirmed to us in the HSE offices, in the presence of nine people, that this will not be the case. We told them we will not allow any pharmacist to be overcharged. We said if this is a model then we will have to tender. In the past two weeks the Minister announced that if this happened, we would go to tender on the wholesale issue.
I have copies of three letters to their customers from United Drug, Cahill May Roberts and Uniphar. I refer to the letter written by United Drug. All those wholesalers own large chains of community pharmacies. United Drug stated in the letter, "We will seek to ensure that customers will not buy medicine at a loss from United Drug;". Cahill May Roberts in its letter stated, "We will support our customers on an individual basis under our current terms and conditions" and that no pharmacist will be charged more for their medicines. The Uniphar letter stated, "Uniphar reserve the right to maintain trading terms and to support our customers and shareholders on an individual basis".
We clarified the matter and I circulated letters from the pharmaceutical industry, from most of the companies, GlaxoSmithKline, Leo Laboratories, Pfizer, etc. These letters have been circulated to all members of the committee. I refer to a letter from the managing director of United Drug which states; "We will supply to ensure that customers will not buy medicine at a loss from United Drug". The letter from GlaxoSmithKline states that no retail pharmacist will dispense medicine at a loss due to the new reimbursement system operating from December. The letter is dated 1 December. The three wholesalers confirmed to Pfizer that the net monthly cost for reimbursement product will not be greater than the amount reimbursed by the HSE.
These letters have been circulated. People have stated in this committee what is disingenuous information. The facts are that in 2006 the dispensing fee paid by the HSE to every individual pharmacist totalled €320 million in 2006 and in 2007 it was €370 million plus €30 million outstanding to pharmacists if they fulfil certain conditions and it then goes to €400 million. Up to January and February 2008, those figures have increased by 10%. The fees received by pharmacists are increasing by 10% year on year. We have the details for each individual pharmacist. These are the facts and this is not a spin by public relations companies. These are the facts and the figures.
On a point of clarification about Deputy Dara Calleary's letter--
I ask members to hold fire for a moment. I thank Professor Sabra. I remind members that we have invited the wholesalers in and they have responded this morning and they will be here in the next two to three weeks. We will then have every opportunity to tease out these issues. I must move on. There are nine people waiting to contribute and the Minister must leave by 12.20 p.m.
There is nothing new in what Professor Drumm has told me about the wholesaler issue, nor in what he has handed me. He outlined to the committee on the first day that the HSE had agreement across the board with the representatives of all the wholesalers. What the HSE has is a loose arrangement with the wholesalers and it is not representative of all wholesalers because we have letters from wholesalers to say there is no arrangement. This is our problem and that has been my problem from day one. As a public representative this is an obvious problem. The issue still has not been clarified.
Under the Freedom of Information Act and with regard to the Dunne report can the Parents for Justice be given access to information received by Ms Anne Dunne?
That is an issue to be dealt with by the Department of Justice, Equality and Law Reform.
Professor Brendan Drumm
I think we have given the committee all the information we have on the wholesale issue. We are not going into negotiations with the wholesalers.
We were not given clarity from day one.
We can clarify that separately at our next meeting. I ask the delegation to give a response to the question about the Dunne inquiry.
The freedom of information legislation is not a political function and it is not a function of the Minister but rather a matter for the FOI officer in the Department, subject to the law. I will ask the Secretary General to deal with that question.
Mr. Michael Scanlan
I confirm that the Department received a request which we looked at under the freedom of information legislation. We took quite a deal of advice over what might be possible to release under the Act and what would not be possible. We have released the information and all the information which we believed is allowable under the Act. Our advice said that all the rest of the information in those boxes had significant legal flaws and we could not release that information under the Freedom of Information Act. I emphasise that officials were doing their best to interpret the legislation and apply it.
I ask members to ensure their mobile phones are switched off. I have been informed from the media people upstairs that they cannot hear what is happening.
I will endeavour to allow as many people as possible to speak. I want to recognise two Deputies who are not members of this committee, Deputy Caoimhghín Ó Caoláin and Deputy Olwyn Enright, who has a particular interest in the issue of the breast cancer problem in Portlaoise. I hope to accommodate both these non-members.
The Minister must leave the meeting before Professor Drumm so there will be a few minutes after the Minister's departure. I will ask Professor Drumm to respond to members' queries after the Minister has left, unless there is something very pertinent to the Minister.
The Chairman will know that I am usually brief in my questions because it is important that spokespersons are given their time. In this instance because of the importance of the meeting I will take a little longer.
I know some of the members of the delegation because I have worked with them. I do not believe any politician blames the HSE for the mess we are in. Our difficulty is that as Deputy Jan O'Sullivan pointed out, there appears to be no structure of responsibility, no direct chain of command. If something goes wrong, who takes responsibility? I am not in the business of saying that people should be fired but someone must be responsible. We are not talking about McDonalds here or an independent franchise with branches around the country, we are talking about a system for delivering a health service to the people. It is far more important that reviews would be carried out on an ongoing basis rather than the type of crisis report that we appear to be getting because something has gone tragically wrong. This needs to be said. I can understand why people at the other side would have a deal of resentment. The nine women from Portlaoise and the women who were misdiagnosed in Cork and Limerick expect us to ask the questions they do not have an opportunity to ask. They might not have thought of asking some of the questions we are asking because they are not familiar with the system. They expect their public representatives to ask such questions. We would be failing in our duty if we did not do so. It is important that we ask questions of this nature.
Although Professor Drumm has on three occasions referred to the judgment of an expert on what is happening with the wholesalers, we are none the wiser. Perhaps someone should be employed to do a bit of spinning. It might make things clearer. We are still not certain how pharmacists are expected to negotiate with wholesalers while delivering a better service. I do not understand why the HSE will not negotiate with the Irish Pharmaceutical Union. I am sure we will get to that point at some stage. People are suffering as a result of what is happening. I do not know how many enemies one can make in lifetime, but some records are being set.
I will talk about matters relating to Cork, which I represent. I have seen a letter which was sent to the network manager in the HSE about the new maternity hospital in Cork. I was at the opening of the hospital in question, at which Professor Drumm and the Minister spoke. Ms Ann Doherty was instrumental in the establishment of the facility. Nobody who has visited the facility will deny that it is a magnificent building and has the potential to provide a magnificent service. I am not sure whether it was the Minister or Professor Drumm who said on the day of the opening that the facility is the best of its kind in Europe. I agree with that statement, with one or two reservations.
The letter I have mentioned was sent to the HSE network manager by a group of GPs, who claim that they encounter serious difficulties in getting their patients seen initially. Although state-of-the-art mechanisms have been put in place in the new building, patients have to wait long periods for treatment or investigation. The GPs said that when they try to refer patients with post-menopausal bleeding, approximately 15% of whom transpire to have malignancies, they can expect to have to tell them to wait a few months. The GPs suggest that the many difficulties in the new facility - for example, theatres have not been fully equipped and opened - mean that it is a disaster waiting to happen. Patients are already suffering a great deal of distress and anxiety as they wait for investigation. It is likely that some patients will soon suffer the terrible consequences of delayed diagnosis of cancer, with a worse prognosis because of the inadequacy of the service.
When I raised this issue with the Minister last November, I was told that the whole system had been geared up. For example, the HSE was advertising for the staff needed to open the two obstetrics theatres which were closed at that stage. They have not yet been opened, however. There is now a waiting list in Cork. That is why I am talking about reviews rather than looking back at what happened. We need to deal with this problem by putting in place the services which are necessary to prevent events like those in the midlands. Health should be about prevention. We spend more on health care nowadays because we are more knowledgeable about what can go wrong as we get older. If we do not deal with what is happening in Cork as a matter of urgency, what happened in the midlands will happen again.
I would like to ask the Minister a question about a matter which I am sure she will say is more appropriate to the HSE. I would like her to answer it, however. The questions Deputies table to the Minister for Health and Children tend to be automatically referred to the HSE. When we eventually get answers to those questions, the answers we are given are often incorrect. I am being polite by using the word "incorrect". What comeback do public representatives have in such circumstances? How can we represent the people properly in those situations? I have significant worries in this regard.
As the Labour Party's spokesperson on disability issues, I have been working for the last few months with the mother of a 25 year old man who has Down's syndrome. He is in terrible discomfort because he needs dental treatment, which will have to be done under anaesthetic. When I did all my business in this case in the normal way without clogging up the business of those who have to answer questions, I was told that the service being sought is available and that there is no dispute in the dental hospital in Cork. I later learned that it is not available and that there is a dispute. What is the situation? Can people over the age of 16 with special needs get dental treatment in Cork under general anaesthetic?
I ask the Deputy to conclude her remarks.
When the Minister is replying, will she update the committee on the state of services for children with diabetes in Cork? The service should not be in the appalling state it is in.
I wish to ask about the insurance indemnity for independently employed midwives. I understand they will not be insured from 31 March next. What is the position of the sub-committee in that regard? Why is it not extending this indemnity? Home births will be affected.
I have to rush the Deputy.
Okay.
I remind Deputy Allen that members are asked to confine their contributions to three minutes.
As Chairman of the Committee of Public Accounts, which is currently meeting next door, I find it unsatisfactory that this important meeting of the Joint Committee on Health and Children, of which I am also a member, is taking place at the same time.
That will not be happening any more.
If my questions seem to be out of context, the witnesses will understand why that is the case. I would like to ask the Minister and the HSE about the allegation in the Irish Examiner that the accurate number of cases of misdiagnosis resulting from the work of Dr. Geagea in Cork was suppressed on foot of an agreement reached by an official in the press office of the HSE, who I understand has since departed that position, and officials in the Department of Health and Children. It has been suggested that the true figure for the number of people who were misdiagnosed was suppressed to avoid “public alarm”. Will the Minister and Professor Drumm confirm or deny this story? Are the Department and the HSE covering up the truth of what happened to patients at Cork University Hospital? Professor Drumm told me at a recent meeting that negotiations about the accident and emergency department at the Mercy Hospital in Cork are ongoing. He said the situation at the hospital will be resolved shortly. What is the up to date position in that regard? What is the position regarding the Drogheda hospital project?
I will not dwell on all the information in the reports. I will let the representatives of the midlands area deal with that matter. My only question on cancer services relates to the cervical cancer screening and vaccination programme. What progress has been made with the programme? One of the lessons we have learned about cancer treatment over the years is that early diagnosis is essential. We need to get moving on that as soon as possible. I accept that a new regional hospital is needed in the north east. When will we know where the new hospital is to be located? We were told that the decision would be announced in November or January, but those dates have passed. I am anxious to get that information as soon as possible.
My other questions relate specifically to the north east. The leaked memo of a few weeks ago made stark reading for those who had access to it. I accept that patients are the top priority of every member of this committee. That will continue to be the case. I do not know whether the leaked document was a discussion paper or a preparatory memo. It showed that cuts in front-line services were planned, which would not result in better outcomes for patients. If better outcomes are to be secured, we need significant investment in community care services, the roll-out of the ambulance service and the development of techniques like thrombolysis. We are not near that stage in the north east.
When Monaghan General Hospital was taken off call, ambulance crews would pass its gate en route to Cavan. Unfortunately, some people never completed the journey to Cavan. I do not want and could not condone circumstances in which this would happen in future. It is a matter of great concern to people. It was pointed out to me that fear of something is dreadful, even when it is does not materialise, and that if people are afraid or worried that something will happen it has consequences for their mental health. This is a serious concern.
I welcome the HSE's reference to having audit and review, which are needed in the north east. The Cavan-Monaghan area has a deficit of €9 million in the area of health. If it was a business, this level of deficit would not be allowed to continue without a serious look being taken at where savings could be made. While I have no problem with that, I have grave concerns if this process were to result in cuts that hurt patients, created longer waiting lists and waiting times, resulted in fewer procedures or impacted on front-line services.
I am also concerned about the famous CT scanner I have mentioned on numerous occasions, which is now housed in a shed somewhere in Monaghan at a substantial weekly rental expense. On average, six to nine patients travel to Cavan each week to have CT scans. I cannot understand the reason this facility cannot be used in the hospital to carry out diagnostics. It does not make sense that private ambulances must be employed at considerable expense to transport people to Cavan to have these procedures when rent is being paid to keep a scanner in a shed.
I agree with Professor Drumm on empowering managers and clinicians and giving them greater autonomy. Managers have told me that as clinicians and practitioners, they know what is happening on the ground and what is needed. By the time the plans and proposals they submit have wafted their way to the top and are returned to them, the original suggestions are often unrecognisable. The expertise of these individuals must be considered.
I am also very concerned about referrals. I am aware that in cancer services access to initial assessment appointments are the only large waiting lists. While we still have long waiting lists, people recognise that they get very good treatment when they get into the system. The problem is getting into the system. When one hears of people receiving letters at the end of January indicating that an ear, nose and throat assessment has been scheduled for November 2008, it is clear there is a systems failure, if one pardons the pun.
I ask the Deputy to conclude.
It is not acceptable to wait so long for assessment. General practitioners in the north east have been told that for the next four months they may not refer children or adolescents for mental health or psychiatric services unless the case is urgent. This is a matter of grave concern.
We must try to allow everyone to contribute.
Why can we not use the complex in Monaghan? It is on its own and a centre of excellence.
Did the Minister consider resigning when she read the reports yesterday and, if not, why not, considering she has been in Government for ten or 11 years, four of them as Minister for Health and Children? I ask this question because these reports are a damning indictment at both the clinical and administrative level. The Minister said she was responsible, whereas the reports state that nobody is responsible. What precisely is the role of the Minister and her Department? It is of a very shadowy nature according to these reports and we may need another report to examine it in more detail. Perhaps its role was not examined in detail because of the terms of reference. I note, for example, that the Minister's adviser was not interviewed.
It is one thing to defend the setting up of the HSE and say the health boards did not work, as the Minister did, but the question is how the HSE is working at the moment. If these reports gave us a bird's eye view of what is happening in a particular circumstance in which a crisis arose, any person - the ordinary consumer or patient - must ask what they tell us about what is happening elsewhere and whether this is the tip of the iceberg.
The main finding, which I will repeat, is that there is a systemic weakness in governance, management and communication within the HSE. The reports also note that there was inconsistency and lack of clarity in communications, which was the inevitable result of the deficiency in overall management. Nobody is responsible. They then repeat that communication was inconsistent, confused and contradictory. In point after point, the reports state that people did not know their jobs, roles and responsibilities and there was confusion. The authors were asked to examine a particular incident, a crisis. One would be forgiven for asking what is going on in cystic fibrosis services and with regard to the 400 people on trolleys in accident and emergency departments in January and all the other concerns we have about the health service. Is there the same confusion of roles, responsibility and authority as is outlined in the reports?
I ask the Senator to conclude as we have five speakers.
People have had considerable time to speak.
That is a matter the Senator may discuss with her colleagues. It is not my problem.
I want to make a number of points and I will ask my questions.
I ask the Senator to be conscious that five people have not yet spoken.
I accept that. On the clinical side, the most important issue is that women have confidence in the system and centres of excellence are in place. This is absolutely clear from the report. I would have expected the Minister to come before the joint committee with a detailed plan of action on how these deficiencies will be addressed. Will she do this?
I do not have time to discuss in detail the conclusions of the Travers report. Basically it stated that the Minister should have had full and periodic briefings on key issues of policy and operational performance. We have learned today that in another letter, written two years previously, Mr. Peter Naughton informed the Department about his concerns after Portlaoise had been designated a centre of excellence. Despite its designation, the hospital did not receive the resources. Who is responsible for that?
On the cutbacks in front-line services, there are reports of a further €400 million being cut--
The Senator should ask Professor Drumm questions after the Minister leaves.
That is fine.
Senator Feeney and Deputy Dan Neville are waiting to speak.
Am I on the waiting list?
Everyone present will be able to ask questions.
We should learn from the reports. While we cannot forget the pain the women and their families have gone through, we should try to move on. I listened to Dr. Ann O'Doherty say this morning that she moved from the UK to Ireland ten years ago and that what happened in Portlaoise would not have happened if the women were treated in specialist centres.
The important point in this regard was made by the Chairman and I thank him for outlining the position that obtained in the midlands ten or 15 years ago. Politicians are told not to interfere and we will not do so. However, if they are to be blamed for interfering, can the same message go out to the medics, the doctors and clinicians? Can they be asked to stop interfering? I recall that the man from whom we have the letter was one of the people who went out carrying placards and seeking to retain the service in the midlands and have it fragmented among three different towns. The distance from Portlaoise to Mullingar must be 50 or 60 miles. What kind of a service can that deliver?
I want to know the position regarding the roll-out of BreastCheck to the north west. Should I ask questions of Professor Drumm later?
We are trying to wrap up questions to the Minister.
In that case, I will put the questions I wished to ask the Minister. In light of the report, will she outline where the specialist centres will be, the timing involved and how the funding will be allocated? Has Professor Keane visited all the centres and has he visited the hospitals that will lose out as a result of the centres?
I thank Senator Feeney for being so concise.
Because my time is limited I wish to deal specifically with two issues. One relates to the delivery of the roll-out of the recommendations of the mental health strategy, A Vision for Change. Through freedom of information we learned in January that the €51 million which we were repeatedly informed would be spent on the roll-out of the strategy in 2006 and 2007 was not spent for that purpose. Only €27 million of the total was spent. I have a letter from the Health Service Executive dated 18 October which states: "This includes an additional €51 million which was allocated in 2006 and 2007 for the development of our mental health services in line with A Vision for Change".
That money did not go towards A Vision for Change, it went towards the deficit in that section. The report explicitly stated that €25 million in additional moneys each year should be allocated for a seven-year period for A Vision for Change. No allocation was made this year, just three years into the seven-year period. It appears that the pronouncements made at the launch of the strategy have now been abandoned.
I asked the Minister of State about this matter yesterday. He told me that despite all the statements from his predecessor, the then Minister of State, Mr. Tim O'Malley, that this was being rolled out over the past two years, the HSE board only approved its implementation plan for A Vision for Change on 14 February 2008. That is two years after we were told this strategy was being rolled out. I received a glib answer from the Minister of State when I inquired whether he had been consulted about the reduction in moneys. He said he was not consulted in 2006 and 2007 for the simple reason that he was not in the job. That kind of glib answer from the Government is hardly acceptable on a serious issue. This area has been neglected and the fact that we are discussing the matter so late is indicative of the neglect.
I wish to put two figures to the Minister to which I referred in her presence in the Dáil yesterday. In 2007 approximately 500 people died by suicide and €3.5 million was allocated to roll out the Reach Out programme. A total of 328 people died in road accidents and €44.3 million was allocated. Why is there such a difference in the Government's attitude to dealing with suicide prevention, which we know it is possible to address?
I raised an issue with the Minister 12 months ago and in October 2007. I refer to the roll-out of increased dyslexia services for Limerick Regional Hospital. Since then--
At the last meeting I attended I did not get a chance to speak.
I am sorry, Senator White, but I am taking speakers in rotation and nothing will change that.
I just want to know when I will get a chance to speak about the items which I submitted.
I submitted seven items and none of them will get a response. Because of the emergency situation that arose due to the publication of the reports we have devoted the meeting to those reports. I do not--
These are emergency situations also.
We are losing valuable time.
Since then a close relative now travels to Galway three times a week to benefit from that roll-out. The Minister indicated to me in November that the new services would be in place in July. Will she confirm whether that is still the case?
We must move on. I thank the Deputy for being brief. I also thank Deputy Aylward for withdrawing his questions due to the time constraints. Deputy Allen had to leave to chair a meeting in the committee room next door.
I will be brief. I wish to be associated with the welcome extended to the delegation. Seeing as there is a lot of bad news this morning I wish to attack the Minister with some good news. On a number of occasions I raised a parochial issue about the redevelopment of the Millbrook Lawns health centre. Perhaps the Minister will come out to me in Tallaght some day and look at the great work that is being done in that regard. Professor Drumm might be kind enough to convey my good wishes and thanks on behalf of the community in Tallaght for the work that is being done. I hope to see it completed very quickly.
I also wish to refer briefly to the pharmacy issue. Again, I wish to be parochial. The Minister will be aware that I live in the Springfield estate in Tallaght where there are 1,800 houses and three pharmacies. Can I tell the people who go to those three pharmacies that those services are guaranteed and there is no problem on the horizon?
I will be brief. When will Professor Drumm be in a position to appoint the four suicide prevention officers to fill the current vacancies? It is serious that they are not in situ.
I have been told that physiotherapy vests are paid for in Kilkenny and in another county but in Limerick a person who had to buy such a vest for a young person with cystic fibrosis had to pay €18,000, including VAT, and no compensation was provided. What treatment will be available to a young person with cystic fibrosis who will reach the age of 18 this summer and whose heartfelt passion is to go to the University of Limerick? His father told me he will lose out, in that a consultant will not be available when he reaches the age of 18.
I spoke with Ms Laverne McGuinness about the introduction of child care protection. I am happy to wait for that and not to rush it.
I have been talking about another issue for three years and I am getting very frustrated. I was told three years ago in reply to a matter I raised on the Adjournment that the GMS contract for GPs would be negotiated when the contracts were being re-negotiated. First, there is a shortage of GPs. Second, it is total nonsense that a GP aged 70 can continue to treat private patients but not treat public patients. After the previous meeting I read an article in the health supplement to which the Minister referred about the review that is to take place. Will the Secretary General indicate when a review will take place of doctors' contracts? I cannot understand this.
I wish to deal with two specific issues regarding Portlaoise, namely, what happened and how it was handled. I am somewhat concerned that much more attention appears to be on how it was handled, and not just by the people beside me.
Regarding the decommissioning of the machine, the HSE said on 6 November that all possible issues connected with the misdiagnoses, including equipment, will be considered. However, the machine had already been decommissioned since August so that report was not possible. Mr. Niall Phelan, the chief physicist, was asked to review the available documentation by Dr. O'Doherty. The phrase "there is no information on" was used four times in his report on equipment. He said a comprehensive review would necessitate a visit to the unit, inspection of equipment and an interview with staff. That did not happen in terms of the equipment. I wish to know why that is the case.
The phrase "going forward" has been used frequently in recent days. It is important to ask what we have learned. The Taoiseach stated in November that it was not a systems failure but the Fitzgerald report has made it clear that it was.
I wish to ask about responses and actions. The biggest concern I have heard from staff in Portlaoise hospital relates to actions that were taken at various stages. When there was a problem with equipment they were told to file an incident report. Many incident reports were filed. I am concerned about the action taken after those reports. I do not care whether an incident arises in a centre of excellence or in Portlaoise, Tullamore or anywhere else, it is not sufficient to tell staff to file an incident report and leave it at that. I wish to know what steps will be taken to ensure this cannot happen again. We accept the handling was appalling. I am glad the nine women are to be met personally as it is very important.
The Minister was highly critical, yesterday and again today, of the media outside the Cuisle Centre in November. It caused stress to some women who were at the centre because the HSE was waiting for a cohort of women so they could all be seen together. The women should never have had to turn up at the centre. They should have been seen individually. It is very important that this be stated. There is no point in blaming the media for being present. The problem was that the women had to be there. It took their dignity away.
I welcome the opportunity to address both the Minister and Professor Drumm.
Mr. John Fitzgerald's report, published yesterday, highlights the weaknesses of management and governance in the review process following the exposure of the misdiagnosis of women in the Midland Regional Hospital. The report states, "the needs of the patients potentially affected receded". Mr. Fitzgerald speaks of systemic weaknesses associated with governance, management and communication in dealing with critical circumstances. It is very serious to allege the needs of the patients receded over the period in question. That in itself warrants address by both the Minister and Professor Drumm.
A commitment was made by the Minister that the cancer diagnosis scandal in the midlands will not happen again, yet I question how this can be taken seriously given the statement made by her following on the revelations on the difficulty of obtaining diagnoses for colonoscopies at a time when there were waiting times of six, seven and eight months. Figures now show that there are waiting times of up to 18 months for these vital cancer tests. The assurances of the Minister have not proven to be of any great worth and circumstances have deteriorated since the death of Ms Susie Long. How can we have confidence in the Minister's assurance that there will be no repetition of the events in the Midlands Regional Hospital in respect of the cancer diagnoses?
During Question Time yesterday, I asked the Minister to justify her statement that these delays would be addressed effectively. She once claimed that the new consultants' contract would make a significant difference and would be an aid to that objective but she did not give a response of any significance yesterday. How many consultants will be allocated, to where will they be allocated and when? I refer specifically to colonoscopies. What is the target and the timetable for the reduction of waiting times in that area?
The Deputy's time has expired.
I did not realise there was such a restriction on time. I have only had a couple of minutes.
The Minister must attend an EU function.
May I ask one more question?
Sure.
There are many issues I would have liked to have addressed in respect of my area in the north east but it is clear that sufficient time will not be afforded to me this morning.
The Minister has made it clear that she will try to return on another occasion within three months to respond to some of the questions.
I welcome that and will therefore close in respect of the pharmacy issue. It is having a direct impact on people throughout the jurisdiction. What would be required to get the Minister to move to a point where she could facilitate direct negotiations between the Irish Pharmaceutical Union and the HSE? I am not here to make any assessment or analysis regarding arrangements for payment, and so on. I am particularly interested in ensuring the Irish Pharmaceutical Union, as the representative body of pharmacists throughout this State, will be recognised as such in negotiations across the board. It is as simple as that. What will it take before the Minister will act?
I call Deputy Charles Flanagan, who lives in Portlaoise.
I am very grateful that the Chairman has allowed me time to contribute, particularly given that I am not a member of the committee.
It is extraordinary and rather ironic that the Minister, in the course of her statement, admonished the media for their involvement in this matter. It is symptomatic of an evasion of real responsibility. Notwithstanding the publication of the three reports, there is still a black hole in respect of the involvement of the Department in the Portlaoise affair from 2001 to 2005. We must determine why the positions that would have allowed for the triple assessment were never advertised. We heard the Minister say nobody could be got for them, but that was after 2005. What happened between 2001 and 2005?
Bearing in mind the content of the Doherty report, the HSE had ample warning, both from the medical committee in the hospital in Portlaoise and individual practitioners, that there were real problems regarding the process. They were not addressed and the report does not amplify this sufficiently.
What will the Minister and Professor Drumm do now to restore confidence in the entire service in Portlaoise? Can they ensure that this year's budget will not be subject to cutbacks?
We all heard about counselling services for the women affected but they were not provided. One of the eight affected women was in my clinic in December and told me she just did not have any contact with the services.
I hope Professor Drumm will answer the questions I asked him. I am amazed the Minister can state she is impressed with the HSE in light of the three damning reports. Nobody is against the establishment of the HSE or the concept thereof, but what has transpired is a dysfunctional, disorganised structure that is lacking in respect of communication, management and cohesion.
Dr. Peter Naughton's letter of 2005 was not dealt with appropriately. The appropriate action would have been to provide the pathologist, radiologist, team leader and machinery, but this was not done. What is the Minister's response to Mr. Fitzgerald's report, which implies that if the same urgency had been shown before 22 November as was shown thereafter, many of the problems would have been avoided.
I support the call of Parents for Justice for information to be released.
Will the Minister and Professor Drumm ensure, from this point on, that whenever a decision is made in the HSE, these four questions can be answered: who made it, why was it made, what did it cost and, most important, how did it impact on patient care?
There are still many questions to be answered on the Midlands Regional Hospital specifically and the two representatives from the Portlaoise area just raised further questions. We need to obtain every item of information available on what happened at the hospital. We particularly need to know why nothing was done to ensure the safety of patients when Dr. Peter Naughton raised the issue at an earlier stage.
I am very concerned about the transition period. It is touted that there will be some kind of Neverland where there will be a very good system for cancer care. I do not know how long this will take, but in the meantime there will be a tight budget for the HSE and waiting times for colonoscopies and other procedures of up to a year and a half. How will we protect patients in the coming year and the years thereafter? Issues arise in this regard that have not been addressed properly today, particularly in respect of diagnosis and ensuring appropriate systems are in place to deal with patients. Our concern must be about the patients.
The time is limited and I cannot extend it. Both Professor Drumm and the Minister need to leave the meeting by 12.30 p.m. There will be another occasion well within the next three months for them to attend the committee again. I will allow the Minister to have a final response.
I must leave the meeting as the Taoiseach is launching the Government's Nice treaty campaign.
The Lisbon treaty campaign.
Sorry, the Lisbon treaty campaign. Concerning letters to Ministers from 2002 on, Dr. Peter Naughton wrote the first letter. Three consultant posts were approved on 5 June 2002. The health board was asked to ensure certain services were provided such as multidisciplinary care. These were not provided.
After the 2005 letter to me, it was handled at the most senior clinical level by Professor Donal Hollywood, medical director for the region. He engaged with Dr. Naughton and a radiologist was appointed. A recruiting campaign was launched to appoint a second radiologist but no candidate was deemed suitable. A pathologist with a specialist interest in cytology was appointed to the Midland Health Board.
We should never have had a breast cancer centre in Portlaoise. Senator Fitzgerald asked who was responsible. Clinicians are responsible for clinical errors, not me. To be fair to the clinicians, they were working in circumstances that would never deliver good outcomes. Some 50 new cases a year could not deliver the outcomes patients were entitled to expect.
The women of Ireland are now voting with their feet and going to the eight centres of excellence. When patients are concerned about cancer, what matters to them most is getting access to the best possible clinical care. They will travel to get that if necessary. That is my experience and my view.
As to Senator Fitzgerald's question on whether I will resign, the answer is "No". We identified what was wrong in Portlaoise and we will put it right. What went wrong in this case was there was no serious incident protocol and this will now be put in place. That is why I say these events will not happen again. I am not saying there will not be errors. Errors are regrettable but inevitable in medical care, even in the best hospitals. We are putting protocols in place and having a single person in charge to ensure it is implemented. If a patient has to be called back, we will ensure they hear it first and not through the media or political system.
Many patients who were not affected thought they were when they heard the reports in the media. We caused much anxiety, unnecessary hurt and upset to many people. There will always be investigations. Issues will always arise. We must learn from the Fitzgerald report. There were failings of management governance and communications but these will be put right. Clear lines of accountability are important.
I have introduced much legislation in pursuing the reform of the health service. With the Medical Practitioners Act, I was accused of not having it doctor-friendly enough because I wanted a lay majority on the fitness to practice committee. That committee has been strengthened and competence assurance has been introduced.
When I introduced the Pharmacy Act to regulate the pharmacy profession, it was the first attempt at reform in 150 years. It provided for a lay majority on the committee regulating corporate entities and pharmacists. It also dealt with conflict of interests that arose with general practitioners establishing pharmacies on their premises and addressed the link between prescribing and dispensing medication.
These are significant new reforms. As Minister I support reform and quality care. That is why I am a strong fan of the national paediatric hospital for sick children. The manner in which we have organised services for sick children has not delivered the best care. That is why I am such a fan of centres of excellence. I appointed a committee, with Professor Niall O'Higgins as chair, to draw up symptomatic breast cancer care standards. Even in the run-in to the general election, we knew many of these hospitals would close but we went ahead and brought it to Government. That is what the reform agenda is all about.
Regarding the Health Service Executive, I accept no organisation is perfect. There are many people who want to undermine it from within and without. Every letter I get on health services speaks of catastrophe and disaster and so on. Some cases may lead to catastrophes and disasters. However, all who work in health have a role to play in delivering changes in the way business is done and in delivering leadership, whether we are clinicians or politicians. I, along with Professor Tom Keane, am encouraged by the clinical leadership now emerging in cancer care.
On Deputy O'Connor's questions on pharmacies, when I represented Springfield in Tallaght, it did not have three pharmacies. Having three there now is fantastic. Last year a pharmacy on Dublin's Grafton Street, the busiest street in the country, closed.
We want value for money for the taxpayers and patients. On average pharmacists in this jurisdiction get €100,000 a year more by the way of fees from the HSE than their counterparts in Northern Ireland. No one can justify that. I know of no other commodity where it costs €600 million to take a €1.1 billion commodity from the factory gate to the patient. If we can save money in this area, it can be used more productively for services for patients.
It is fine for the Opposition to criticise the sum of money applied to cystic fibrosis or cancer services. When it comes to supporting the tough decisions, such as how wholesalers are remunerated, I do not see much support from across the floor.
What about direct talks?
Deputy Ó Caoláin constantly criticises me--
Is the Minister opposed to representative talks?
Deputy Ó Caoláin constantly criticises me for supporting corporate entities and the private sector.
I have not done so recently.
These are private entrepreneurs and health care professionals. No one more than me wants to see them succeed. Business does not succeed if it does not get a fair return on its investment.
They are also entitled to fair representation.
Since 2002, there has been a 26% increase in pharmacy outlets, despite the prediction there would be a catastrophe and the community pharmacists would go. With an increased fee for dispensing, we want to separate the price of the commodity from the professional service which a pharmacist supplies, dispensing medication. We want to pay them adequately. In Northern Ireland they are paid £1.11 to dispense medication. Here they are paid between €2.26 and €2.60. The HSE has said at least €5. There is now an independent process in place to examine the issue. The HSE has not changed the contract it has with pharmacists.
It has changed the remuneration, which is essential to a contract.
That is not a fact. We have a virtual market in Ireland. Uniphar owns 400 pharmacies and finances another 150. Unicare owns 72 pharmacies and United Drug has invested €300 million in the sector. Health care professionals, like others, will always do well in a well-developed country like ours. I said the same to the lawyers when we were establishing the Personal Injuries Assessment Board. I think they can confirm they did not all go out of business. Of course, they were not dealing with patients.
We can go back to that in another forum.
On parliamentary questions not being properly answered, if there is inaccurate information, the Deputy should make it available and we can have it investigated. Professor Drumm has said that too on other occasions.
BreastCheck is unique worldwide in that not only does it diagnose, it provides treatment too. We have been praised highly for the manner in which we have rolled out screening. We want to have the same high quality service for cervical cancer. That will begin in the middle of the year as some of the procurement issues are still being finalised.
Some ten years on.
Ten years on, but when the Deputy's colleague Ivan Yates was Fine Gael spokesman on health in 1989 he said unless we get our act together and set up a single organisation, we could be spending €13 billion by the turn of the century.
I have no problem with the concept. My problem is with the detail, the Minister's stewardship and the ethos in the health services that has evolved under her.
Whether it is working is the question.
Regarding Deputy Neville's question, I have asked the HSE in this year's service plan to implement A Vision for Change.
BreastCheck has been rolled out in counties Mayo, Galway and Roscommon. As it is a population screening programme, it cannot be rolled out everywhere at the same time. It will be rolled out in other counties over the next year and a half.
Regarding the Cork maternity hospital, I will ask the HSE to deal with that matter. As regards suicide, I understand we are spending €8 million a year.
What is being spent on the implementation of Reach Out, the national strategy for action on suicide prevention?
There is no question to be answered as regards information being suppressed. As we saw from the Fitzgerald report, we must get away from these big announcements about numbers until the patients are contacted. We know the consequences and all of us here, regardless of political persuasion, want to put patients first.
We want to get away from the cohorts.
I agree with the Deputy. Sometimes we all use the language of the system - and I include myself in that regard. No offence was meant, I can assure the Deputy.
What was offensive was leaving those 97 women to be dealt with as a cohort. It was the actions that caused offence, not the words.
The Deputy should be aware there are two issues involved. There is the issue of the misdiagnoses and then the issue of how that was handled.
That is correct.
As I said earlier, steps are going to be taken on foot of the report as regards how these matters are handled in the future. I have every confidence in the CEO of the Health Service Executive, Professor Brendan Drumm, and his team in that regard. I believe I have answered everything. If there is anything--
What about the GMS contract?
In that regard the issue was about doctors having to resign their GMS contracts at the age of 70, but they can do private work. These are issues we have to examine. We are not yet in a position to begin negotiations, but Professor Drumm will comment on that. Those negotiations are imminent.
As regards the pharmacists, we want to negotiate a new contract with the IPU. Obviously, this has to be independently priced, but we want to negotiate a new contract. Until we negotiate the details of such a contract, obviously we cannot set about pricing it.
I wanted to ask about people over 16 years of age with intellectual disabilities.
I shall ask the HSE to deal with that.
Before the Minister goes, I want to say a word of thanks. I realise she is under serious time pressure.
I have two quick questions, as regards the Cuisle Centre in Portlaoise - by way of ensuring the commitment as regards staffing is adhered to. The Parents for Justice group is in the Gallery and asked the question at our last meeting as to why its funding from the HSE was suspended. I shall ask for a quick response from Professor Drumm on that issue. He only has five minutes with us.
The Early Language Intervention group is also here and has submitted questions, for which a response will be sought later. I shall ask Professor Drumm to please wrap up within three minutes.
Professor Brendan Drumm
On the Chairman's question as regards Parents for Justice, does Ms McGuinness want to comment on that?
Ms Laverne McGuinness
Funding for Parents for Justice was suspended in 2007, but it was told at the end of 2006 that this would be the case. A review is being carried out and we expect to have the details over the next number of weeks. Some irregularities in the accounting mechanisms were highlighted, so there are reasons for the review at this stage.
Has the facility that provides direct advice and supports to grieving families who have gone through traumatic experiences had to close? I do not believe it is of any value that the HSE told Parents for Justice in 2006 that there would be no funding in 2007. The fact is the HSE has stopped that critical funding, which was in excess of €300,000 annually. We want to hear today whether it will be restored.
Ms Laverne McGuinness
There are two issues involved. One relates to counselling and the other to the review which showed there was an irregularity. Some of the members themselves asked that such a review should take place. As regards counselling, some €120,000 will be put in place to fund this area during 2008. It is a question of whether Parents for Justice will provide that particular service, and that aspect is being examined as we speak.
We recognise that counselling must still be carried out, independent of the suspension of the funding, and that is being addressed. Money has been set aside for this particular aspect of Parents for Justice's activities.
When will this review be completed?
Ms Laverne McGuinness
The overall review, as distinct from the overall funding, for Parents for Justice, will be carried out over the next eight to ten weeks.
I thank Ms McGuinness. There is a final question for the Secretary General, Mr. Michael Scannell, as regards the whole area of cervical cancer screening, vaccinations, etc. We have met with the groups concerned over the last few months. Experts' advice is to the effect that if we embark on a vaccination programme by way of vaccination and screening, we can reduce the incidence by 95%. It is a stark statistic and we need to have a response on that by the next day the Secretary General appears before the committee. Thankfully, we are having a presentation next week from BreastCheck and cervical cancer groups---
Is he going to deal with our questions?
We do not have time.
There is a two-tier system here. Some of us asked specific questions. Members of the committee have equal status under the rules of the Oireachtas. We accept the Front Bench must have special concessions, but we should not be swept out like this.
I am not going to have any allegation made about sweeping out.
They are not answering us.
Deputy Neville will have to talk to his own party about--
No, I am not talking to my party---
I am the Chair and we agreed procedure in advance.
We agreed, as the Minister was leaving early, that we should hold our questions for Professor Drumm.
Let us be clear as to what was agreed.
That is precisely what was agreed. That is what the Chairman told Senator--
I want to clarify something, please.
I am sorry, Deputy Lynch, but I want to say something in this regard. What I said was that the Minister was to be out of here at 12.10 p.m., while Professor Drumm was to remain until 12.30 p.m. I cannot do anything further than that.
The Chairman asked Senator Fitzgerald to address her questions to the Minister because she left.
Those questions were quite rapid and I had to deal with that.
Professor Drumm has not answered my third question.
Professor Drumm is trying to get back in here as the Deputy argues with me.
I was going to suggest that Professor Drumm might tell us how he intends to deal with the remaining questions.
Professor Brendan Drumm
I will try to deal with them. Some of them relate to the mental health area, which Ms McGuinness will be happy to deal with as she has the relevant information.
We absolutely agree with Deputy Lynch as regards regular review other than crisis reporting. This harks back to Deputy O'Sullivan's earlier question about audit and the need for clinical directives. I should point out, however, that this will raise some enormous challenges for the Irish hospital structure, not least in the Deputy's city and up and down the country. Not many people will want to hear what this ultimately means but it has to happen in any event.
I am not going to return to the pharmacy issue. We are not aware of people suffering as Deputy Lynch suggests. However, we were quite upset that, for instance on RTE two mornings ago, an elderly person could be brought in without any reference to us, to talk about the risks of old people not getting their drugs, when we had a contingency system in place. Everybody in this House should ask questions as regards how the elderly are being used in this argument.
It is the fear which is as real as anything else.
Professor Brendan Drumm
I am asking for some degree of accountability on both sides of this argument. One can ask about all the conflicts in relation to this and who is involved, but this is a very complex industry. The pharmacy wholesalers are coming in to address that issue, so let them answer too. If they are actually telling their customers they are going to overcharge them, that is a most unusual business model. I am perfectly happy to move out of the wholesale business completely. I do not see why I or taxpayers are involved in it. I should be perfectly happy to leave it between the manufacturer and the retailer - and let the games that are being played be sorted out at that level.
I am just surprised that we are constantly being charged with not managing the system. Let us be clear: this €100 million, if it goes somewhere else, it is coming straight out of frontline services. Let everyone here be clear if it is spent on pharmacy, within my Vote this year it comes out of frontline services. Let there be no doubt about it. If that is the way the House wants it dealt with, then perhaps that is the way it is. However, let us be clear, that is how it will operate.
We are managing the system to bring value for money for patients. Let us see who will come back and how many pharmacies will close.
Some voices here are not being prescriptive as regards the financial arrangements. We are demanding the right for direct engagement, so Professor Drumm should not try to muddy the waters. We are getting enough of that from the Minister.
Professor Brendan Drumm
It is a remarkable lobby by business across this House. Perhaps the public needs to be asked by me whether it wants us to back off from this. In the event, we shall be back here to be asked why we did not balance the budget.
That is avoiding the argument members on the Opposition side have been making.
How does he reconcile the fact of 714 grade 8 personnel when there were only six in 2000?
Professor Brendan Drumm
Now we are into another issue. Deputy Reilly cannot deal with the pharmacy issue, because it is too difficult.
Can I respond to that?
No, or I shall suspend the meeting straightaway. Professor Drumm has the right to respond.
Professor Brendan Drumm
Deputy Allen's question has been dealt with. We have asked the Mercy Hospital in Cork to open the accident and emergency unit there. It should be open. It is up to the Mercy Hospital board to open it. The days are gone when we continue to invest in new, improved facilities that suddenly require extra staff to put the same number of patients through. It should be opened and there is a responsibility to open it.
The question on the site for the hospital in Drogheda is a very fair question. It has been dragged out. I have been assured for the umpteenth time that the final analysis of the figures is as good as complete and that it will hopefully be available for our next board meeting. I hope we will have it within the next four weeks and I accept fully that is has been a very drawn out process. The whole layout of services there must remain in our focus.
There is a superb system on the website for the child and adolescent psychiatry services for Monaghan. One of the most inspirational places in the country is on the site, so I would be surprised if there were access problems to the service. I will check it out, but I commend it as a site for the provision of community services, and not just in child and adolescent psychiatry.
We are at one on the issue of waiting lists. The HSE has brought forward the issue of waiting lists and stated that it is time to deal with real waiting lists, which is the length of time it takes to see a consultant. This will be the focus of our priorities this year and we need a real approach to waiting lists in terms of the number of patients seen at individual clinics around the country, where there are major variations. The waiting list for neurology patients at St. Vincent's Hospital has been reduced to about 12 weeks by running a very innovative system, even though there are only two neurologists working there. The hospital's problem now is that people are drifting from elsewhere in the country, sometimes from places where service provision is better. We accept that is a major issue for everybody here.
Due to the financial challenges in the north east, the situation regarding CT scanning in Monaghan will remain the same, and there will certainly not be any further roll-out of it this year. The cost of running the CT scan is far in excess of the cost of installing it. Due to the current financial environment, I will not mislead anybody by saying that something will be set up this year. It will not be set up this year.
We tried to deal with the leaked memo on Monaghan before and it was part of a business-as-usual assessment, asking people on the ground in the HSE to suggest where money could be saved. It never was a document for implementation. Could parts of it end up being implemented? As I said earlier, we are putting a focus on saving non-patient related costs. Part of it is procurement, including the pharmacy issue. If we do not make those savings across the board in how we operate corporately, then we have even bigger challenges than those that are obvious to us. That is part and parcel of the business we are doing.
Senator Fitzgerald spoke about cutbacks in front line services. I hope this will not be an issue, but it will be a challenge that we must deal with month by month. I accept the point made by Senator Feeney and the Chairman, when commenting on the health board structure, that our decisions are made in a much more complex arrangement. I accept the suggestion that there is a responsibility at a clinical level in all areas for the force for decision making that comes from the powerful voices of clinicians. I hope that those people act in a way that focuses on what is best for patients at all times. We have some great examples of where they do this, but I accept fully that it can be a mixed situation and that it may be unfair on one half of the equation.
Senator Feeney asked whether Professor Keane has visited all the centres. I cannot answer that, but I can find out for her.
Ms Laverne McGuinness
Deputy Neville asked about the A Vision for Change implementation plan. The policy document was available in November 2006 and the implementation plan went to the board in February, but much work had been done on the plan already. It identified six priority areas for us, one of which is child and adolescent psychiatry. There was €25 million available and at the end of 2008, 72% of the 2007 budget will be spent on what was recommended as part of the original proposal. There will be eight additional child and adolescent psychiatry teams in place, and 30 child and adolescent psychiatric in-patient beds, which is an additional 18 beds by the end of 2008. There will be 20 new beds in Cork and 20 in Galway in 2009.
Twenty six of the consultant psychiatrist posts for multidisciplinary teams are new posts, but 23 of them are in a temporary capacity while we await the appointment of the other consultants. Much work on forensics has been done under the Mental Health Act 2001. There was a great deal of work to be done regarding the setting up of the tribunals and 9,500 staff had to be re-trained over that period.
Much has been done regarding A Vision for Change, but it is more important to change work practices. We heard this morning about clinicians working with us and as we speak there are 30 clinical psychologists and mental health workers meeting to see how we can roll out best practice in child and adolescent psychiatry. We are starting there and moving on to other areas. It is about using clinicians working in the service to roll out our models of best practice throughout the country. A Vision for Change is about implementing best practice of what is available in the community and we are working on that with the clinicians.
I wanted to ask Professor Drumm two questions. The first was about the disturbing findings in yesterday's report on internal structures in the HSE, which many people--
Please ask the question.
What will Professor Drumm do to address the points that came out in the report? The budget cutbacks have been quoted at €400 million in the media. Is that accurate?
Professor Brendan Drumm
Deputy O'Connor was concerned about the pharmacy services in Tallaght and asked whether I could guarantee that a pharmacy will not close. I cannot do that, but we have not seen any evidence of pharmacies closing and we will have to wait and see.
What about my question on the extension of renal dialysis in Limerick? It was promised for next July and I just wanted to know whether it was on stream.
Professor Brendan Drumm
It is going out to private tender. I do not have the answer here, but I will get it for the Deputy. We are trying to extend the existing machine, while a request for another machine is being put out to tender.
Ms Laverne McGuinness
I do not know the exact date the four suicide prevention officers will be employed. I can tell Deputy Neville about all that has happened in 2007, but he knows that. I just do not have the information on the four posts at the moment.
This is a serious issue in those communities that need them. When will we have the four posts?
I ask members of the committee not to make speeches. Senator White, there are 15 people here looking for answers. I cannot condense all the answers into one second. We need to restore a bit of order.
Ms Laverne McGuinness
I will get back to the Senator White on that.
Ms Ann Doherty
The vests represent a new form of treatment for cystic fibrosis sufferers. Some clinicians have started to authorise it and we wanted to look at how effective it is as a form of treatment, which is being done by our population health directorate. We will then be able to make an informed decision on whether this is the way we should invest our money.
There will be no further debate.
Professor Brendan Drumm
We have invested hugely in staff for cystic fibrosis. I cannot see why an 18 year old would not have follow-up services in Limerick.
With regard to GPs over 70, there are two issues. First, we need all the GPs we can get. Second, at present we cannot issue a new GP card unless we can show an absolute need to the IMO or unless a GP retires. In essence, in many parts of the country a GP remaining on would prevent a new GP coming into place. It is an agreement that was signed many years ago. It is not unlike some of the challenges we face elsewhere. We all accept we should use everyone we can.
On Deputy Enright's question on the equipment in Portlaoise, we have discussed this issue several times today. I am happy for anybody to examine the equipment but it is clear from Dr. O'Doherty's report that she was reading mammograms that came from the same equipment. Let us be fair with regard to the conditions on the ground in Portlaoise. Two days after the event on RTE, the staff were working within the confines of that service. Was the equipment ever ideal? The answer is that it probably was, but it is very hard to have a centre that will always have ideal equipment. However, we must not leave this meeting on the basis that anybody in Portlaoise was outside of the norms in what they might have been expected to do in that service. We need to be fair on both sides.
May I interrupt? Deputy Jan O'Sullivan must attend a vote, as must other members. The Deputy has a question.
On the situation at Portlaoise, particularly Professor Naughton's letter, can Professor Drumm give us an assurance that if in future a clinician expresses concern, he or she will know where to express that concern and that there will be a response?
Professor Brendan Drumm
The HSE will respond. However, there is not a place I go in Ireland on a daily basis where clinicians do not express the concern that their systems are under-resourced.
There must be a system whereby they would know where they can go with their concerns and where those concerns will be responded to and investigated if necessary.
Professor Brendan Drumm
Absolutely. I hope that answers Senator Fitzgerald's question.
Will Professor Drumm address the incident reports, the fact so many were filed and the guarantees that this will not happen again?
Professor Brendan Drumm
A huge amount of risk management was in place in the midlands. This takes us back to the question of how we deal with this issue. There needs to be a completely different response to risk management and serious incidents. The answer to the overall question, which was also raised by Senator Fitzgerald, is that a serious incident unit will be put in place.
On the issue of cohorts, the patients were being brought back by Professor Naughton to be seen by him as a surgeon. The cohort came into play when, for all sorts of reasons, the whole issue blew up. To be fair, at that stage the patients deserved to be seen very quickly. This links to Deputy Allen's question as to why do we not have all the information on Cork. Because we wanted to protect these people, it was thought we should not put that information out there until everybody was informed and until the study was completed. This needs to change completely, which we accept.
I dealt with the budget in some detail earlier. I said we faced a €250 million to €300 million challenge, which could grow depending on demand-led schemes.
We must wrap up as it is 1 p.m. Before I do so, I promised the Parents for Justice group that I would write to the Attorney General to ask him to come before the committee. I have a communication dated 11.15 a.m. this morning stating the Attorney General is declining the invitation to come before our meeting as his principal role is adviser to the Government and he is not obliged to explain advice given outside that forum. I will talk to the Parents for Justice group following this meeting.
I thank the Chairman for chairing the meeting and Professor Drumm and his team for attending.
I thank Professor Drumm and everybody involved. I apologise for running over time.