While we await the arrival of the chief executive of the Health Service Executive and the chief executive officer of the national cancer screening services, I remind members of the precedence in the order in which questions may be asked as agreed by the committee. The standard procedure is that the Fine Gael spokesperson is first, followed by the Labour Party spokesperson, the Government spokesperson, members in order of a show of hands and, finally, non-members in order of a show of hands.
Health Issues: Discussion.
It has been flagged that Professor Drumm——
I understand he is outside.
Professor Drumm is very welcome. We will proceed as previously agreed. I call the Minister.
I thank the Chairman. I want to reiterate in public session my congratulations to you, Chairman, on your appointment as chair of this committee. It is an important committee and I want to wish you well. As Minister for Health and Children I look forward to working with you. I have circulated a script. I do not propose to read it because I believe it is a waste of time — everybody here can read as well as me — but I will deal with some of the main issues.
Since we met here in March when we had a long discussion relating to health issues three issues have arisen. First, the OECD external review of public services in Ireland was published and from a health perspective that was very helpful. The OECD placed a heavy concentration on outputs and urged us to get away from the constant obsession with inputs. Outcomes and results are very much part and parcel of the health reform agenda and what we can achieve for the huge inputs the taxpayers invest in our health services.
Attention was drawn in the OECD report to the fact that Ireland's population will grow between now and 2036 by between 1 million and 1.5 million from what it is today. The number of older people will increase by 230%, to 1.5 million. By 2021, 30% of those aged 65 and over will live alone. Approximately 80% of GP consultations and 60% of hospital bed days are related to chronic illnesses and their complications. That figure is similar to that in many other countries. The prevention and management of chronic illness is a major issue for our health services and for the HSE in particular.
The OECD commented on the need for the reconfiguration of acute hospital services. That must be mirrored and in many cases preceded by related reforms in primary and community care. It looked at the reform in the north east and went on to state that it was based on sound principles clinically. It stated that the reform programme makes sense and will lead to safer, better quality treatment and options for citizens. I want to comment on that. Everything we are doing is focused on the patient safety agenda and the way we provide a safer, higher quality of care for our patients. That involves reconfiguration of services to make sure that hospital services are provided in an environment that is safe and quality assured and included in national programmes.
That brings me to the cancer control programme, which is now under way and is overseen by Professor Tom Keane and the team of clinicians he has assembled. That programme was devised after a group of 23 people gave of their expertise and advice. A total of 17 of the 23 were medics and it is now being implemented by medics. I am a strong supporter of clinical leadership and clinical buy-in. We have had a number of debates in the House on the cancer control plan and one of the significant issues is that there is a huge public buy-in. That is my experience. It does not happen in every instance but it does across the country. We already know that many patients are moving from environments where they believe their care cannot be quality assured to places where it can be so assured. Already this year, 17 hospitals have ceased doing breast surgery and that, by any standards, is major progress in a relatively short period of time.
I have no doubt that we will discuss later the cervical screening programme which is being rolled out this year. The intention is to have an 80% take-up. Approximately 240,000 women will be screened on an annual basis. The programme is being rolled out in a different way to the manner in which BreastCheck was rolled out but we have been informed by the very successful experience of BreastCheck, which has a 78% participation rate, which is 8% ahead of the target, and one of the highest we have come across in the world.
BreastCheck was the first population screening programme in the world to introduce digital mammography, which is something of which we can be proud. Learning from that experience, the national cancer screening service is in the final stages of rolling out the cervical screening programme. The next screening programme recommended is colorectal screening. We may want to talk a little about that later. In introducing such a screening programme, we want to make sure that it is evidence-based and delivers on the potential people expect of it. There is no recommendation for prostate screening anywhere in the world and we have to follow what is best practice in this area.
Another area on which I comment which has gone relatively unnoticed, is the new consultant contract. A new contract to meet the needs of the public health system has been demanded since the 1980s. The new contract negotiated and agreed by 80% of the Irish Hospital Consultants Association's members, who represent 75% of practising consultants, and by approximately 70% of the Irish Medical Organisation's consultants is very encouraging. The HSE has advertised for the appointment of 129 new consultants in the health system, more than half of whom will be additional consultants and approximately half of whom will fill replacement posts.
The significance of the new contract is the working arrangements for consultants, including a longer working day, structured cover and, in particular, clinical leadership, which we believe is important. In the best hospitals we have seen here and overseas, those hospitals that organise around clinical leadership on surgical teams and medical teams are the ones that perform best. The new contract will be progressively implemented. We have approximately 6,000 doctors working in our hospitals, of whom 4,000 are non-consultant hospital doctors, many of whom are junior doctors, and 2,000 are consultants. We need to change that ratio around. The intention is to fund many of the new posts by substantially reducing the dependency on junior doctors in the system. The current ratio is neither safe for patients nor does it represent appropriate use of the money this State can invest.
We know from the OECD, which has verified this, that 78% of our health budget comes from taxpayers' money. That is somewhat higher than the OECD average and such health funding has increased substantially, by approximately 7%, in recent years. Whether health systems are funded by insurance, taxation, or a combination of both, or by private health insurance, we must strive to provide higher quality services for the population we serve and to provide health care in a setting that better meets the needs of our citizens. We know that 95% of our health needs can be met in terms of primary, community and continuing care. That is a huge part of the health reform programme, which I am sure Professor Drumm will mention.
Those are my opening comments, and I will be happy to take questions on what I have said or on many of the other issues about which the Deputies and Senators are concerned.
Would Professor Drumm like to address the committee at this point?
Professor Brendan Drumm
Thank you, Chairman. On behalf of the HSE, I congratulate the Chairman on his appointment as Chairman of this committee. I assure all members of the committee of our continued co-operation with the work of the committee. I restate, as I have done at all committees, that we will make all the information that we have available to the committee as required. I will give brief updates on the progress we are making and deal with a number of specific issues, which the committee indicated it wished to raise with us.
I am accompanied by my senior colleagues; Ms Laverne McGuinness, national director of the PCCC and Mr. Tom Finn, assistant national director of the National Hospitals Office, who is acting as director there in the absence of Ms Ann Doherty who is on leave. We will try to answer any questions members may have.
As we reported yesterday at the launch of our annual report, the HSE is providing services to more people and is providing more services each year. This trend has continued into 2008. Record numbers of health care professionals are delivering these services with a budget provided by the public that is at an all time high. This enables us to provide many excellent services and deliver on our mission, which is to enable people to live healthier and more fulfilled lives. I will illustrate this point with some examples.
People in Ireland are healthier than they have ever been and are living longer than at any time in the history of the State, with people's life expectancy having stretched by about four years since 1996. Independent research continues to show satisfaction levels with people who use our services to be extremely high, in the 80% to 90% range. Currently, approximately 1.3 million people, or 30% of the population, have medical cards and can avail of free medicines and GP care. We estimate this year we will spend €2.78 billion, or the equivalent of €7.6 million each day, on demand-led schemes such as the medical card scheme. This is hugely important in the context of ongoing financial challenges. Some 90% of people now have access to GP services on a 24-hour basis. Last year the out-of-hours services took more than 800,000 calls.
An additional 850 long-stay beds were made available for older people who were not well enough to return home after receiving hospital care and more than 20,000 older people now avail of these types of facilities. Between now and 2012 we plan to develop 3,000 community care long-stay beds for elderly people, which will involve an investment of approximately €600 million of taxpayers' money.
In the community, home help services, mainly for older people, have increased by 6%, with more than 4 million hours delivered already this year. Many people have received home care packages, about which there is often some confusion. They are advanced care packages for people who in any other circumstances could not be cared for at home. These packages include the provision of not only nursing care but physiotherapy and occupational therapy as required for people in their home environment. In terms of the number receiving these packages, we are ahead by 29% compared to the number this time last year. This is a critical issue, as it confirms our commitment to move to support people, even with quite complex conditions, where they want to be cared for in their own homes.
Primary care teams, from whom we believe people can get 80% to 90% of their care, are taking hold, with 90% in advanced development. The HSE remains fully committed to having half of the targeted 530 primary care teams well developed by the end of 2009. We welcome the commitment of primary care professionals to this goal. I emphasise the commitment shown by general practitioners throughout the country to supporting this process as it evolves. The critical issue is that these are real teams, the members of which work as teams in their local communities, not merely nominal names on a list.
The HSE has also received 450 proposals from the private sector to provide facilities for primary care teams in 131 locations and negotiations in this regard are well under way. In addition, the HSE will shortly advertise for proposals to develop primary care centres in more locations. These are in addition to the 70 primary care centres already developed or being developed by the HSE, as there is a significant number of areas throughout the country in which there is no commercial interest in developing centres.
Central to the primary care team approach is the assignment of existing community-based staff such as therapists, public health nurses, general nurses and home care workers along with general practitioners to these teams. I emphasise this point. There seems to be a suggestion that primary care teams are dependent on the appointment of a raft of new workers to the health service. The creation of primary care teams represents a complete reconfiguration of our existing staff. While additional staff will be taken on, the major change programme in this respect involves getting people to operate as a generic service for the community at large through one door of entrance. That means many of us changing how we do things every day.
Approximately 630 HSE allied health professionals have been assigned to primary care teams. In addition, more than 500 GPs participate in primary care teams in various stages of development together with a number of practice nurses and other GP practice resources. Some 222 new posts have been filled and allocated to primary care teams around the country, in addition to the reconfiguration of our existing staff, and a further 77 new posts are in the process of being filled. Another 300 posts have been allocated and it is envisaged that recruitment of these will start towards the end of this year. Therefore, there is a great commitment not only to the appointment of new people but to the reconfiguration of our existing staff to these teams.
In hospital services the data show that, on average, length of stay is reducing in many hospitals. We are monitoring the performance of hospitals and beginning the same process in our communities at a very detailed level. We have a health statistics programme up and running which on a monthly basis shows us activity levels in every significant hospital unit, down to the level of activity in an individual clinic. We are rolling out the same programme across primary and community care services, as it is incredibly important that we begin to use this data to identify the huge variations we see in workloads in different parts of the country. Preliminary data show that the Mater Hospital, for example, has reduced average length of stay from 12.5 days in 2007 to nine, which is a huge change.
The shift towards treating more patients on a day case basis continues; almost half of all hospital patients are now treated on such a basis. Day case attendances are up by 10% for the first four months of the year compared with the same period last year. We saw over 1 million people in our outpatient clinics in the first four months of the year, an increase of 9.4% on the same time last year. It is an area on which we are very focused for 2008. We are particularly focused on trying to see more new patients and reducing the huge number of return patients who tend to come to our clinics. We saw almost 400,000 people in emergency departments in the first four months of the year, an increase of approximately 4.6%. While it might appear that I am over-stressing the statistics, they are important to illustrate that a great many parts of the health service are serving the community well. We will continue to see these increasing numbers because of the increasing population, if for no other reason.
I will turn briefly to palliative care. Significant ongoing resources are provided by the HSE for the delivery of palliative care services by a range of statutory and voluntary palliative care providers; for example, in 2007 a total of €75 million was spent on such services. In fact, this figure probably significantly underestimates what was spent on them, as it does not include significant inputs in terms of drugs used, public health nursing time and payments to primary care practitioners for the care of palliative patients. This investment in palliative care services allows for the provision of a wide range of supports for palliative care patients, including specialist inpatient beds, home care teams, palliative supports in acute hospitals and day care services.
On average, 330 patients are treated per month in specialist inpatient units; some 2,500 patients access home care services; 80 patients access intermediate care in community hospitals; and 260 patients benefit from the provision of day care services. This year the HSE service plan commits to delivering a further €3 million in extra moneys for additional developments. Currently, we are completing a multi-annual five year plan for the development of palliative care services, with significant involvement in this process from the voluntary sector. The plan will provide the framework for revenue and capital investment to ensure equitable provision of services across all parts of the country. The decision to undertake the plan was based on discussions between the Minister for Health and Children, the HSE and bodies such as the Irish Hospice Foundation, the Irish Cancer Society and the Irish Association of Palliative Care. It is intended that the plan will be complete by the end of June and will provide a very sound planning framework for the sourcing and investment of additional resources. Palliative care is a key priority for the HSE and will continue to be so.
The Minister has referred to the consultants' contract. The independent chairman of the contract negotiations, Mr. Mark Connaughton, SC, has begun to draft the final version of the documentation. Once he completes his work, consultants will be offered the new contract and will have until 31 August to accept it. In the past few weeks the contract implementation team has progressed 129 consultant posts to advertisement under the new consultant contract. It is intended to commence interviews for a number of these posts in August, with the remainder of the interviews to commence in September.
I will deal with the employment issue, as it has received much coverage in the media. There is a perception that the HSE is operating a recruitment embargo, but the figures absolutely contradict this. There is no recruitment embargo. In September 2007 there was a recruitment pause, but a derogation process was also put in place to ensure frontline and critical posts were filled. Accordingly, recruitment activity and the filling of vacant posts continued throughout the latter part of 2007. Some 900 derogation requests were processed during that time. The recruitment pause was removed towards the end of 2007.
In January we established in the four HSE areas employment groups which examine requests to fill vacancies. Our priority within this process is front-line posts. Since January, 3,584 posts have been approved and are being filled. This represents almost 90% of approved requests. Of these posts, 80% represent medical-dental, nursing, health and social care professionals and other patient and client care staff. I emphasis, however, that we are not just in the position of continuing to replace staff when they retire or putting new people in place in standard processes. There are many processes in operation in areas of front-line health care provision which are very inefficient when compared to other very efficient processes elsewhere. We are determined that it will not simply be a response to a claim for more resources to continue to do what we have always done. Where highly efficient processes are in place in areas such as speech and language therapy and other therapies, we are determined that those processes will be rolled out nationally, rather than continuing to support situations where we do not get an adequate return in terms of value for the money invested. It is not always as simple as making further appointments. That is the way the system has operated historically but, despite huge increases in the numbers appearing at the front-line services, we still are often challenged by increasing waiting lists. That challenge must be examined in broader terms than just providing more staff. We must examine the efficiency of how we are providing those services.
I am convinced that we are making good progress in reforming health services. Our recently published report confirms this. Completely reforming Ireland's public health service into a modern service where almost 90% of care is provided outside acute hospitals must happen progressively; it cannot happen all at once. The suggestion that some place in the world has a magic bullet for transforming health services is untrue. If it is, many health services throughout the world have failed to find it. A commitment to change is necessary, not just from those who work in public health but also from those who are in a position to influence changes such as the social partners, public representatives, the media and advocacy groups.
As a community, everybody has a role to play in the future of the public health service. Whether this role is as a user or provider of services, we must at all times ensure quality and safety are never traded for convenience and consensus. In the final analysis, the provision of health services will continue to be a significant challenge financially, not just in this environment but in the future because Ireland's population is ageing. We are provided with a fixed amount of money each year, which we fully accept. We must accept, however, that with a growing population and a population that will age each year, there will be an increase in demand-led schemes. We will have to deal with this but we must also take actions to ensure we get value for money. Actions such as freeing up resources from negotiations and large procurement such as pharmacy services can help us to bridge that gap on an ongoing basis but we need full support in driving value for money. As we are often criticised for not managing the system, it should be recognised that when we do manage it — we do so very actively — we are doing so on the basis of freeing money for front-line resources, not for any other reason.
I thank members of the committee for their attention. We will provide any information we can and if we are not in a position to provide it today, we will do so within a number of days.
Mr. Tony O’Brien
I add my congratulations on the appointment of the Chairman and wish him well in his new role. I also thank the committee for the invitation and giving us the opportunity to come here today. I am joined by my colleagues, Dr. Alan Smith who is a consultant in public health with the national cancer screening service and by Dr. Marian O'Reilly who heads our cervical screening division.
The national cancer screening service was established by the Minister in January 2007, following the launch of the strategy for cancer control. The role of the service is: to carry out, or arrange to carry out, a national breast screening service for the early diagnosis and primary treatment of breast cancer in women, BreastCheck; to carry out, or arrange to carry out, a national cervical cancer screening service for the early diagnosis and primary treatment of cervical cancer in women; and to advise on the benefits of carrying out other cancer screening programmes where a population health benefit can be demonstrated. Our role also includes advising the Minister from time to time on health technologies, including vaccines relating to the prevention of cervical cancer. We have an overall obligation to implement special measures to promote participation in our programmes by disadvantaged people.
The national cancer screening service's founding principle is to maximise expertise across screening programmes and to improve efficiency by developing a single governance model for cancer screening.
BreastCheck, the national breast screening programme, is a free service using mammogram examination. It is provided for women aged 50 to 64 on an approximate two-year cycle. The programme began in 2000 in the eastern region, which covers counties Dublin, Kildare, Kilkenny, Carlow, Wexford, Wicklow, Meath, Louth, Cavan, Monaghan, Offaly, Longford and Laois. It operates from two static units and a number of mobile screening units. Up to the end of March this year, BreastCheck had provided almost 390,000 breast screenings for women in the catchment age range. This resulted in the early diagnosis of 2,439 instances of breast cancer in individual women.
The southern unit of BreastCheck was opened in November 2007 in Cork and covers the catchment areas of Cork, Kerry, Limerick, Waterford and Tipperary South Riding. It serves a population in the age range of approximately 72,000 women. Screening is under way in counties Cork and Waterford and is due to get under way later this year in Tipperary South Riding. Assuming a minimum uptake rate of 70%, it is expected that the first round of screening in the southern region is likely to result in the diagnosis at an early stage of 174 women with breast cancer.
The western unit, located in Galway and serving a population of approximately 58,000 women, covers counties Galway, Sligo, Roscommon, Donegal, Mayo, Leitrim, Clare and Tipperary North Riding. Screening is under way in Galway, Roscommon and Mayo and it will shortly get under way in Tipperary North Riding. Assuming a minimum uptake rate of 70%, it is likely that the first round of screening in that region will result in early diagnosis of breast cancer in 141 cases.
According to our most recent annual report, which carried a full analysis of outcomes for 2006, the service provided screening for 63,000 women. The overall acceptance rate in that population was 78.1%, which exceeds the target of 70%.
Of those who attended for screening, 1,903 were recalled for assessment, resulting in 337 women receiving a diagnosis of breast cancer. Critically, in 2006, for the first time since the programme began, we achieved a particular charter standard of ours, exceeding the 90% target for women who needed admission to hospital, receiving that admission within three weeks of diagnosis. That was achieved in 94.4% of cases.
These standards are of particular importance to BreastCheck and the uptake rate is critical to our ability to reduce mortality from breast cancer. It is significant that in its 2007 Health at a Glance publication, the OECD ranked BreastCheck fifth in the world for its participation rates, ahead of long-established screening programmes in countries such as the United Kingdom, the USA, France and Australia. As the Minister mentioned, BreastCheck recently became the first national breast screening programme to operate entirely through the digital mammography medium. That is an important development for a wide variety of reasons.
I will turn briefly to the national cervical screening programme. The Irish cervical screening programme pilot and phase one has been in operation in the mid-west, the former Mid-Western Health Board region, since 2000. Following the establishment of the national cancer screening service in January 2007, its governance was transferred to the NCSS board. The NCSS therefore became responsible for establishing the national programme to meet the needs of 1.1 million women living in Ireland aged 25 to 60.
It is important to note that, on average, 180 new cases of cervical cancer are diagnosed each year in Ireland. The average age of a woman who receives such a diagnosis is 46 years. Some 36% of women with cervical cancer die from the disease within five years of diagnosis. The average age at death from cervical cancer is 36. On average, 73 women die from cervical cancer each year in Ireland.
The NCSS is currently in the final stages of preparations for the launch of the national cervical screening programme. The programme will be quality assured, organised, cost effective and available free of charge to all women living in Ireland aged 25 to 60. This is being grounded on a quality assurance process and the provision of a number of specific legs to the stool of the screening programme. Members of the joint committee will be aware that we recently completed a procurement process in respect of cervical cytology on the basis of third party accreditation, ten-day turnaround and guaranteed capacity.
We also have in place specific programmes with regard to smear taker or primary care setting. We are at an advanced stage in finalising the contract for smear takers and we are in final discussions with the GP committee of the Irish Medical Organisation. We expect to publish the final contract in the coming days.
Cytology and access to onward assessment and treatment are an important part of the programme. In December 2007, our quality assurance group for colposcopy and gynae oncology began a process of quality assurance and baseline assessment of all existing colposcopy services with a view to ensuring that they have the appropriate capacity to meet the needs of the programme. That work is also at an advanced stage.
Screening will be provided every three years for women aged between 25 and 44 and every five years for women aged between 45 and 60 years, in line with international evidence. The purpose of cervical screening is to identify and treat pre-cancerous cell changes before they have a chance to develop into cancer. A smear test is a screening test, not a diagnostic test. This is an important point that should be made.
A national, quality-assured cervical screening programme has the potential to cut current mortality rates from cervical cancer in Ireland by as much as 80% per annum. However, it is important to stress that no single screening test is 100% accurate. For this reason the screening programme will offer a woman repeat smears — up to 11 or more smears in her lifetime — at intervals dictated by international best practice using laboratory services that have been accredited on a third party basis. This will minimise a woman's risk of cervical cancer and any possible risk of a false result.
Our aim is to achieve a high level of uptake in this programme as well and the necessary target is 80%. For this reason we have concentrated heavily on making access and confidence key elements of the programme.
I will touch briefly on the issue of HPV vaccine. In furtherance of its remit to advise the Minister, the national cancer screening service board commissioned a health technology assessment to be carried out by the Health Information and Quality Authority, HIQA, into human papilloma virus vaccines. Together with the national immunisation advisory committee and HIQA, we have provided advice for the Minister in respect of HP vaccine.
Colorectal screening is another area of considerable focus for the NCSS. Colorectal cancer is the second most common cancer in Ireland and presents a serious public health issue. The mortality-to-incidence ratio for this cancer is relatively high, with more than five deaths for every ten incident cases. Early detection has proven results in improved survival rates. The Minister has asked the NCSS board to explore a national colorectal cancer screening programme. In April 2007, we established an expert group on colorectal screening, chaired by Professor Niall O'Higgins, and including many of the country's leading experts in this area. The group completed a preliminary report which is being validated by an international panel at the same time as a further health technology assessment is being completed, commissioned by us, by HIQA. We expect to be in a position in the late summer or early autumn to complete the report and transmit it accordingly to the Minister.
That is a general update on the work of the NCSS. We will be happy to take questions that members of the joint committee may have.
Thank you very much, Mr. O'Brien. I am aware that the Minister and Professor Drumm need to leave at 1 p.m. and I will therefore ask members to be as brief as possible with their questions. Mr. O'Brien will stay on for a further 30 minutes, so I suggest that questions be put to him at that time. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.
I welcome the Minister, Professor Drumm and Mr. O'Brien and his team. Traditionally, we make statements and then ask questions but I would prefer to get straight down to questions because many arise. The Minister mentioned an OECD report and the increase in public health spending as a percentage of GNP. That has only occurred in the past two years after approximately 20 years of below average spending. One cannot catch up in a couple of years by spending the average when one has been in deficit for some time before.
Turning to the other issue, it is all very well to talk about new services to be put in place, which we welcome, but we need services for those who are currently ill while we develop the new services. That is a major issue for people. The Minister mentioned the OECD report for the north east. Her original plans were for one hospital but the OECD report recommends two for the region.
The following questions probably cut across both reports but perhaps I should go through Professor Drumm's contribution first. He mentioned that life expectancy has increased for both males and females, which is true. However, that is not only down to medical improvements but to social change and social improvements as well. He mentioned a published independent research paper which showed that people have very high satisfaction levels with our service when they can get access to it. However, nobody has surveyed people's satisfaction levels in terms of their ability to access the service, a huge issue to which I will return.
Professor Drumm mentioned that 1.3 million people — 30% of the population — have medical cards when several years ago, it was 36%. Neither Professor Drumm nor the Minister mentioned the disgraceful fact, which is not in Professor Drumm's remit but is certainly within the Minister's, that the current income threshold for a medical card for a single person is a little over half the minimum wage.
Professor Drumm mentioned primary care teams and all the great developments to occur there but we have been waiting for them since 2001. That was prior to him taking up the post so I do not hold him responsible for that. However, I do not like to hear it put in such a fashion as to suggest that there has been a phenomenal improvement for patients because there has not been. Patients receive very few additional services than what they received three years ago.
Professor Drumm said that 500 general practitioners are participating in primary care teams. I would like him to define what that participation means and how many are in each category. He mentioned that 300 posts had been allocated and that it is envisaged that recruitment of these will start at the end of the year but he also mentioned that there is no recruitment ban. Therefore, we can expect those posts. Will he outline the nature of them? Are they physiotherapists, occupational therapists, health visitors or otherwise?
Professor Drumm mentioned that the average length of stay has been reduced in many hospital and he specifically mentioned the Mater hospital and that the length of stay has been reduced from 12.5 to nine days. What is the readmission rate as a consequence of early discharge without the proper support in the community?
Professor Drumm also mentioned palliative care, all the improvements in that area and the amount of money spent, yet we know there are people on waiting lists for palliative care — people waiting to die. He mentioned the funding. What about the €21 million allocated for palliative care which did not go into it and went elsewhere? I will return to that later. I turn to something said at the Committee of Public Accounts two weeks ago, that is, that two thirds of the posts had been filled in the hospice service. I had a telephone call this morning from one of the leaders involved in this who is prepared to be quoted, although I do not believe it is fair to do so. He said that only 50% of those posts have been filled.
Professor Drumm mentioned the consultant contract which I welcome and on which I congratulate him on completing. However, it would seem from what he said that it is unlikely that any consultants will be in place by the end of this year if interviews are only taking place now. As he pointed out previously, there is a long lead-in time for a consultant to give notice, leave his or her current post and take up a new post. Will Professor Drumm comment on that?
Professor Drumm said that 3,584 posts had been approved and are being filled. Will he tell us how many have been filled as opposed to how many are being filled? He said there had been improvements in speech and language therapy yet 4,000 children are waiting for speech and language therapy in one part of Dublin alone. We would like that addressed.
The money proposed to be invested in the primary health care strategy to make it happen was estimated at €1.1 billion. That was in 2001 but that money has never materialised. I understand approximately €20 million has been spent. There are virtual teams and promised premises but these are no substitute for the services I mentioned. Professor Drumm's talk of a shift to primary care can only be construed as talk until such time as there is a real service. I fully support the plans to move more of our care into primary care where it can be carried out more effectively and efficiently but at the rate at which it is happening, it will be 50 years to 100 years by the time we have all the primary care centres. A recent statement mentioned that instead of €1.1 million per team, €200,000 had been given and that instead of 13 people employed per team, only three were employed. How many teams received €200,000 and how many teams got three additional staff?
I refer to the general issue of capital projects. The number of capital projects completed and then left idle is astounding. It is false economy and very poor management to spend millions of euro and then leave such projects idle with no staff. I refer to the accident and emergency department in Cork, which only operates from 9 a.m. to 6 p.m.; to the wing in Mullingar hospital, which lies mainly empty; to the new medical ward in Clonmel hospital, which lies mainly empty and which is not being used for medical admissions; to half of Tullamore hospital, which is not in operation; to the lack of staff to operate ICU beds in Galway, which cost €4.6 million; and to the several million euro spent on homeless facilities in Dublin with nobody to staff them. How many millions of euro have been spent on capital developments which are now lying idle and delivering no return or service to patients or clients?
I turn to the north east. How many people have been called for review? I refer to the 4,600 people and 6,000 X-rays involved. Most important, are they being contacted as the X-ray reviews reveal a problem or are they waiting in a cohort to be dealt as happened in Portlaoise? In other words, as soon as the person reviewing these X-rays discovers there might be a problem, is the patient being contacted immediately or are the files being left in a corner as happened previously? Has the patient and his or her GP been informed so that the GP can advise his or her patient? Were any ultrasounds involved? If there were, they must be repeated because they are a real time examination.
Will the Minister or Professor Drumm tell the committee why no action was taken by the HSE until May even though this was highlighted in November? That is six months in which somebody's tumour continues to grow, even though he or she might not know they have one. I would like an explanation for that. Why were all the warnings from doctors, management, Judge Maureen Harding Clarke and others on the overdependence and reliance on locums in radiology in the north east ignored thus putting in place a system which would maximise the impact of human error on the patient?
I heard both the Minister and Professor Drumm outline in a wonderful way how things have improved. However, that is not the case for the patient. There are two core measures we can use. The first is accident and emergency waiting times and the other is waiting lists for procedures in our hospitals for people who have seen a consultant. The figures from the Irish Association for Emergency Medicine show clearly a huge increase from April last year to April this year in people waiting overnight for 12 hours on trolleys. In Galway, the figure rose from over 100 to 444 and in Beaumont the figure rose from approximately 380 to over 900. The internal Health Service Executive report, which was leaked yesterday, shows that half of accident and emergency patients are waiting for more than 12 hours. That is based on a 2 p.m. census. What would it be at midnight?
Outpatient waiting times, the other area one can measure, have increased by 10% according to an independent OECD report. As a general practitioner, I know that any adult looking for an ear, nose and throat appointment in Beaumont Hospital will be told to go somewhere else because it has a two-year waiting list and cannot give an appointment. That is before we talk about all the other areas, such as neurology, neurosurgery, urology, etc. How do all these hard facts square with the nice presentations made at this meeting?
I want to ask about the redirected moneys. This has not been picked up by many people but it is a serious issue that this Government, through its elected representatives of the people, can determine a programme for Government and put in place policy initiatives specifically for palliative care, mental health and funding for disabilities, and that the HSE, through either incompetence or deliberate obstruction, can spend that money, not in those areas but wherever it so desires. The Minister told me in the House a few weeks ago that this first came to light in 2006 and again in 2007. This undermines democracy. It means that neither this House nor the Department of Health and Children has any true say on health policy in this country, and that the HSE has the final say and can determine where the money goes. When was the HSE given authority to determine the spend? What control will the Minister or this House have over this issue in future?
If I leave out an area, I apologise to those concerned. Many people in this country have questions to ask the Minister and Professor Drumm because of the services they cannot get for their loved ones or for themselves.
Will the budget overrun, which is put at €517 million, result in a restriction on the issuing of medical cards and drug cost reimbursements? I would ask the Minister to reply to that with a "Yes" or a "No".
What is the projected overrun for the year? We were told it is €517 million. What is the overrun to date? What is the cause of the overrun? Is it hospitals, medical cards or the drug payment schemes? Is it all three and if so, could the Minister possibly apportion under each heading where the overruns are occurring?
On intellectual disability, we heard the chief executive officer of St. Michael's House this morning state that he can no longer offer places or comfort to people whose children are born with Down's syndrome. The funding is not available. I have mentioned the palliative care situation.
While it is a political decision, does Professor Drumm agree with the Central Mental Hospital moving to Thornton Hall and the stigmatising of mental illness in this way? What is the Minister's response to the long list of august people who have expressed their concerns along with Amnesty International, Gheel Autism Services and approximately 25 other organisations? It beggars belief that the Minister can fly in the face of those who are using, run and have concerns about the service, and go ahead with her political will to get value for money.
The Minister mentioned patient-oriented services and stated that all her actions are geared toward improving patient care. Most of the time when one looks at them more closely, one finds it is about saving money and about cuttingcosts, not about putting the patient first.
I stated previously that I agree with Professor Drumm's thrust towards a move to primary care. How can this take place when the funding is not available in primary care to put in place the services necessary for us to reduce or even maintain the current bed numbers? Currently, people are ill, people are dying and people are in pain, and the service they should have is not available. It is not acceptable for patients to lie on trolleys for two days. It is not acceptable to wait in accident and emergency for more than 12 hours before seeing a doctor. A good friend of mine, who is only just out of hospital, waited six days for an angiogram and held up a hospital bed in the interim. That is an example of where the gross inefficiencies arise.
On a point related to co-located hospitals, 57,000 bed days were lost last year between Beaumont Hospital and the Mater Misericordiae Hospital alone because there was nowhere appropriate in the community for people to be referred to for their further rehabilitation following their acute phase of treatment. That still remains undone. Promises for 3,000 places are welcome, but promises are not services. It is always promises for tomorrow while services are taken away today.
Does the Minister or Professor Drumm want to respond at this point?
I am happy to respond, if that is the way the Chairman wants to deal with it. On the expenditure Deputy Reilly mentioned, health expenditure increased in Ireland by an average of 7.2% between 1995 and 2005, while the OECD average for the same period was 4%. It is not that this happened only in the past two years. Since the middle of the 1990s we have been increasing public spending on health progressively and substantially. So it was by the end of 2005. I do not have later figures. This compares like with like because it applies purchasing power parity, which is the relevant test where one wants to compare two different situations.
Per capita spending in Ireland is just under $3,000 and in the OECD it is $2,700. We are spending approximately $250 more per capita per year than the average across the world’s wealthiest countries, notwithstanding the fact that we have one of the youngest populations. Some 11% of our population is over 65. The comparable figure in France is 16%. It is closer to 20% in Germany and it is approximately 18% in the UK. There is catch-up and there is much in terms of capital investment. After Norway, we apply the highest percentage of national income to capital investment in health of any country in the world.
The issue, as the OECD stated, is not just the amount of money we can apply to health from public or other sources. It is also how we organise services around quality and patient safety in a way that delivers them at best value for money possible. That applies to the HSE in its remit to provide public health services. It also applies to many voluntary organisations that are in the service delivery business.
There are 500 organisations in the intellectual disability sector alone. That is a matter to which I want to apply some thinking and I have been talking to some people in that sector. Many of them have CEOs, directors of finance, public affairs companies and a host of back-up services which clearly are needed by them as individual organisations. If we could encourage the coming together of some of these organisations in an innovative way, we would have more resources to apply to services for the individuals who need them.
On the medical card, it is not comparing like with like to state when Ireland had 18% unemployment, mass emigration and per capita income was one third of what it is today that 36% of the population held medical cards and now, when we are three times richer, there is 5.5% unemployment and net immigration, only 31% of the population hold medical cards. I am not a great fan of percentage comparisons for many reasons but if we compare the percentages, we must compare similar economic circumstances. Clearly, with rising levels of unemployment, we will see an increase in the number of people with medical cards. The year before last we increased the income threshold by 25% and instead of dealing with nominal income, we have moved to disposable income. We also have factored in the cost of child care, travel to work, mortgage and rent to ensure we target as best we can those who need the services most.
Some 200,000 extra people in Ireland in the past two years have free access to their general practitioner. The bulk of them, 140,000, as I recall, have full medical cards and somewhere between 60,000 and 70,000 have the GP card, which is a graduated benefit for those who do not meet the income threshold for a full medical card. There is a 50% add-on for a GP-only card. On this year's funding, clearly those who are entitled to medical cards will get them. That is not an area of funding.
Professor Drumm is better equipped than I to deal with the issue of HSE spending but I understand 50% of the overrun is on the hospital side, with the other 50% on the community side. If the trends that emerged in the first part of the year were to continue for the remaining months, the overspend would eventually reach something of the order of €300 million. On the community side, the overrun relates to the drugs area and medical cards.
If it is to divert development moneys or moneys allocated in the budget for disability, mental health or palliative care services, the HSE, under the letter of sanction for expenditure, is required to obtain prior approval from me and the Department of Finance. Depending on the areas from which moneys were diverted, this would be the subject of a Supplementary Estimate and a matter for the committee. The HSE faces a major challenge in continuing to provide day-to-day services, particularly when one takes rising costs, wages, etc., into account. That is why so much of the focus is being placed on how we might do things better.
If one considers the data being produced by Professor Drumm and his team, it is clear that there are huge variations. For example, the number of patients seen by a consultant in a certain part of the country can differ greatly from the number seen by another consultant operating in the same specialty. One must ask why this is the case. One must also ask why 18% of outpatients do not turn up for appointments. I referred to a number of innovation awards, one of which was given to the physiotherapy department at St. James's Hospital, where the number of those who do not attend was reduced from over 20% to approximately 10% following the introduction of an innovative system relating to the making of appointments. This means that more people have been seen at the department. In the context of the neurology service at St. Vincent's Hospital, Dr. Tubridy and his team, through innovation and changes to work practices, have been able to reduce waiting times from approximately 18 months to a matter of weeks. This doubles the time doctors can spend with patients. I salute this innovation.
There is a fund in place this year to support innovation. Some doctors have informed me that if they can be given small sums of money for 12 to 18 months in order that they might see their patients in a different way, they will be able to reduce both in-hospital stays and the need for particular hospital beds. We must encourage and support innovation of this nature. All the health Ministers I meet from countries in Europe and elsewhere are concerned about the financial sustainability of their health systems and focusing on innovations.
Professor Drumm will probably deal with the north-east review. As stated, however, we are overly dependent on locums and junior doctors. I have engaged in discussions regarding the qualifications of locums. I am of the view that locums should be on the specialist register. There is a shortage of consultants. As stated, there are 6,000 hospital doctors in Ireland. Of these, 4,000 are non-consultant doctors, while the remaining 2,000 are consultants. We want to change this ratio because we are spending a great deal of money on providing a service which does not meet the best standards from a quality or patient safety perspective. I am sure Professor Drumm will provide examples in respect of this matter. There is one hospital which has 33 doctors and where 15 admissions take place each day. One does not need to be a genius to know that this is neither safe nor financially sustainable. As regards the manner in which we reform the service, we must be able to deal with such matters because that is what is demanded in the context of change and patient quality.
The most important people in the Central Mental Hospital are the patients. I have, like many Deputies and Senators, visited the hospital, the facilities at which are completely inadequate to meet the needs of very sick patients in the 21st century. The first priority is to put in place a state-of-the-art facility. The Government was able to identify a portion of land for this purpose. We need to be innovative. It is proposed to move the Central Mental Hospital to the north side of Dublin and I accept that this will inconvenience some of the staff. We regret this. However, the new hospital will be further away from the prison than the Mater Hospital is from Mountjoy Prison. Nobody states the Mater Hospital is co-located with Mountjoy Prison.
The latter is an existing arrangement.
Dr. Kennedy, the medical director of the Central Mental Hospital, walked the land where it is proposed to build the new facility with the former Minister of State and was asked for his opinion. I accept that opinions are now different. However, the most important aspect of this matter is to ensure a new facility for patients is put in place as quickly as possible. The land in Dundrum is extremely valuable and we want to use the money that can be realised from its disposal to invest in mental health services in the Dublin area and elsewhere. I do not agree with the assertion that the new hospital will be co-located with the new prison. That is not the case. The two will be completely and utterly separate.
The State has acquired a portion of land at great expense. Deputy Reilly's party was extremely critical of the purchase. It makes sense to proceed with building the new hospital if planning permission can be obtained, which is another issue. The new hospital will be subject to planning permission because it does not qualify for an exemption.
This is not about patients.
It is. The quicker we can get them out of the existing facility the better.
A replacement facility could be built at the existing location.
The Minister to continue without interruption.
The Minister is making assertions that are untrue and I cannot allow them to pass. There is a list of people, both nationally and internationally, who are concerned about this matter and who are being ignored, including the patients and their carers.
I have a list of members who want to contribute.
This is because of the way the issue is being presented.
No, it is because of the Minister's drive for value for money.
The new hospital will not be co-located with the new prison.
This has nothing to do with co-location.
Deputy Reilly is bulldozing across the Minister's contribution. He should have some manners.
I beg the Senator's pardon but I am speaking on behalf of people who have no voice——
We are all doing so.
——and who are mentally ill. They are going to be shoved out to north County Dublin away from their loved ones.
The Deputy should cop on. The stigma is in holding them there.
I ask the Minister to continue with her response.
Many of the other issues raised by Deputy Reilly in respect of accident and emergency department waiting times, outpatients waiting lists, etc., are probably ones with which Professor Drumm should deal. There are a number of public hospitals which have the capacity to refer patients awaiting essential treatments and surgical procedures to the National Treatment Purchase Fund, NTPF, but some of them are not doing so. I am involved in discussions with those who operate the NTPF in respect of this matter. When resources are available to provide services for patients, it is a great pity that the needs of such patients are not being put first. We must ensure patients who are being obliged to wait — I understand there are three hospitals involved in this regard — are put first and referred for the procedures they require through the NTPF. We intend to introduce a number of initiatives in respect of this matter. The NTPF is also dealing with persons who require outpatient appointments in certain specialist areas, another initiative that is proving successful. Deputy Reilly referred to ENT waiting lists. I will pursue that matter with the NTPF.
I am aware that at two hospitals the time is six months rather than three months. Deputy Allen will refer to a letter relating to this matter when he returns.
We will take supplementary questions at the end.
It is three months from the time somebody——
It is now six months. Will the Minister answer my question regarding——
If the Deputy wishes to ask supplementary questions, he will have an opportunity to do so at the end of the meeting.
The main question I asked relates to when the decision was made——
There are other speakers offering.
I accept that but my question is important. When was the decision made to allow the HSE to spend the money in question as it saw fit? This is a key issue.
I ask the Deputy not to disrupt the meeting. There will be an opportunity to ask supplementary questions at the end.
Professor Drumm
Many of Deputy Reilly's questions relate to primary care teams. I will ask Ms McGuinness to deal with them.
Ms Laverne McGuinness
The broad thrust of the Deputy's questions relates to what is happening as regards the roll-out of primary care teams. The total funding received was €32 million. This was to commence 100 teams in development in 2006 and a further 100 in development in 2007. Some 97 of the 2006 teams are in development, of which 72 are fully functioning. There are three staff members per team. The cohort of staff and the composition thereof depend on what is required by a particular team. With regard to their effectiveness, it is important to understand they are providing for added service over and above that which was previously provided. I will provide a number of examples to illustrate the point.
There is a link between the primary care team in Togher and the palliative care project. Arklow has an outreach facility for X-rays with St. Vincent's Hospital, the existence of which has meant that, to date, approximately 400 people have not been obliged to attend hospital. There is a home-first initiative in our south Wicklow primary care team. We have a wounds clinic ongoing at Inchicore and a chronic disease management project in place at Irishtown. We have an early pregnancy initiative in the Ballymun primary care team. A home detoxification initiative is ongoing in the south Connemara primary team while an advanced diabetes clinic is ongoing in the Donegal team. We have a faults prevention programme in the Limerick team. We have a warfarin clinic going in various primary teams. There was a reduction in waiting lists for occupational therapy and physiotherapy in various primary care teams.
We are examining how we evaluate the outcome and benefit of putting in place these primary care teams to the patient. The 97 teams will be fully operational by the end of the year. An awareness programme about the benefit of the teams to the public and how they will benefit people in their locality in the context of their health and well-being is lacking. We will create such a programme over the summer months with 27 programmes run for local initiatives starting from the end of the June. I have a list if the Deputy wishes to see where they will be going on.
The Deputy asked about the other 100 primary care teams for 2007 and this is also linked to his question about the funding tied to 300 posts. We said as part of our service development plan that, funding permitting, we would seek to put in place those posts but the greater challenge we are addressing is the reconfiguration of the staff currently working in the system. A total of 65,000 staff must be realigned into primary care teams. That work is under way and 100 of the other teams will be in development by the end of the year and some new posts will be in place, perhaps not all. With regard to the totality of 300 posts that went in for 2006, 222 are in process and a further 70 are in the later stages of recruitment. Most of those, therefore, will also be in place by the end of the year.
The Deputy also asked about the number of general practitioners. We said 500 GPs would be aligned to primary care teams. A total of 220 are participating and we are in negotiation with other GPs to come on board in the next stage, which is the formulation of the next 100 teams. We are rapidly moving forward this year to putting in place primary care teams in a more meaningful way. It must be understood that a great deal of ground work had to be done on where the teams and the social care networks would go and how we would go about that. All the planning work was carried out in 2007. It is complete and everything is mapped. We are working towards the implementation of the policy and how best it fits in with the people's lives and how it will change and transform their lives.
Will Ms McGuinness define "participation"?
Ms Laverne McGuinness
The GPs are aligned to primary care teams. They participate in the teams. The primary care teams are, therefore, happening and there is a GP there. We clearly said even in the new capital programme where we sought and received expressions of interest that we will not proceed with capital developments by private property facilities unless we have GPs signed up to them. We have that for the next 20 with which we are proceeding.
Professor Brendan Drumm
I can get the specific figures for readmission rates to hospitals. Such rates are increasing. We are determined to bring down the average length of stay. They are extraordinarily high and this is not based on acute lack of long-term services in the community. The average length of stay for an appendix operation can vary from three to six days and that does not depend on somebody being in the community. There are huge issues relating to average length of stay in hospitals, which are not dependent on services in the community. I accept there are many that are dependent and, therefore, we need to deal with the issue in general. It is a major challenge to move money into the community and out of the hospital sector, which is what has to happen.
We could not proceed with the advertising of consultant appointments until the agreement of the contract. We proceeded within a week of the agreement of the contract. It is clear people must be given a number of months to apply and go through the PAS system. This is moving at a pace but the Deputy is correct that even when these people are appointed, there will be a significant time lag as they are trained. Some will take up posts quickly as they are in training in Ireland. Others are in training overseas and will not take up posts as quickly.
I refer to the accident and emergency service. The Deputy referred to yesterday's newspaper article and perhaps this has something to do with the way we publish the figures. The view of the Evening Herald was that 40% of people are waiting in accident and emergency departments for more than 12 hours. That is the number of people waiting as a percentage of the number of people waiting. We admit 1,000 people a day to our accident and emergency departments. During the first three months of this year, the average number waiting for more than 12 hours was 50, which is 5%. By May, it was 3% or 30 people, not 40%.
How does Professor Drumm square that with the figures of the Irish Association of Emergency Medicine?
Professor Brendan Drumm
I am not squaring with anybody's figures. These figures are collected and anybody can audit them at 2 p.m. All sorts of vested interests can deal with figures in any way they want. I am dealing with actual figures and anybody who wants to can audit them. We have counted the figures the same way since I joined the organisation and nothing has changed. In March 2006, 240 people were on trolleys on average on a daily basis while by March 2007 it was 107 people. That is a hell of a movement compared with the system we took on. The notion that the health service has worsened rather than improved——
What about 2008?
Professor Brendan Drumm
Our staff who work extraordinarily hard in achieving that should not be demoralised by attacks that are often based on nothing to do with patient care.
Professor Drumm referred to March 2007 but I alluded to March 2008.
Professor Brendan Drumm
I have no problem comparing March 2006 with March 2008. When we took this on seriously over the winter of 2005-06, the numbers were 2.5 times what they are now. It is unfair to our staff to make out that we are not making headway. To call it a crisis when it has improved so much is demoralising for them and it serves nobody's interest. The figures are 5% in March, down to 3% in May 2008. Anybody can have these figures. The fact that somebody is extrapolating the figures to say the rate is 40% is as much our fault as anything in that we measure percentages based on the number waiting and we ignore the fact that almost 90% of patients are admitted to wards immediately. Let us not undermine the service completely by using figures that are not accurate. Perhaps some of the fault lies with us because the way we portray our figures does not do us justice and we will have to fix that because, to be fair to the press, that may be part of the problem. We will deal with that issue. The figures are nothing like they were being portrayed.
That is not the reality. Is the HSE measuring from the time patients enter accident and emergency departments or from the time they see a doctor and a decision is made to admit them?
Professor Brendan Drumm
We would love to move to a system of medical assessment units and accident and emergency departments and we would love the consultants involved to fully sign up to apply a consistent process in such departments. The largest department after Tallaght hospital is in Waterford Regional Hospital and practically no patient ever waits, despite approximately 62,000 passing through it every year. I would love that process to be in place in every accident and emergency department with the full support of those who work in them to implement a system that clearly delivers superbly for the people of Waterford and should be delivered for everybody else. The staffing level is one of the lowest in the State. There are ways of fixing this but that means everybody must sign up to it with people not running their own little bit to suit their own agenda.
I was asked about the Mercy Hospital and South Tipperary General Hospital and opening units on the basis of the resources they have. The Mercy Hospital has 27 admissions a day. It has 120 doctors and 400 nurses and, therefore, it should be able to open its accident and emergency department. That is reasonable.
That is within Professor Drumm's gift as chief executive officer of the HSE.
Professor Brendan Drumm
It is within their gift to do that.
Will Professor Drumm repeat those figures?
Professor Brendan Drumm
The Mercy Hospital has 27 admissions a day, 120 doctors and 400 nurses
What are the accident and emergency department numbers?
Professor Brendan Drumm
There is one member of staff for every 1.5 attendances at the accident and emergency department. In his practice, the Deputy would have seen 30 people a day. It is common to have one member of staff for every 1.5 to two attendances. In parts of the country, there is one member staff per attendance in an accident and emergency department. I doubt it is an underresourced system. In the south Tipperary situation there were 94 doctors and 344 nurses for 34 admissions. Nobody can tell me there is a place in the world where this level of resources has been put in place and it has not been possible to open a new ward or department for fear the system would collapse. If our system is built up further in terms of that type of support, it will collapse. Taxpayers will not support it. I do not know from where the money will come for it.
The issue of the waiting time for procedures was raised, for example, waiting six days for an angiogram, etc. We have no excuse for that. There is no reason somebody should have to wait six days for an angiogram when we have hospitals in our city with 400 doctors for 100 patients admitted. Nobody should have to wait for an angiogram with that level of resource in place.
There is a question as to whether we need a vast improvement in the management of that resource. We do and we are very active on the ground in efforts to improve the situation. We are working with individual hospitals and at management and board level to ensure we get better value. We have had huge co-operation in this regard, for instance in Dublin from the DATHS, to move towards a system that will improve these processes. It is a big challenge, but we are getting great co-operation from staff on the ground.
The Deputy referred to the redirected money as being either a result of incompetence or deliberate obstruction by the HSE. That is strong language to apply to us in this situation. It is neither. As I pointed out earlier, we work from a fixed resource and face significant challenges in that regard because of increasing unemployment, an increase in the number of medical card holders and increases in demand-led schemes. We have to provide the money. The Deputy suggests we stop providing these services in order to balance the budget.
We have a fixed amount of money, so we must either stop something or redirect money. We are driving a €300 million value-for-money programme currently, and the effort to save on spending is hitting every back room of the organisation, for example, travel and subsistence, telephone calls and training are all being cut back. When we remove that €300 million, we are still left with a significant deficit because of growth in the schemes and services generally.
Neither I nor anybody else on the team has the ability to print money. We must move it or else stop doing things we are doing and put in the new services. I am delighted the decision on moving any money now rests back in the hands of Parliament, because it is a decision we are not comfortable making. We are delighted, if it is seen as a democratic deficit, that the decision is taken back from us. The decision is about driving real value for money.
As I said in my opening statement, when we were trying to drive real value for money in our biggest area, procurement in pharmacy services, which could have helped the situation, we lost €30 million in the first three months because of the delay in implementing the plan. We would have freed up significant amounts of money otherwise. We need to take some serious business decisions in terms of how we procure things and get value for money and we need support for that approach. If we keep doing things the way we do and stop some services, we will not be able to cope with increased demand. We must find a balance one way or the other. We do not have a choice. The decision on redirecting funds is not one we will have to take in the future, so that concern is gone. What we chose to do was not incompetence; it was due to increased demand within the fixed amount of money provided to us and in a situation where sometimes we find it difficult to drive solid business cases for freeing up money.
When was the HSE given that authority?
Professor Brendan Drumm
What authority?
The authority to spend the money where the HSE felt it was needed and not spend it in the areas that have ——
Professor Brendan Drumm
That authority existed long before the creation of the HSE. Development money has been moved in the health services for years. Perhaps Deputy Reilly was not on the Eastern Health Board or anywhere like that, but it is not a new discovery. Perhaps Ms McGuinness would like to respond now on the issue of palliative care.
Ms Laverne McGuinness
The funding for palliative care was €9 million in 2006 and €5 million in 2007. Some 70% of that funding was allocated and the related posts put in place for 2006 and approximately 30% of the €5 million for 2007 was allocated. The rest is overall vote balancing.
I draw the committee's attention to the fact that while the money may not have been spent on specific initiatives under palliative care, other funding was spent on palliative care. For example, some home care packages in the west, which are quite significant in terms of cost, were for palliative care. Drugs for some of the demand-led schemes were also for palliative care. In addition, some 44 intermediate care beds were provided at a cost of €7.1 million for palliative care. Therefore, there was additional spending on palliative care. However, of the totality of the 2007 funding for posts to be put in place, only 30% were put in place. We had an overall spend on palliative care of €75 million, which does not include drugs and appliances. Palliative care is delivered through a number of programmes, so it is not just in one little box called palliative care funding. There are funds ——
It was said at the Committee of Public Accounts two weeks ago that two thirds of the jobs were not filled.
Ms Laverne McGuinness
I was at the Committee of Public Accounts meeting and what I said was that 70% of the funding for 2006 was spent on palliative care.
The impression I got was that 70% of the jobs were not filled.
Ms Laverne McGuinness
I gave the figures for jobs at the time.
Professor Brendan Drumm
Deputy Reilly raised the issue of the north-east radiology review. I will ask Mr. Finn to comment on that. As Deputy Reilly knows, we are not willing to comment on numbers as we think it is wrong to start dealing with numbers at this stage as the review is not complete. However, Deputy Reilly asked questions relating to the process that we need to clarify.
Mr. Tom Finn
The process of reviewing X-rays started on 15 May 2008 and it is an eight-week process. There was a delay from the time of the issue being identified to the time the process started and that is directly related to the time it took to get clinical advice and to put together a team of clinical experts, both internally and externally, to review these patients. Before the process started, all of the patients who were identified as having X-rays which would need to be reviewed were contacted, as were their GPs and the consultants involved. We were all made aware of that.
As the X-rays are read and in the event that something abnormal shows up on the X-ray as opposed to its original reading, each GP and patient is recontacted with a plan from the hospital as to how their care will need to be progressed. That is where matters stand currently. The eight-week period will continue until the second half of July.
The six-month delay is unacceptable.
We will have time for supplementaries when everybody else has had the opportunity to speak. Has the HSE finished responding?
Professor Brendan Drumm
We have finished, but the issue of speech and language therapy may arise and perhaps we should deal with it now.
We can come back to that. I ask members to desist from engaging with people on the opposite side of the room so that we can get through our business more quickly. We will take Deputy O'Sullivan's questions now. Afterwards, we will take the others in blocks in order to make the best use of the time.
Will I get a response to my questions directly after asking them?
Yes.
The first point I want to address is the ring-fencing of development funding. We have not got a clear commitment on this. From what I have heard, it is not clear development funding will be ring-fenced. We have got a commitment that the HSE will return to the Minister if it wants to use the money elsewhere, but I would like a clear commitment from the Minister that money allocated by the democratic process for specific purposes, whether palliative care, disability, mental health or any other purpose, will be spent on the purpose for which it was allocated. It is not enough of a safeguard that the HSE must go back to the Minister on it.
It is crucial to much of what is under discussion that we be assured that where money is allocated, it will be spent. Professor Drumm made the point that back in the old days of the Eastern Health Board — I served on a health board in the past — development money was diverted. That was in a different context because the public representatives who got those allocations could stand up at public meetings and say the money could not be diverted to something else. What is happening now is that money is diverted without anybody knowing about it.
The money for 2006-07 for mental health was diverted before any of us knew about it. We are now playing catch up in that area. I have a specific question about an undertaking given by the Chairman's predecessor with regard to palliative care. He undertook that the money that was not spent in 2006-07 for that purpose would be reallocated to palliative care. I want a clear commitment that the money allocated for this year, €3 million, will be spent on palliative care and any money that is allocated in the future for development purposes, will be spent on those purposes. I ask for a correct statistic on palliative care jobs. We were told 75% of them had been filled but I understand only 50% have been filled. I ask Ms McGuinness to respond.
Both Professor Drumm and the Minister told us we need to do things differently. I ask the delegation to give us some evidence of HSE leadership in this regard. We are constantly being told we need to reorganise the way we run hospitals but it is Professor Drumm and the Minister — the Minister politically and Professor Drumm who is in charge of a very large budget — whose job it is to make sure these things happen. It is not good enough to say that certain hospitals have longer-stay patients as a result of certain procedures. It is up to both these people to do something about it. Does Professor Drumm agree with the quote in the Irish Medical Times this month from Professor Tom Keane who talks about multiple levels of management not being required in highly organised clinical systems with good guidelines? He refers to many of those levels having been eliminated in Canada, to the benefit of patients. Instead of talking, what is Professor Drumm doing about reorganising how we spend our money, particularly within the hospital system?
While I am on the subject of the hospital system, I ask Mr. Finn and Professor Drumm if they will agree with me that the hospital budget has been cut in real terms of the percentage increase allocation. Taking inflation into account it represents a cut in real terms. How do they intend to protect patients from the effects of this cut?
I have some specific questions about hospitals. How many beds are being closed or are currently closed, specifically in the National Rehabilitation Hospital? I refer to the reply to the Committee of Public Accounts last week which stated that 622 patients were occupying beds in acute hospitals who could have been discharged had step-down or community facilities been available. If there were 622 patients in beds who could have been discharged, how is all the talk about treating people in the community being translated into action?
I had reason to visit an elderly person in my constituency earlier this week. I walked past about six empty beds in a long-stay public health institution before I reached the patient I intended to visit. Elderly people who are ready for discharge are occupying acute beds while beds are empty in public institutions. This is a joke — and "joke" is the wrong word. It completely contradicts the words we hear about delivering care in the communities and getting people out of hospitals and so on. I await a response to that point. Are beds available and what beds are closed within the public system?
I refer to the case-mix model used to fund hospitals. When hospitals, through no fault of their own, are unable to discharge patients, will they be punished — if that is the word I can use? Has the community disability money been allocated? I refer to a case which was highlighted, where somebody in Beaumont Hospital with a disability who is employed and has an apartment and who has been ready for discharge for the past two months is unable to go home because he cannot get the personal assistant he will need in his home. He is in danger of losing his job, losing his apartment and is occupying a bed that should be used by another patient. The reason for this is that the disability money has not been put out into the community. The Minister of State, Deputy John Moloney, told me last week in the Dáil that the money has still not been allocated. This is having an effect in other ways on the provision of disability services.
Can the Minister and Professor Drumm assure us that cytology labs expertise will be maintained in light of the decision of the national cancer screening service to give the contract to foreign companies? Can they assure us that the people trained in this area will get jobs here? I refer also to physiotherapists, speech therapists and occupational therapists who will graduate this year and others in temporary employment who have been given notice. Can they give us an assurance that this expertise will be retained here for the benefit of patients and that these people will not bring their skills abroad and stay abroad forever?
I agree with what has been said about the Central Mental Hospital being moved. This is a wrong decision and I want the Minister to give an answer on the alternative proposal drawn up by Jim Power on behalf of the relatives of patients in the Central Mental Hospital, whereby some of the land in Dundrum could be sold off and a new facility built there. Will the Minister consider this plan? It has the backing of a wide variety of organisations. The Minister's comment that it was just about staff in south Dublin is a very unfair comment; this is about the patients who are very vulnerable. This decision needs to be revisited.
Will the Minister ensure that the expert advisory group's report on diabetes will be implemented? The committee had a presentation on the subject yesterday. This illness affects a large number of people. The way the service is currently being run is not cost-effective, considering waiting times and access to care in the community and in hospital. The report's proposals should be implemented.
On community services for people with acquired brain injury and muscular dystrophy, we have had presentations on these issues and my colleagues will elaborate. I ask for an assurance that the Minister, Professor Drumm and Ms McGuinness will address the real issues facing people in the community and when they require hospitalisation for their condition.
On the proposal for co-location of hospitals, the Minister knows my political views on this issue and we are totally against the concept. On the issue of the banks not funding them, I understand talks are ongoing. What is the situation in this regard? Can the Minister clarify how in practice the same service will be delivered to public and private patients on the same campus in two separate hospitals? How can this be achieved in a way that makes sense from a clinical point of view and that is not divisive?
I have some specific questions about the palliative care issue. I refer to the situation in Milford hospice in Limerick which has been given the capital money for the development of a day care centre. Significant private funding was raised on the understanding there was an agreement that the revenue money would be provided to run the centre when it is built. A doubt has arisen and I ask for a clear commitment on behalf of the people in my area that the money will be provided. This ties in with the issue raised by Deputy Reilly of capital projects being put in place without revenue funding.
I have other local issues to raise as well as BreastCheck but I will address them to Mr. O'Brien. I want to ask about reliance on the private sector to provide the additional kidney dialysis that is needed in the mid-west. I know people from the mid-west who are travelling to Galway for kidney dialysis. I know some very sick people who go in at midnight for their dialysis because of the pressure on the service there. Planning permission has been granted in this regard. The purpose of involving the private sector was to allow it come on stream more quickly. Would it not have come on stream considerably more quickly if it had been done through the public service rather than involving the private sector? All speed should be used to address the needs of kidney dialysis patients in the mid-west.
Parents for Justice and the NRB have approached this committee and we were told the matter would be addressed today by the Minister. I believe the Minister was advised these issues would be raised today. Will she meet representatives of Parents for Justice? Why did she not publish the Dunne report in an expurgated form? Would she agree to the appointment of an independent person to investigate all the issues in regard to the NRB?
The HSE is carrying out a review of the funding provided for Parents for Justice. I have indicated that I would be happy to meet its representatives when that review is completed. To meet in advance would not make sense. The initial report by Anne Dunne, SC, was not publishable. We took legal advice from the Attorney General on what matters could be published. Following the closure of the Dunne inquiry, which was costing more than €20 million, I appointed Dr. Deirdre Madden to bring conclusion to the issues. She issued a report that has now been implemented. We will need legislation in the area of retention of tissue and so on. The Department is preparing that legislation.
There has been a significant increase, I believe 50%, in the number of patients accessing kidney dialysis in recent years. The company awarded the tender in Limerick is similar to the company that has been providing a service on the north side of Dublin in recent years. Clearly the patients require the service regardless of whether the service is funded publicly or procured by the HSE on behalf of the patients. I understand the planning permission issues in Limerick have been resolved and I hope that important service can commence as quickly as possible. Subject to patient safety requirements, I would like to think we could provide dialysis during the daytime rather than in the middle of the night for every patient who requires it as close as possible to where they live. We know many patients receive dialysis in their own homes. For those who need to travel we would like to think that in the future, as developments occur in this area along with developments in community, primary and continuing care, the great toll that travel takes on many patients could be reduced over time.
One of the main questions the Deputy asked was whether the moneys allocated in previous years for new developments in mental health, disability and palliative care could be reallocated. That money has been spent and there is no question of additional moneys being given to make up for the lost money of recent years, if we want to use that terminology. The challenge for the HSE is to live within its budget. This year it will get an increase of 9%, which even taking last month's inflation level, is considerably in excess of twice the rate of inflation. An increase of 9% year on year is substantial by any standards. It is no secret that next year it will not be like that because we know that the economic situation of this country today, like many other countries, as an open trading economy is very different. Therefore we will not be able to have spending increases in the region of 9% in the future. That will pose a huge challenge.
When Professor Drumm talks about 27 admissions, 120 doctors and 400 nurses, and 1.5 patients to one member of staff in accident and emergency units, it is clear these are not sustainable staff-patient ratios. Based on the OECD analysis we have the highest staff-patient ratio in the entire world by an enormous factor. It is twice the ratio France has, for example. I mention this because if the new moneys allocated are to go to the developments that have been earmarked by the Government and approved by the Oireachtas and if existing services are to be supplied on a business as usual basis, we will not be able to do the two. I hope many of the reform initiatives being pursued will receive the wider support of the public, including the support of the public's representatives. On the one hand we want everyone to spend the new money on the new developments, but we do not seem to get any support for some of the changes being put in place on the ground.
The Deputy asked for leadership. I hope that as Minister for Health and Children I have been supportive of the very necessary changes at operational level, mainly around patient safety, but they are not without resource implications as well. It cannot be the case——
What has been done about, for example, the recommendations following what happened at Portlaoise or in the Rebecca O'Malley case?
They are being implemented. Perhaps the HSE will deal with that. They are being implemented. In some situations——
What about patient advocacy services at local level?
I ask the Deputy to allow the Minister to finish.
Among the issues that arose in the report on the Rebecca O'Malley case — Professor Drumm may like to deal with this — is that we need to move cancer care to multidisciplinary teams. We are in the process of putting multidisciplinary teams in place in the eight centres that have been identified. In some places the pathology services needed to be provided in a different facility and so on. We did not have multidisciplinary meetings and many deficiencies were brought to light in those reports. The HSE and the Department learned from that experience. There is no point in having reports unless we learn from them and put into effect the recommendations.
Specifically regarding advocacy for patients, every group that I have appointed, including the Medical Council, An Bord Altranais and the Pharmaceutical Society of Ireland, now has a lay majority. In all case I have appointed patient representatives to these groups, including people like Margaret Murphy and some of the women from Patient Focus. These are people who are clearly identified as advocates for patients. We need to do much more.
What about the specific recommendations on hospitals?
With Professor Drumm, I recently launched an initiative regarding patient advocacy and the need for the service to respond more appropriately to the views, experience and complaints of patients. All of that is in hand. Regarding the question about leadership in the first instance, leadership means knowing what the problem is. If we cannot measure something and know what the issue to be addressed is, we will not achieve very much. Great work has been undertaken by the HSE to great effect in collecting the data, whether it concerns performance, absenteeism, non-shows for outpatient appointments, or the ratio of return visits to new appointments, which does not happen in other countries. Identifying the issues is a necessary prerequisite to introducing innovative solutions and to challenging all of us who work in the system.
I am a strong fan of the power of the audit. When people see their performance audited, that in itself can be a powerful driver of change. Professor Drumm and his team are working, hospital by hospital, on the changes necessary to deliver improved services for patients and to use the resources allocated by the Oireachtas to greater effect. Everybody here is aware of that. Sometimes when that happens we get major objections from those who work in the system and from those who represent those who work in the system. However, the vast majority of the patients and, I believe, employees in the system want to see the change succeed. The vast majority of nurses, doctors and other health-care professionals want the system to operate to the highest possible standard. As Professor Drumm said, staff get demoralised with the constant attention to the negatives and no attention to the major positives that are being achieved.
The Minister is doing that by telling us that people are blocking change.
No, I am identifying deficiencies that need to be put right if we are to identify possibilities for extending services. As I said earlier, the moneys allocated to the palliative care area this year will be spent in that area. I am aware that the HSE commissioned some research into cytology and laboratory facilities. Perhaps Professor Drumm would like to comment on that. Mr. O'Brien will comment later on the cytology tender process. Some 80% of the marks in that process were allocated for quality and turnaround time. The other 20% of the marks were allocated on the basis of value for money. It was not a case of going for the cheapest option. A total of 80% of the marks were allocated for quality and timing. It is important to get the results back quickly. As the Deputy knows, it is not satisfactory or safe that people have to wait for between six and nine months to get the results. I am quite satisfied with the two-year contract. The challenge for the public health service is to ensure that, in two years' time, it can meet the requirements and standards necessary in areas like accreditation and turnaround times in a cost-effective fashion.
I know the economist, Mr. Jim Power, well. He has compiled a report for the Central Mental Hospital. Some other advice has been received in that regard. We have been advised that his suggestion would hugely devalue the site. I am not convinced about the idea that a new hospital can be built on the site. I am not sure one can get more than enough money to do all of that. There would be a dislocation to the service while it is being built. The hospital would be a construction site, in effect.
It is a big site.
Many people want the hospital to be kept on the south side of Dublin. We are talking about patients so we need to get on with building a state-of-the-art facility as quickly as possible. A site has been identified. We need to proceed with the project quickly, subject to planning requirements. If there are planning difficulties, that will be a different issue.
We intend to implement the findings of the report of the advisory group on diabetes. The HSE has undertaken a pilot retinopathy screening programme in the north west. It hopes to roll out the screening programme throughout the western region this year. I welcome that. The early identification of chronic illnesses is an important aspect of the management of such illnesses.
I was also asked about co-located hospitals. I am not in a position to comment on the banking arrangements agreed by the promoters of these projects and their banks. I am not an expert in that area. It would not be appropriate for me to comment further on the matter, other than to say that these projects cannot involve any transfer of risk to the public hospital. They need to be win-win projects. Perhaps Mr. Finn, who is handling this matter for the HSE, might like to comment further. I understand that normal engagements are taking place between the promoters of these projects and their financiers. I do not think anything outside the norm is happening in this regard.
There will be a single clinical governance structure at each site. Deputy O'Sullivan speaks as if we do not have any private activity in public hospitals at present. In an ideal world, there would be no such activity. My wish is for that to be the case. In 2006, half of the elective procedures in a Dublin hospital involved private patients. That did not reflect the nature of the hospital's catchment area. I have discussed the matter with a number of clinicians in the hospital. It is not a satisfactory situation.
The idea behind the current programme is that it will give us better facilities, including isolation facilities, in public hospitals. We hope it will be a win-win situation for public hospitals and patients. I genuinely believe that to be the motivation behind this project. It will deliver capacity for less than half the cost. The nurses and other staff who staff private beds are heavily subsidised by the taxpayer, to the tune of approximately 60%. It does not make sense that those beds are ring-fenced for one class of patient in our public hospitals.
Does the Minister have figures in respect of the subsidy to which she refers?
Yes, I have.
I understand that such figures have not been made available to insurers.
To which insurers does the Deputy refer?
I refer to the insurance companies paying——
One of the biggest criticisms I get from the health insurers is that we are trying to move to the commercial cost. All of them are screaming about that.
Does the Minister have specific figures to support her claim that private patients are subsiding public patients to that extent?
Yes. We can give the Deputy figures relating to the cost of the beds and the costs the insurers pay.
If I could get those figures, I would appreciate it.
We can certainly do that. The Deputy must have been made aware by the biggest insurer in the market that the insurers are critical of the fact that we are starting to charge the commercial price of those beds. That will lead to the imposition of a huge increase on them. Their complaints verify, if such verification were needed, the fact that these beds are so heavily subsidised for one group of patients.
If we could get figures, that would be helpful.
I will get them.
Thank you.
I am not aware that there is a long-stay facility in which there are vacant beds. It may well be that this is the case. We may need to reallocate staff within the facility in question. Perhaps it would be more appropriate for the Deputy to raise that matter with the HSE. It is clear that we have been providing for hugely increased capacity for older people. We have been making such provision on the public side while supporting people going into private facilities. We hope to introduce appropriate legislation to ensure that those who are in a private nursing home and those who are in a public facility are treated equally. As Professor Drumm said earlier, we are greatly increasing home supports for older people. We have come from having a tiny base a couple of years ago to supporting 11,000 older people in their homes. It is clear that we have to continue to move in that direction, with appropriate supports, to allow people to move more rapidly from the acute system to community-based settings — their homes or long-term care settings.
I thank the Minister. I note that Senators have left the meeting as a division has been called in the Seanad. Seven other speakers are offering. Before I call Professor Drumm to respond, I remind all speakers of the need to be as concise as possible. I want everyone who wishes to speak to be able to do so.
Professor Brendan Drumm
I do not argue with what was said about ring-fenced development funding. I would be delighted for it to be dealt with in a democratic manner. If we are to take on the enormous challenges we face in that regard, somebody will have to find the money needed. I would be delighted if that decision were to be made by someone else.
I have been asked to give assurances that money will be spent on developments in the future. It is absolutely a matter for directors and Ministers, and so on, to make such decisions. If demand-led schemes continue to grow, that will have potentially significant knock-on effect elsewhere in the system. Such growth might be driven by unemployment. Tough decisions will have to be made. I would be delighted if such decisions were to be made elsewhere. That would bring a real honesty to it.
Members spoke about the need for leadership if things are to be done differently. It is not about me. It is about the team of people who work with me. That team has shown enormous leadership. When we started out here two and a half years ago, we got abuse left, right and centre. People spoke about the need for bigger, wider and taller hospitals, with rooms all over the place. It was suggested that was all that was needed to solve the problems in accident and emergency departments. We have shown enormous leadership in changing that debate and bringing Ireland out of its time warp in terms of health care provision. We have brought total transparency to the system. Details about our entire performance will be on the system by January of next year. We will be able to get details, down to an individual level, of what is done in outpatient clinics in every hospital in the country. Such a degree of transparency in our health service, in which huge inequity has existed, was never considered before. Some facilities had three times the resources of others, even though they were doing half the work.
We are bringing real equity to the system. Our superb staff have faced huge challenges as a result of the historic failure to provide for equity in terms of how resources are allocated. Historically, resources have been provided in response to letters from people who threatened to go public unless they got such resources. We do not do that. We provide money on the basis of performance. That is a huge leadership issue that has been undertaken by this organisation. I accept that it has not been welcomed everywhere. It has been welcomed by most of our staff, however, because that is the way they want to work. I will continue to confirm that we have a wonderful staff. I admit that they have lacked direction at times but they are getting there.
I will give examples of what I am talking about. We could argue about primary care teams, but the bottom line is that general practitioners were not showing any interest in primary care teams two and a half years ago. They are showing enormous interest in them now. We cannot get them all up and running overnight, as some people want all these things to be done in this country. We have made progress with them to the point that there is enormous interest in driving to get them done. Two and a half years ago, consultants constituted the most powerful, but most demoralised, group in this system. More recently, however, I have met consultants throughout the country — most recently in Deputy O'Sullivan's own area — who are happy to take leadership roles. That huge step forward has resulted from the leadership the organisation has shown.
I will comment on areas allied to transparency. Matters like outpatient waiting times have been mentioned. We took up that subject with The Irish Times, which highlighted it as a huge issue. I introduced that issue. They were never measured before. Figures for outpatient waiting times were traditionally not produced. We are delighted to produce such figures because that is the only way we can take the matter on. That is how the system needs to be led.
On the issue of associated areas, our estates function has enormous leadership within the organisation. We have moved to a position in which we have a highly competitive estates function as against being seen as a soft touch, historically, in terms of development. We now design to build 50-bed nursing units in the community and have done so in places such as St. Mary's in the Phoenix Park and Cherry Orchard. These units were designed, built and completed in ten months at a cost close to 20% below the cost two to three years ago. This is an example of a HSE function showing real leadership.
On the issue of procurement, we have developed a comprehensive category management approach. We will buy everything centrally, rendering massive savings over the next five years. This does not only apply to pharmaceuticals, an area in which I hope the HSE will be supported for taking on very highly profitable deals of old. These deals need to be taken on by the health service but in doing so we sometimes lack support. I hope we will receive support in other areas of procurement.
There are many areas in which the leadership team has more than shown leadership and is changing the system and reorganising. The Deputy referred to the issue of staffing. We are taking on this issue. We will evolve the organisation very quickly to bring in much more senior clinical leadership, de-layer the organisation and, I hope, empower staff more at local level. That is a natural evolution for the organisation.
In terms of beds being vacant in a long-stay facility, we will take up this issue if we are given details. In some facilities we are no longer allowed to fill all beds for health and safety reasons because the wards were overcrowded. That may not be the issue in this case. We would be pleased to provide clarity on the matter when we receive the information.
Perhaps Mr. Finn will address the issue of cytology laboratories.
I asked about beds at the National Rehabilitation Hospital.
Ms Laverne McGuinness
I do not have precise figures but I will revert to the Deputy on the issue.
Mr. Tom Finn
In recent days, I have answered a number of parliamentary questions on cytology, an issue we will discuss later with our colleagues from the screening programme. The current capacity of our cytology laboratories will not be required in future. We are currently determining what level of capacity will be needed but it is probably in the region of 50% of current capacity. This means 35 to 40 members of the current staff of 70 will continue to work in the cytology labs. We still expect the laboratories which have cytology services to continue in their quest for accreditation and to become accredited. This will take place over the next two years as the remainder of our laboratories become accredited. We are in the process with the representative agencies of determining how best to utilise the remaining staff.
How will the laboratories be able to start doing the work in two years if their staff are to be moved?
Mr. Tom Finn
As I indicated, we will retain cytology services in our laboratories and only the screening service will move. A large cohort of other cytology services will be continued in the hospitals and the clinical expertise will be retained. Capacity is a separate issue but we will retain clinical expertise in each hospital.
As Mr. Finn is aware, a significant number of people are acquiring qualifications and staff working in the system will lose this skill in two years.
Other members wish to contribute.
Professor Brendan Drumm
On acquired brain injury, the HSE accepts that this is a huge challenge. Ms McGuinness will briefly outline what we are doing in this area.
Ms Laverne McGuinness
On acquired brain injury, a working group has been established by the HSE and Department of Health and Children to examine the overall rehabilitation strategy. Its terms of reference have recently been scoped and will it have a steering group and working group. Its work will include examining acquired brain injury and all rehabilitation services in the country. This work has not been done before. The matter is, therefore, being addressed.
Professor Brendan Drumm
We hope the group can complete its work by the end of the year. The Deputy has raised an issue of immense importance to people on the ground.
Ms Laverne McGuinness
On Milford Hospital, ten palliative care beds have been funded for the hospital and have been opened as part of the cohort of funding allocated under the palliative care heading. If the Deputy has more specific details or questions I will respond to them.
I refer to future funding for a capital project that is under way.
Ms Laverne McGuinness
I will have to check with our estates.
Professor Brendan Drumm
I will ask Tom Finn to address kidney dialysis in the mid-west.
Mr. Tom Finn
Last Friday, An Bord Pleanála informed us that there were no planning objections to the site the HSE has chosen in the area. In March 2007, we met clinicians in Limerick and identified the need for additional capacity. It was agreed at that time that the quickest route to securing this capacity — this is still the case — was to use what we have as an existing framework for the dialysis providers across the country. We already have these services in Kilkenny and at two sites in Dublin.
We had a successful tender which was held up by an initial planning problem. We examined other options, including providing our own sites, but the time lines would not have been shorter. We have secured planning permission and the centre will open in Limerick in 2008. It will also have patients from Galway. I believe some of the patients who currently travel to Tullamore Hospital for dialysis will start to use the service in Limerick by the end of the year.
I am in constant communication with the patient advocate and have met and communicated with her several times in the past couple of months to keep her abreast of the position. We notified her in recent days that planning permission has been granted.
Patient satisfaction rates in the other centres where private dialysis is provided is 100%. Similarly, a significant improvement has been recorded in the physiological lab values of patients, purely because they no longer have to get up in the middle of the night. They now come in for dialysis at 7 a.m. and are home at lunch time. This is a positive development which will continue. I have met patients in each of the sites to ensure we were getting a quality service. We review these services on a biannual basis to ensure they continue to be of a high quality and patients are happy with them. We continue to monitor patient satisfaction in all the centres.
I am conscious the two principal spokespersons have spoken for a considerable period. I ask other Members to be concise in their contributions.
I welcome the Minister and Professor Drumm. I extend my best wishes to the Chairman and thank him for his courtesy.
Professor Drumm indicated that in the event that information is not available, he will ensure replies are forwarded to members. I am happy if that process applies in regard to my questions. In light of Deputy O'Sullivan's encouragement to mention local issues, I may mention Tallaght once.
Only once.
The Minister knows I would like to be in Tallaght this morning because Tallaght Hospital is celebrating its tenth birthday this week. While I am proud of the hospital, I also accept it faces challenges.
I was interested in Professor Drumm's comments on people in Ireland being healthier. I welcome this clear health promotion message, not only as a public representative but as a person who survived a serious heart attack. Not everyone who knows me was pleased I survived but I am delighted to be here. I am also delighted with the response I received from the services. I am keen to discuss cardiac rehabilitation in Tallaght Hospital and other hospitals, as well as in primary care.
Professor Drumm commented on the HSE's commitment to primary care and the linkage with general practitioners, which is an important issue. I need to be more convinced about this commitment, specifically as it applies in my constituency. Professor Drumm should not be offended but it is important he gives this commitment because practitioners — home helps and so on — wonder about these issues. I am aware there are exciting plans for Tallaght in this regard. We need to be reassured that they will be realised.
I have raised the hospital in the home service on a number of occasions recently. The Minister's reference to the power of the audit was important because I remain confused about the reason the hospital in the home project based in my constituency was cancelled. The service catered for every hospital in the Dublin region, primarily Beaumont Hospital. I fail to understand how this scheme, a good news story, could be cancelled. If it has been cancelled and there are no plans to revisit it, what contingency plans are being made to provide services for those people who were being kept out of hospitals and off trolleys? Despite raising this issue in recent times, I am still not clear about what is planned in this regard.
I support what was said on the Parents for Justice issue, in which we all have an interest. We need to know what is happening. I support what was said about disability services, disability moneys and the campaign by the Disability Federation of Ireland to ensure, in the short term, that the €50 million it says was to be released this year, but which has not been released, will be made available. We need to know the plans in this regard.
I remain interested in the delivery of children's services in the Dublin region. I will not make a speech on Tallaght but stress that children's services are important to the Dublin region. It is a countrywide issue, as Professor Drumm will remind me, but I am talking about Dublin and established services. People need to know when established services are being threatened.
The same can be said for cancer services. I was delighted to meet Professor Tom Keane and am very impressed by the efforts he is making but I still need to know what will happen in Tallaght in this regard.
My final point concerns the differences in aspects of HSE policy and the direction of funding for hospitals. In respect of my local hospital, the HSE stated that, because of what it regarded as inefficiencies, moneys would not be paid over and that, in effect, the hospital would be penalised and new consultants would not be appointed. This is penalising patients. How will the HSE deal with these issues? All the hospitals in the Dublin region and throughout the country are facing financial challenges. There is a considerable campaign running in respect of Crumlin. I need to be convinced about the manner in which the HSE is dealing with the specific challenge. It should be dealing with the problems within the hospital and not upsetting the patients further.
If some of the issues I raised need to be dealt with later by correspondence, I will be quite happy to co-operate in that regard. I wish the Minister and Professor Drumm continued success as they grapple with the problems in the health service.
I, too, welcome the Minister, Professor Drumm and Mr. O'Brien. I have a number of questions. If the delegates would prefer to send me their responses, I will be happy to wait for them.
There was some talk about general practitioners. We are experiencing a major challenge in the north east in that people are finding it very difficult to be put on general practitioners' books because general practitioners are taking no more patients. We must plan for challenges that will arise in this regard. Given the age of many of the general practitioners in the north east, it seems many of them will be retiring at the same time. What plans has the HSE to deal with this potentially considerable problem?
Let me refer to the new working hours arrangement for nurses, which involves a working week of 37.5 hours. I am aware from contact with some nurses this week that nurses in Our Lady of Lourdes Hospital, Drogheda, were told they would be put on a 37.5 hour week. The rosters were put up but the rug was pulled from under the nurses two weeks ago. They are still working the hours they were working prior to the new arrangement and will not be able to get time off in lieu of the extra hours they have worked. I want this to be clarified.
On the residential care facilities, I accept and agree we have an ageing population and that there will be increased demand. We do not have enough residential care places at present to cope with demand. I am aware of residential care facilities that are trying to comply with the new standards laid down by the Health Information and Quality Authority, HIQA. Although the facilities have been in operation forever and a day, have done an excellent job and have upgraded and made changes as they saw fit and in accordance with what they were allowed to do, they will lose bed capacity because there will have to be larger spaces between beds to comply with the HIQA standards. Where will we find the extra places? They do not exist.
Reference was made to inappropriate admission and inappropriate long-stay terms. In many cases, patients are inappropriately placed because there is nowhere else for them to go and there is no residential bed for them. This is a considerable concern and challenge and I would welcome the delegates' comments on the issue.
We have all had considerable correspondence from families and patients who are in desperation regarding subvention and subvention top-up. Since the cost of a bed has increased, the families are in financial trouble as they try to keep their loved ones in various facilities. In view of the delay over Fair Deal and bearing in mind the money set aside therefor, can anything be done to ease the financial pressure on the affected people?
I welcome the statement that the cervical screening programme will be rolled out before the end of the year. Is there a timeline in mind? In rolling out the programme, we need to consider the vaccination programme proactively. One complements the other and prevention is better than cure.
In the north east, there is a significant problem at weekends in that families have considerable difficulty in having post mortems carried out on the bodies of their loved ones who die tragically, be it in an accident or otherwise. I am sure this is replicated throughout the country. Families must often wait up to three additional days for the post mortem to be carried out. It is not right that any family should suffer undue distress because of this. The necessary funeral arrangements cannot be made and the grieving process cannot begin until the families have the bodies of their loved ones returned to them. What can we do to alleviate this?
I could not let the day pass without mentioning Monaghan General Hospital, in respect of which the transformation plan is ongoing. I agree that negative publicity and spin demoralise staff. We have certainly experienced this in the north east. For a number of months, the talk was that the services would all be gone by the end of June. Now that it is nearly the end of June, I am thankful that has proven to be inaccurate. November was mentioned also. Is that a realistic date? How far are we on that? Is there a commitment by the HSE at the highest level that no service will be removed until a better one is in place? I advocate the allowance of a period in which to build patient confidence in the wake of all the negativity and fear. We need the ambulatory and thrombolysis services and primary care teams to be in place for a period to allow patients to have confidence in using the service. That, in itself, would bode well.
The HSE is losing the PR battle and it is too late getting the message out. When the good news comes, we have already received the leaked document. The HSE is putting issues on the back burner and defending rather than actively promoting its initiatives, as it needs to do.
In the north east, there is talk of operating within budget and using existing resources. We are already in deficit and I find it difficult to understand how enhanced services can be put in place without providing additional money and without affecting frontline services or causing undue or unnecessary discomfort to patients. While I welcome innovations for missed appointments I am not surprised it happens. When one gets a letter in January stating an appointment will not be until 12 October, it is no wonder appointments are missed. In this technological age, when everyone has a mobile phone, surely a text reminder, for example, could be sent to remind patients of appointments.
I remind members, the Minister and Professor Drumm must leave at 1 p.m. I ask members to prioritise their questions.
Those involved in providing palliative care have reluctantly come to the conclusion that the funds promised for 2006 and 2007 will not be released. Will the allocated €3 million for palliative care be released this year? Ms McGuinness earlier referred to 300 additional staff for palliative care and the €3.2 million spent in that respect. What is the average salary of these staff?
How many patients have been called back for the diagnostic test review in the north east?
Professor Drumm spoke of consultants being enthusiastic and taking a leadership role, which is to be welcomed. Some consultants, however, in Cork University Hospital are dispirited that they must spend as much time in management meetings as treating patients. One consultant who deals with vascular surgery informed me he could clear his patient lists, both public and private, within a few months if he had theatre space. Two theatres remain closed in the Cork University Hospital maternity wing. One consultant there has informed me that women with stress incontinence — resulting from either age or child birth — could be treated if these theatres are opened. He informed me recently there are no staff to sterilise the instruments At a time when everyone is concerned about hospital acquired infections, one has to ask why.
The maternity wing is a magnificent facility. Professor Drumm said on the opening day that it was the best in Europe. It is bright and inviting and clearly the birth rate has gone up in Cork as a result. My other question may either relate to the Department or to the HSE. Why would one ask women about to give birth if they want an epidural? Why is it not a standard procedure? Not giving an epidural is the equivalent of a dentist saying he will start the filling but if it gets too bad he will give something for it.
The Deputy cannot ask me as I am no expert in this.
I had four children without an epidural and I would say go without it.
There are those of us who have a higher pain threshold than others. There is no need to ask about the procedure in this day and age. It should be standard unless a woman says she does not want it.
I know the problems with the BCG vaccine backlog in Cork are historical and a result of a decision taken by the various health boards. The former health board in Cork decided it would not automatically give the BCG vaccine. A change in policy has occurred, however, due to various incidents of TB in the Cork area. The backlog is getting larger, with up to 30 children being vaccinated every week when the weekly birth rate is much higher. I do not understand why the vaccine cannot be given in the health centres, just like when there was a polio scare in the 1950s.
People in Cork are concerned the accident and emergency department at the Mercy Hospital will not open. Despite the fact it is in the Middle Parish, it is considered to be the only hospital on the northside. Every effort should be made to resolve that issue. The opening of the facility needs negotiations.
The rehabilitation until was to be based in St. Mary's Orthopaedic Hospital but the arrangements fell apart. I do not understand why additional research must be conducted in this area. It has already been done. It should not be about waiting until the whole unit is in place but about putting in place sufficient staff at the start, letting them see the further needs for the unit and then expanding it.
There are still 300 people with intellectual disabilities inappropriately placed in psychiatric units. Why? We were informed their transfers would be completed by 2006. A third of these people only have a mild intellectual disability. They could be living in the community. They will probably require intensive socialisation after being in a psychiatric unit for a long time. The notion that a person with a mild intellectual disability can be in a psychiatric unit in this day and age is incomprehensible. I do not understand why it is not a matter of priority.
Given the numbers offering, if members could confine themselves to questions for two minutes rather than statements, everyone would have an opportunity and hopefully we will get some answers.
I am happy the HSE has decided to increase the number of adolescent psychiatric beds from 12 to 30. I was assured this would happen in the third quarter. Is this still on target? The crisis in child psychiatry services continues to escalate. The HSE has pledged that all children in south Tipperary on the closed waiting list will be seen once off as a matter of urgency. It is unclear how soon they will be seen and what delays will be experienced when they are referred for further treatment, if and when necessary. Currently, the HSE is in the process of selling lands attached to St. Luke's psychiatric hospital, which will realise something like €12 million. I would definitely like that €12 million utilised in the mental heath area, because that is where the moneys are being released from. Is that possible?
Given the ongoing need for an ambulance service, when can we expect the question of one being based in Carrick-on-Suir to be addressed? I was assured this would addressed. I have one final brief point, and Deputy Flynn will probably mention this as well. It relates to retinal screening for people presenting with diabetes, when the complications add considerably to the cost. I am referring specifically to retinal screening and the prevention of complications, thereby avoiding huge loading onto the cost of treating those complications, and the additional services that are required. I was quite horrified yesterday to hear there is only one psychologist in the entire country dealing with people with any of the diabetes retinopathies or other conditions associated with them — people who may be suffering from an associated depression because of a diagnosis, the loss of a vital function such as sight or perhaps a limb. Research supports the hypothesis that their worst fear is blindness or anything associated with it.
I welcome the various groups. I want to point out that it is not all doom and gloom as regards the health service. We all have good stories about public patients being looked after straightaway. It is important to point this out and to back up Professor Drumm when he says there are vested interest groups everywhere, not alone in health. It is right, too, to say that Professor Tom Keane has visited all our parliamentary parties. I shall only speak for my own and say we were enormously impressed with him and the passion he has instilled into the job he was brought over to do.
I thank the Minister. Last week she allocated €150,000 for travel from Sligo to Galway for radiotherapy patients and that has been very much welcomed. My questions are mainly concerned with the cancer area because we are losing our unit in Sligo, which is going to the specialist centre in Galway. Perhaps Mr. Tony O'Brien might say where the north west, particularly Sligo, is as regards BreastCheck. I am delighted the Department is finalising plans for cervical cancer screening, which is welcome. How will that be rolled out? Will it be rolled out along the same lines as BreastCheck or will it be one immediate approach? If it is to be rolled out like BreastCheck, could the Department start in the areas that do not have the latter to give us something and then work through the country?
I support Senator Prendergast and I wanted to ask about eating disorders and the position regarding child and adolescent psychiatry. Are we still on target? I ask this in relation to Eithne Donnellan's report in The Irish Times today on health behaviour among school children. We see an increase in the number of school boys thinking themselves too fat and going on diets. It was a very interesting article. We see a decrease, however, in young girls believing they are too fat. It is still a problem, but not confined to one gender, as we used to think. It is spilling over to young boys.
As regards Thornton Hall and the moving of the Central Mental Hospital, the Medical Council, of which I was a member, visited the Dundrum site about six years ago. I recommend that everybody read that report. People were absolutely shocked, not at the service and care patients were getting, but rather at the conditions that medical and nursing personnel and patients were subjected to in that old dilapidated building. As a member of the Medical Council I visited Tallaght hospital, which has a lovely bright new psychiatric wing, and Portlaoise hospital. It is only right that mental hospitals are located in proper buildings where the most vulnerable people in society may be treated. There is concern, however, whether among medical or nursing personnel or the families of CMH patients, over the move to the Thornton Hall site. It is important that they are reassured that the money from the sale of Dundrum will be put back into psychiatric services and that the move is better for them.
I apologise for my absence for about an hour, but I had meetings elsewhere.
As Professor Drumm knows we had a four-hour session at the Committee of Public Accounts on 29 May and I do not want to go over some of the issues that were raised then. I must, however, go back to the issue of palliative care and the redirection of moneys from this into other areas that were not authorised by the Department of Finance. He told me on the day that new structures were in place as regards the manner in which funds were being redirected, and that he would have to get clearance from the Department of Finance. I should like him to confirm that in more detail today because there is still some ambiguity.
The Minister on a number of occasions has announced major investment for palliative care. On 29 May Ms Laverne McGuinness told the Committee of Public Accounts that "70% of posts sanctioned for palliative care are in place". That is a direct quotation from the evidence given. This morning Ms McGuinness informed the committee that 70% of money was spent but only 30% of the posts were filled. I should like to know where the truth lies because there is a serious contradiction between the evidence given here today and that given to the Committee of Public Accounts on 29 May. I would like that clarified.
As regards the Mercy Hospital, which my colleague mentioned, the accident and emergency unit built a year and a half ago is still closed. We are being told it might be opened from 8 a.m. to 8 p.m. — business hours almost. People do not have accidents during business hours and I want to tell Professor Drumm that many people are being highly paid to manage our health services, and there is a Minister responsible. In the name of God, who is going to take the situation there by the scruff of the neck and make a decision to open that €5 million accident and emergency unit, to replace the Dickensian one there at present? Who will take the decision and not just pass it on to the local management of the Mercy Hospital? Somebody must be in control to take the decision to make that service available to the people, as tragedies are happening on a daily basis because of the appalling conditions there.
I have just received a telephone call to say that 30 jobs are going at the Mercy Hospital in Cork. How does that complement Professor Drumm's earlier statement that there is effectively no embargo or job losses. In fact, we have an embargo by stealth with cutbacks resulting in a loss of jobs which are not being replaced. Who is making the decisions as regards what categories of staff are being let go? As of today, 30 more jobs have gone in Cork's Mercy Hospital. Nobody can tell me that this will not impact on the quality of service for people who are sick and vulnerable.
The matter of BCG was raised earlier. I have an e-mail from a member of the public who was told her six month old child was in 1,500th place on the list, and that there are about 3,500 on the waiting list in the Cork area. Cork has had a number of outbreaks of TB recently affecting schoolgoing children, who subsequently have to be treated with strong antibiotics for a period of six months. Again, who is in control and who is responsible for these appalling cutbacks? The person who wrote to me was told that only six children per day were being vaccinated due to the HSE recruitment freeze. Yet we are told today that there is no freeze. Who is playing games? Where is the propaganda war? Somebody said earlier that the HSE is underselling itself and is not doing itself any justice with its publicity. However, there is a very effective publicity campaign from a very highly resourced propaganda machine within the HSE and this campaign is masking the truth. I put down several questions yesterday about acute hospitals throughout Cork city and county, yet the Minister replied that it is not her responsibility, but rather that of the HSE. At local meetings with the HSE, it is very hard to separate truth from fiction. Who is in charge? What is the extent of cutbacks in our acute hospitals? There is an embargo and there are cutbacks in staff numbers, and nobody can tell me otherwise. Let us have the truth about these cutbacks, the BCG and the recruitment freeze.
Officials from the National Treatment Purchase Fund were at the Committee of Public Accounts on 29 May. We were told waiting lists were being reduced, yet that seems to conflict with the facts. I know of people who have been waiting for up to six months for outpatient appointments. I have documentary evidence of this, yet they have not been approached by the NTPF offering them appointments. People must be aware of the scheme and must be proactive in making approaches to the NTPF, but those who are out of work due to illness are not aware of this facility and are not being made aware of it by some of the hospitals. How does this system work? Why are people not being contacted by the NTPF in a time of crisis for them? A member of staff in this House has a partner who has been out work for the past two months but cannot get an appointment for some time and has never even heard of the NTPF. In spite of all the propaganda and hype, the NTPF is not being proactive in making people aware of their rights.
I welcome the groups to the meeting today. My first question is about the consultant contract, in particular the five hours of structured overtime that will apply at weekends. Will this apply between 8 a.m. and 8 p.m., as is the case with the Monday to Friday arrangement, or will it be on a 24 hour basis? What is the position on consultants operating in accident and emergency departments, when much of the heavy workload occurs late at night and in the early hours of the morning? Will they still be covered by the same provisions as the other consultants under the contract?
With regard to rolling out the national cancer strategy, at previous meetings of this committee, Professor Drumm mentioned that when a hospital loses a service, a big effort is made to try to locate other services that could easily be provided in a local hospital in that hospital. What plans are in place to locate additional services in Mayo General Hospital following the transfer of cancer diagnostics and surgical services to Galway in September? Is September still the target date for the transfer of that service? Can Mr. O'Brien give the committee some idea of the development of the oncology unit at Mayo General Hospital, as well as the parking issue at University College Hospital in Galway? At a recent meeting with Professor Keane, I asked him if it was possible to have designated parking at UCHG, and he said that it was possible. It would be another step in trying to convince the public that the service would be better. What are the transport arrangements for patients travelling from Mayo to Galway?
The fact that colorectal cancer is the next cancer to be dealt with was mentioned. What is the timeframe for its roll-out? Senator Prendergast referred to retinal screening. A diabetes group raised this in our meeting yesterday. The group stated that due to the embargo on recruitment within the HSE, the roll-out of retinal screening in the HSE West area would not go ahead, even though money had been allocated for it. The group seemed to indicate that it had formally been notified of this, so I would like that position to be clarified. Money was allocated for a pilot scheme in the north west, but there seems to be some problem with that as well.
I compliment the Department on the uptake of the breast screening programme being the fifth highest in the world. This is a fantastic statistic for Ireland. What areas in the west do not have a service? Mr. O'Brien mentioned that Tipperary will be the next area to receive the service, but which counties will follow after that?
There is a 1% cut across the board in the various groups providing services to the HSE. Groups like Western Care and Muscular Dystrophy Ireland have been before this committee in the recent past. It is very blunt to put a 1% cut in place across all these groups without any prioritisation of services or areas that might need additional attention at this stage. What is the thinking behind that blanket cut? Another disturbing cut in the west has been in mental health services, which have always been the poor relation in this country's health services. Music therapy and other therapies that used to enhance the lives of people at the day care centres have recently been cut in the west. This was confirmed at a local HSE meeting that I attended last Monday. This is unacceptable, especially since this area has been badly served in the past.
Professor Drumm mentioned the community-based long stay beds. Where is Ballinrobe nursing home in the pecking order of the capital programme between now and 2011? Will it be built by 2011? People are very anxious about this. At the launch of the HSE report yesterday, Professor Drumm announced that there will be a new discharge policy in hospitals within the next six months. What must be in place to have that service up and running within six months? I presume the 24-hour period following admission to a hospital is used for assessment, and I am sure that there is not a given number of days a patient will spend in hospital according to his or her condition. What is the thinking behind this new policy? How will it improve the situation within the accident and emergency departments?
Deputy Flynn raised a few of the issues that I wished to raise, so I will stick to two issues. The first is about the major investment in palliative care. It is very frustrating to hear about multi-million euro investments in this area, yet in my own county the rug was pulled from the development of an eight-bed unit, even though the HSE had given a written commitment about it. It is very hard for people to trust the commitments given by the HSE on the delivery of services when projects are withdrawn following written guarantees that they would go ahead.
The second issue is the north east transformation programme, which is being used as a blueprint for the reconfiguration of services in County Roscommon and County Galway. As we know, the Minister was in Athlone last Friday week and made comments regarding the future of inpatient surgery services at Roscommon County Hospital, which will be amalgamated with Portiuncula. This was a reiteration of a comment made in the House the previous day and a decision made by the HSE on 28 April. Subsequent to the HSE statement and the Minister's statement, there have been comments in the local media to the effect that no decision has been made regarding the transfer of services and that Professor Drumm is now coming to visit the hospital and to the meet the surgical team.
To come back to the point made earlier by Professor Drumm, it is very demoralising for staff when they do not know what is going on and when they have not been communicated with regarding the specific plans and what decisions have been made. One arm of the State seems to be contradicting the other as to what exactly is happening.
I have three questions. First, what is the current status of the plan regarding the transfer of inpatient services? Second, what is the objective of Professor Drumm's visit to the hospital next week to meet the staff, considering that consultation with those staff by HSE management has taken place for the past two years? Third, we are told that Louth County Hospital is the blueprint for the transformation of services at Roscommon County Hospital. If this is the case, my understanding is that accident and emergency services will be transferred from Louth County Hospital to Drogheda. If there is a similar plan for the future of surgery in Roscommon, the HSE should at least be honest and tell the people what is going on. The Minister has a reputation for being honest and frank. I urge her to clarify the exact position.
I am conscious of the time constraints. Perhaps we should have concluding remarks from the Minister and Professor Drumm. If members accept this, we could arrange for a written response to be issued to the members on the specific questions that have been raised.
There should be no time constraints. We are developing a habit of having time constraints on our meetings, which is not acceptable. We meet quarterly and unlimited time should be available. It is not good enough to get written answers to questions asked publicly. That is part of the problem with transparency. When we put down questions in the Dáil, we are told it is a matter for the HSE and we get a subsequent response from the HSE in writing but in private. Nothing is ever on the record. That is part of the problem. We need to have——
We knew at the commencement of the meeting that the Minister and Professor Drumm would have to leave at about 1 p.m. We agreed with that scenario at the outset. We may consider how we might better use our time in these meetings when we meet in future but faced with today's scenario, it would be appropriate to hear some concluding remarks and to arrange to ensure that the responses are issued as quickly as possible to members. The secretariat will assist us in this.
With respect, the question asked by Deputy Naughten requires an answer today. The meeting is taking place next week.
Professor Drumm will deal with that. I call the Minister to reply first.
There is a Cabinet sub-committee on European affairs at 1 p.m. that I am anxious to attend for obvious reasons. In response to Deputy Allen, some of the issues he raised in his questions were dealt with when he was out of the room.
I was out of the room because I was on other official business.
I am not saying that the Deputy was not out of the room for good business reasons. I am simply saying that some of the issues he raised around the Mercy accident and emergency unit were dealt with.
Some of them were not dealt with.
I know. I am simply saying it is not a good use of our time to deal with issues a second time.
Deputy O'Connor's questions were mainly for the HSE and I will leave them to Professor Drumm. With regard to Deputy Conlon's question on the 37.5 hour week for nurses from 1 June, this was agreed at the suggestion of the national implementation group when the industrial action was taking place on the basis, agreed by both sides, that it would be cost neutral and there would be no diminution of services. Only those sites where that could be achieved were allowed to progress. That is the agreement. It is not an agreement that we would move to 37.5 hours regardless of the consequences. It can only done on the basis that it will not cost any more and will not reduce services to patients.
With regard to residential standards, those standards are draft standards from HIQA and are currently the subject of a regulatory impact assessment. The standards are a matter for the Minister to sign off on. I am conscious of some of the issues the Deputy raises. There are two different issues. One is the quality of care, on which there can be no compromise. The second is the environmental issue, such as size of rooms and so on. We need to move in an incremental fashion. We cannot move today to a situation that may be desirable eight or ten years from now.
I do not know what regulatory impact assessment will be made, but I accept the Deputy is correct in this regard. I have physically visited nursing home rooms that I would regard as being of a good standard if I had relatives in those rooms, and I have been really satisfied with the quality of care in the facility, but it would not meet the standard. In all we do, we are talking about incremental improvements but there can be no compromise on the quality of care.
We know that 30% of those in long-term care have low to moderate levels of dependency. When the Fair Deal is introduced, it will be to support people who have higher levels of dependency. There will be exceptions for social reasons but, generally, we will be supporting on an equal basis those in public and private care on the basis of high levels of dependency.
The HSE has made a request to the Department to divert some of the moneys that were earmarked for the Fair Deal to enhance subvention. That matter is under active consideration at present. We will revert to the HSE. I have some sympathy with the position the Deputy outlines. We had hoped to have the Fair Deal in place by now.
The Deputy made a point about texting for appointments, which relates to some of the innovation issues to which I referred earlier. One of the reasons there has been such an improvement in the physio department of St. James's is that it uses texting reminders, and I understand this system is used in many hospitals. Of course, modern communications are important in this area.
I will let Professor Drumm deal with epidurals and so on. I recently had a meeting with the independent midwives, who are all for natural birth at home. They will come under the quality assurance regime of the HSE from later this year. It seems there is an increasing number of people who are anxious to give birth at home, believe it or not. Perhaps I should not say "believe it or not" but I understand from the independent midwives that there is an increase. We want to make sure this comes under the quality assurance regime.
Perhaps the HSE will deal with the question of the 300 people in the psychiatric units. I am advised the number is 200. There are plans in regard to those at St. Ita's in Portrane. Some 70 patients will be moved next year into community nursing home units that are being fast-tracked for St. Dympna's in Carlow and I understand 60 patients at St. Ita's will be relocated.
The figure was 308 two weeks ago.
I have been handed a note that states it is 200. Perhaps the HSE will clarify this. Whatever the figure, there is a plan to move those people as quickly as possible into more appropriate settings.
Senator Feeney referred to the bus. I was a shocked when we had to allocate €150,000 from our lottery funding for a bus as I did not know buses were so expensive. However, when the Senator brought to my attention the poor condition of that bus, we were happy to make an allocation from our health lottery funding to what is a very important facility for those patients who are travelling five days a week for a period of six weeks or more for radiation oncology in University College Hospital, Galway. I hope we can have the bus has quickly as possible and it should not take long to get it.
Deputy Allen referred to the National Treatment Purchase Fund. The patients can self refer but they need to get their records from the medics. As I said earlier, I am in discussions with the fund in regard to how we can make sure the patients can access treatments that are available from the three hospitals in the country which do not seem to be referring patients.
On palliative care, which is an issue for the HSE, assurance was given that €3 million will be spent this year. It is not true to say that all new development moneys are diverted. The cancer programme, for example, involves new development money which is being spent on cancer care. The palliative care money will be spent. I understand the HSE intends to spend the money allocated for vaccines and so on. Clearly, there are issues that arise concerning money spent in the past and we cannot reallocate what we do not have. It is a question of using the resources we have to best effect.
On colorectal screening, we are awaiting recommendations from the Health Information and Quality Authority and the cancer screening services. There are issues in regard to how the programme should be rolled out, the nature and frequency of testing, the population group involved and so on. We recently received advice on the cervical cancer vaccine and it is my intention to make a decision in this regard in the summer. Among the issues that arise is parental consent. The vaccine must be given at intervals of six months, so it makes sense to commence vaccination at the start of a school year. The roll-out of both these programmes will depend on the availability of resources. In each case, the resources required are not inconsiderable.
Deputy Naughten's question may be answered more adequately by Professor Drumm. As I said in Athlone, a decision has been made to have a single department of surgery operating between Portiuncula Hospital and Roscommon County Hospital. My understanding is that the latter deals with three to five inpatient surgeries per week, or 20 or 22 per month. All decisions in this regard must be guided by safety and quality concerns. Professor Drumm may wish to deal specifically with that issue.
The pilot retinal screening project in the north west is being rolled out throughout the west this year. The HSE delegates may wish to comment on that. Professor Drumm will be better able to deal with the questions on the details of the consultants' contract in regard to overtime and accident and emergency cover.
Professor Brendan Drumm
I assure Deputy O'Connor that Tallaght has not been forgotten in the context of the primary care roll-out. We intend to bring forward significant investment in that area. Deputy O'Connor asked about the hospital in the home service. There was enormous resistance to this programme from many stakeholders and we had great difficulty in establishing it. We have also put in place community intervention teams, including one in the Deputy's area, which have been highly successful. The continued expansion of the community intervention teams to take on most of that work is the way forward. We can introduce the Deputy to the person who is running the one in his area. It is a state-of-the-art, quality assured system with great leadership, which will increasingly allow people to avail of many of these services in their own homes. We have one scheme in Cork, one in Limerick and two in Dublin. We intend to expand the service, using the west Dublin model, as an excellent means of allowing people to be cared for at home.
The Deputy asked about the new children's hospital. There will be significant investment in Tallaght and west Dublin in regard to the development of a comprehensive ambulatory centre. Much of the day surgery, which comprises the greater part of surgery for children, for the entire city will be undertaken there. It will be run by the children's hospital on that site. This represents a significant investment and is part of the work of the development board set up by the Minister to deliver on the children's hospital development, which will include the Tallaght development. If he wishes, I will ask that the Deputy be provided with updates as the project progresses.
On cancer services in Tallaght, we are now seeing the coming together of hospitals in Dublin in a way that has not been evident heretofore. The Mater Hospital and St. Vincent's Hospital are co-operating to form a Dublin academic centre. I met recently with the provost of Trinity College, Dublin, and the groups being set up to facilitate a much closer working relationships with Tallaght and St. James's hospitals. As a result of these developments, we will see a significant change in how many services are provided. I assure the Deputy that there will be a comprehensive plan for cancer services across those two sites. This is clear from my consultations with those who are driving this process in both hospitals and at the academic centre in Trinity.
I have been critical of Tallaght Hospital in the past in regard to the challenges it has faced on the financial side. There has been a significant level of interaction on this issue between the board of Tallaght Hospital, as represented by Mr. Alan Gillis, and myself. We owe Mr. Gillis a great debt for his work on this issue. We are all now much happier that the system is being dealt with in a far more constructive way. Notwithstanding my past criticism, I acknowledge that those involved have engaged with us in a positive manner. This is a good indication of the challenges that may confront Mercy University Hospital in Cork. It shows what can we done if there is increased co-operation at the boundary between the statutory and the voluntary.
Deputy Conlon asked about GP recruitment and training. This undoubtedly represents an enormous challenge. We are working with the Irish Medical Organisation and the Department to reach agreement on how we can open up access for GPs to set up practice. To be fair, however, it makes sense that GP practices should not be established indiscriminately. Our initial engagement on this issue has been positive and I am hopeful we will see a situation where practices can be opened more easily in places of need. The training issue represents a significant challenge and we are examining it in a comprehensive way. We are engaged in consultations with some of the major stakeholders to ascertain changes that may be required to the numbers going into training and the structure of that training. It may be the case, for example, that some people could go through shorter training periods based on the experience they already have. It is an issue on our agenda.
I will come back to the Deputy with a report on the issue in regard to Our Lady of Lourdes Hospital. I do not know why that change has taken place. The Minister referred to the new standards for residential care. It is a significant challenge. Oriel House, which is located in the Deputy's area, represents the best in class nationally in the provision of long-term residential care, with the correct skill mix being deployed to ensure the patient is at the centre of the delivery of care. It is more than simply a question of infrastructure; it is also about how we provide that care. Having said that, the long-term care provided in our public sector is a beacon that is unparalleled elsewhere in the world in terms of the level of care patients receive.
A text message service to remind patients of outpatient appointments is available in several hospitals and it is our intention that this be extended. A similar reminder service is increasingly being used to alert general practitioners when laboratory results are available. Again, it is a question of extending that service.
I will get back to the Deputy on the issue of post mortems in the north east. It is an issue of which I have had personal experience in recent days. I am not sure how easily we will resolve the difficulties in this regard. I agree it can be traumatic for people who must wait two days before their loves one's remains are released. We may need to work with the Royal College of Pathologists on this. It is a highly sensitive issues and it is in all our interests to get it right. The Deputy's experience and my own in recent days suggest the system is not working as we would like.
In regard to the reconfiguration of services, we said we would not transfer services in Monaghan or anywhere else to another location unless there are demonstrable benefits for patients in doing so. Ms Bridget Clarke, who is here with us today, is a nurse from the north east who is leading on this issue. She will absolutely confirm that this remains the case. Members may speak to Ms Clarke later if they wish. She and I can offer assurances in this regard.
My colleague, Ms McGuinness, will comment on the subvention issue.
Ms Laverne McGuinness
The increase in subvention applications is huge. We have made a submission to the Department on the possibility of utilising some of the Fair Deal moneys for this purpose. The Minister has acknowledged that due to the delay in the implementation of the Fair Deal scheme, there has been a growth in applications for subvention. Our application to the Department is being considered.
Will each region be a beneficiary of that?
Ms Laverne McGuinness
It will be dealt with between the Department and the HSE.
That is not what the Taoiseach indicated yesterday.
To be fair, the Taoiseach understood the Deputy to be asking about legislation to bring in a new scheme, which we cannot do. We are bringing in the Fair Deal scheme.
With respect, I specifically asked whether any measures were proposed to provide intermediate relief to people who have been hanging on by their finger nails for the last nine months. The implementation of the Fair Deal scheme was promised before Christmas. Were one to check the record of the Dáil, one would find that is what I said. The Minister should not try to reframe the question.
The subvention scheme is the only extant scheme and, as the Deputy is aware, many people do not qualify for it because of the current criteria. This cannot be changed without enacting new legislation. The request from the HSE is to divert some of the moneys that will not be used for the Fair Deal to enhance subventions. This is what is under consideration.
Does the Minister hope to have a decision in this regard soon?
Yes.
Did the Minister indicate the Fair Deal will be for high dependancy patients only? Did I understand her correctly?
It will be for high levels of dependency. We are not going to support people in long-term care who do not need to be there. We will try to support people at home.
I refer to the category of high dependency. The Minister is aware there is a specific——
The HSE is working on a unified assessment of need that will encompass both financial and care need.
Professor Brendan Drumm
In response to Deputy Lynch, €3 million will be spent on palliative care this year. This constitutes development money and it is within the sanction that it should be spent on palliative care.
As I stated, we are unwilling to address issues regarding the numbers of patients in the north east. It is outside the scope of how these will be dealt with in the future. All the figures ultimately will be available on completion of the review.
As for consultants at Cork University Hospital, I do not know how much time they spend tied up in management team meetings. However, as for whether it is an issue that the sterilising unit does not work or is holding someone up, there are almost 3,500 staff in Cork University Hospital. I find it hard to believe the sterilising unit is holding up——
It is not the sterilising unit but the staff to operate it and to take specific——
Professor Brendan Drumm
There are just short of 3,500 staff within the institution. If there are 120 admissions per day and if it needs more staff, I doubt they will be provided within a context of the current level of staffing. The HSE at corporate level in Dublin cannot manage the sterilising unit in Cork. It can provide staffing, as does the taxpayer. Sometimes one hears such stories to the effect that a single issue stops things or the system suddenly depends on a single little piece of it that is not working. While I can check this and revert to the Deputy if the sterilising unit is responsible, I——
I suggest there are similar instances nationwide about which Professor Drumm has heard all morning at this meeting. If this is the case, surely he cannot simply state the hospital in question should open the unit because it has enough staff, when the people on the ground state it does not. If there is not a meeting of minds, in respect of the accident and emergency unit in the Mercy University Hospital, someone must be prepared to step in to say, "Hold on a minute".
Professor Brendan Drumm
As Deputy Allen brought up that issue again, rather than dealing with it three times, I will summarise. Epidurals are available and we certainly will not begin to tell people they are obliged to have epidurals or they are obliged to opt out. Ethically, that would be completely unacceptable. We cannot tell people they are obliged to have a procedure. People must request a procedure.
I know that but still——
Professor Brendan Drumm
Let me be clear that I do not consider this to be an issue.
In fairness, that is to misconstrue the question. The Deputy stated that it should be presumed, and therefore available, unless patients decline it. She did not state it should be shoved down patients' throats unless they state they do not want it.
Professor Brendan Drumm
I do not accept that at all. That we presume that a patient should have——
I refer to availability. That is what she stated and was implying.
Professor Brendan Drumm
One should be very careful in this regard. Is the Deputy suggesting it should be presumed that people will have something done to them?
There should be availability. It should be presumed they will need it unless they state otherwise. In other words, what she is really referring to is not that the patient must decline it, but that it is available to them, rather than being obliged to ask for it, after which someone would be obliged to fetch it.
Professor Brendan Drumm
Is the Deputy stating that epidurals are not available in Cork University Hospital?
Let me put it this way——
Professor Brendan Drumm
No, I must be clear in this regard, because this question has been turned around a little.
Professor Brendan Drumm
Perhaps Deputy Reilly can clarify this for me.
That is what I understood from her question.
Professor Brendan Drumm
Well I am a little sorry, because that is not the way I understood it.
Perhaps I could answer the question because, after all, I asked it.
Professor Brendan Drumm
That is how it should have been left. I do not know the reason we were obliged to——
No, Professor Drumm is trying to turn around what I said. My point is that it should be assumed that women want an epidural and therefore it should be available, other than——
Professor Brendan Drumm
I cannot accept that.
As Professor Drumm never will be in that position, I do not expect him to understand.
That is unfair.
What is unfair about it? It is a fact that he will not.
He is a clinician. Moreover, I am unsure it should be assumed. I am unsure that women would want this to be assumed. Women need to give their own indication as to whether they want it.
Professor Brendan Drumm
That is an enormous assumption.
Perhaps Deputy Lynch can clarify her question after which Professor Drumm will respond and that will be an end of it.
Yes, if I can. I refer to pregnant women who are going into hospital to have their babies. I understand women make different decisions on how they give birth and I have no difficulty with that, as it should be a matter of choice. If they choose to have an epidural, it should be available. When in labour, they should not be obliged to pursue someone to make it available.
Professor Brendan Drumm
I have a difficulty, in respect of epidurals and everything else, that one would make an assumption that people would avail of a service. As for having it available, I completely agree with the Deputy.
While I do not wish to delay proceedings any further, such assumptions are made about people every day of the week. The notion that Professor Drumm would not make this assumption about pain relief is astonishing. As a clinician, he makes such assumptions every day of the week.
Professor Brendan Drumm
It is not our call in respect of carrying out interventions on people. That is a decision on which people must make their own informed consent.
The question of epidurals is beyond the committee's remit.
Professor Brendan Drumm
That is an amazing story. Ms Laverne McGuinness will respond with regard to the question on delivery of the BCG vaccine in Cork.
Ms Laverne McGuinness
The difficulty regarding the vaccinations in Cork was because there is only one supplier of vaccinations Europe-wide and technical difficulties arose in respect of their supply. That meant there was unavailability in November and December and consequently the programme could not be rolled out as planned. This resulted in a significant backlog and waiting list. As the vaccine is now back in supply, the waiting lists are being addressed and plans are being put in place to ensure the BCG vaccination also will be carried out in the neonatal unit in Cork University Hospital. In recent weeks, the waiting lists have been reduced by approximately 300 and the issue is being addressed as we speak. However, as there is only one supplier of the vaccine, this obviously gave rise to highly significant waiting lists and backlogs in that area.
Why are two general practitioners providing it?
Ms Laverne McGuinness
What they are talking about is that they have put in an advanced methodology to ensure that more vaccinations are administered. They had planned to do so anyway, in order that more clinics would be provided to carry out the vaccinations. Is that okay?
We will move on to the issues pertinent to Mr. O'Brien. Before doing so——
Professor Drumm should respond to my question.
Professor Brendan Drumm
Perhaps I should respond to the Deputy separately because I have gone through the Mercy Hospital issue in detail earlier this morning. While I can do so again if he wishes, but——
As for the Mercy Hospital, the question asked was who is in charge and who will make a decision.
Professor Brendan Drumm
Briefly, the Mercy University Hospital is a voluntary hospital and the HSE does not manage it. While we provide it with a budget each year, the HSE has no role in managing the Mercy hospital. As I observed to Deputy O'Connor in respect of Tallaght hospital, ultimately we engaged in highly constructive interactions to deal with an issue without putting in more resources. However, as for stating that jobs are disappearing from the Mercy hospital, it should be noted it is significantly over-budget. It is an extremely small hospital unit on a national scale and it is way over-budget. Were we to condone simply putting in money to bail out such budgetary issues, the hospital system in Ireland would collapse. What would happen were Tallaght or Beaumont hospitals to decide suddenly to over-run as well, on the grounds the HSE would simply provide the money?
This is a local management issue within a voluntary organisation in which I have no managerial role. If that needs to change and the system is collapsing on the Mercy University hospital, then we will need to deal with that issue. However, it is an independent entity——
The HSE should deal with it because the system is collapsing.
Professor Brendan Drumm
It is an independent entity. While someone may wish to approach the HSE seeking input to resolve this issue, I cannot cross the doors of the Mercy University Hospital to manage it. Legislatively, that is not possible for me.
Cutting its budget would constitute crossing the door. It was penalised last year.
Professor Brendan Drumm
I did not cut the budget.
It was penalised last year.
Professor Brendan Drumm
It is part of the same system as every other hospital in the country. Why should the Mercy be dealt with differently?
It was penalised because of the report that was done on its——
Professor Brendan Drumm
Case mix, yes. Every hospital——
Its budget has been cut because of penalties and Professor Drumm now states it is overspending.
Please, we have received a response.
Professor Brendan Drumm
Do we run the system for the Mercy University Hospital or for the country? I often am accused of——
That kind of smart response is unacceptable. I represent people who are affected by the cutbacks there. There have been cutbacks as I speak today and I seek straight answers. Who is in charge?
Professor Brendan Drumm
I will return the question by asking whether, if the Mercy University Hospital is running €4 million over-budget, the HSE is supposed to give it the €4 million?
It is over budget because penalties were imposed last year.
Members have been here since 9.30 a.m. this morning and will not receive an answer to this question.
Professor Brendan Drumm
I am going to Cork next week for a couple of days——
Deputy Allen left the meeting for an hour and is now hogging it.
Professor Brendan Drumm
——and this issue may reach some resolution.
Hopefully it will.
Professor Brendan Drumm
I spend much time in Cork and it has the opportunity to develop some of the best health systems in the country because of its population base. However, it needs some serious decision making by the people there as to how they carry out their business.
Professor Drumm might address Deputy Naughten's question.
Ms McGuinness might address the quality of care and the conflict of evidence.
Professor Brendan Drumm
We dealt with palliative care in detail. I will clarify the number of posts because that is a contradiction——
Ms Laverne McGuinness
I apologise to the Deputy if I was unclear. The percentages are 70%, which is related to the 2006 funding, and 30%, which is related to the 2007 funding. The amounts were €9 million and €5 million, so 70% of the funding for 2006 was used to fund posts. I have the breakdown of the posts. A total of 30% of the 2007 development funding on palliative care was spent on palliative care. This would also have been to put posts in place. I have the breakdown of that funding.
In respect of the important question I put to Ms McGuinness this morning, I am told that 50% of posts were filled, while the Committee of Public Accounts was told that 70% of posts were filled — not 70% of funding. All I am asking is whether 70% of posts been filled or whether the figure is 50%, as I have been informed by the Irish Hospice Association.
Ms Laverne McGuinness
It relates to some 70% of funding. Funding primarily relates to posts, so it is all revenue funding for community services. There is 70% in one year and 30% in the next year — that is, 100% out of 200%, which is 50% of the total. Is that where the 50% figure would have come from? The figures I quoted were 70% and 30%. I remember mentioning 28 clinical posts at the Committee of Public Accounts and I have the figures written down here.
The evidence given to the Committee of Public Accounts was that 70% of the posts were in place.
Ms Laverne McGuinness
For 2006.
It did not say that.
Ms Laverne McGuinness
I apologise, it was 2006. We attended the Committee of Public Accounts in respect of 2006.
Ms McGuinness said the posts are in place.
The Committee of Public Accounts should do its own business. We are trying to transact our business. We have had a number of questions to which we are trying to get responses. I want to go to Deputy Naughten who has raised a question and has not come in on a number of occasions. He needs clarification on a particular point.
There is a difference between "were in place in 2006" and "are in place in 2007".
Most definitely.
What was said was that 70% of the posts are in place, but they are not.
Ms Laverne McGuinness
A total of 70% of the posts in respect of 2006 are in place. When we appeared before the Committee of Public Accounts, we were being questioned in respect of the 2006 Accounts.
We are talking about the current situation.
We are not here to second guess the Committee of Public Accounts.
We will pursue it further.
Can the delegation address the issue raised by Deputy Naughten?
Professor Brendan Drumm
This is in respect of Roscommon. I am going to the west next week and will meet people from Roscommon, Portiuncula and Galway. I do not know where that meeting will take place but we must all be in a room together. What we must be absolutely clear on is that there is no roll-out of any blueprint from any place. What is very clear right across the country is that workloads and demands to justify the appointment, in Roscommon and everywhere else, of acute surgical services present the major challenge. There is nothing like the workload that is required to maintain acute surgical services on a significant number of sites up and down the country. Roscommon and Portiuncula are particularly challenged but it is not unique to those particular locations.
The proposal was that we would centralise 24-hour surgery, which, to be honest, is the minimal amount, on the Portiuncula site; that there would be a surgeon in attendance each day at Roscommon from 8 a.m. to 8 p.m.; and that overnight surgery, which is a minuscule number of procedures each year, would be carried out at Portiuncula if it was required. The reason I want the people from Galway to be at the meeting is that there is a significant opportunity to start bringing services out of Galway and into Roscommon, a process which has already started in Portiuncula. We see ourselves moving to a situation where 90% of surgery can be day surgery. A considerable amount of this surgery is not even carried out in Roscommon at the moment but is carried out in Galway.
Regarding the Dundalk model, the one thing one can say about Dundalk is that it has now one of the most active day-surgery units in the country and has got rid of waiting lists in the north east completely because of the way that unit now works rather than because of Our Lady of Lourdes Hospital. Ironically, it has been the changes in Dundalk that have led to that.
It is a significant challenge but in terms of recruiting people and given the scenario of the workloads that are now there, it is almost impossible to put three or four surgeons in each of the units. I do not have an easy solution if people anywhere in Ireland are threatened but what we need to do is bring in cranes rather than bulldozers. It is to build a different facility and to say that we are bringing services there such as ambulatory services, day services and CAT scanning, which is already there, and utilising them for the best output for the people locally. I am not being dishonest with people about that. I might meet the clinicians there because they are critical, as well as the managers from all of the hospitals, to see how a fair deal in respect of how we get the work done can be achieved. We have waiting lists for procedures in Galway that could easily be done in Roscommon.
Does the Chairman want me to conclude? In respect of the point made by Senator Prendergast——
Perhaps written responses could be sent to those members of the committee who have left us at this point.
Professor Brendan Drumm
I can reassure the committee 100% that the lands at St. Luke's——
In respect of the finances——
Professor Brendan Drumm
----the funds there will be going into mental health services. I must come back to the Senator in respect of child psychology services. There is a superb child psychology service in Clonmel in which I have been recently. I must come back if there is an issue with it. It even has open access one day a week, so one would have to say that it is superb. I must find out if there are problems there.
I must get back to the Senator in respect of ambulance services in Carrick-on-Suir. Retinal screening is being rolled out down the west coast and is going to Galway and Mayo. It is a superb service — the best in the world.
I thank Professor Drumm for coming back to that point. I await a written response in respect of Carrick-on-Suir.
Professor Brendan Drumm
We will try to get the written responses.
Deputy Flynn raised a number of matters to which Professor Drumm might respond in writing. Deputy Ó Caoláin, who was not with us earlier, wishes to make a very brief intervention at this point.
I extend my apologies to Professor Drumm and his colleagues in the delegation for being late. I was otherwise engaged on the floor of the House. People talk about a recruitment embargo and staffing freeze. Professor Drumm rejects all these as applying across the health services. What terminology does he apply to a situation where new posts cannot be filled until other positions are closed down, for the want of a better word? One could use the term "natural wastage". How does Professor Drumm describe it? In layperson's terms, it is seen in many cases to have the same net effect.
I am particularly concerned about a number of areas. If these have already been addressed, Professor Drumm should tell me and I will accept that. Colleagues can bring me up to speed because I am not up to date with what has already taken place here this morning.
I am very happy to see an increase of 300% in training posts for an outflow of qualified speech and language therapists. However, as I understand it, no new posts have been created within the system for these additional trained speech and language therapists and to offer directly to the children concerned the professional supports and assistance they clearly need. Obviously, in these cases, the earliest intervention possible is hugely important. It has been indicated to me by people going through the system of qualification that such is the dearth of opportunity within speech and language services currently that, having been trained within this jurisdiction, their qualification and professional expertise will be exported, with no opportunity to be engaged within the system here. Can Professor Drumm give us an update in respect of same and what steps are being taken to open up post opportunities at least reflective of the numbers that are being trained through the system currently?
There was an announcement in the past week vis-à-vis nurses going through a training programme in Sligo. Heretofore, there was an automatic access of six months and direct engagement at Sligo General Hospital, which is not now available to some 40 nurses going through the training process. This direct and immediate opportunity for deployment within Sligo General Hospital and perhaps other hospitals in the catchment area — I cannot be certain of the detail — is not currently on offer. The nurses are being told that there will be no opportunities presenting. Is this reflective of that area only or is it indicative of a situation applying across the jurisdiction? Can our guests indicate whether nurses trained within the jurisdiction will have jobs in HSE services?
I must ask the Deputy to conclude.
Of my several remaining points, I will make one. Psychology services were referred to. Regarding child and adolescent psychiatric services in the north east, specifically counties Cavan and Monaghan, a missive from the director of said services was sent to all general practitioners in February or March to the effect that only emergency referrals would be taken for the foreseeable future. What is the current state of play? It has been indicated that additional posts within child and adolescent psychiatric services must be filled. When will those posts be in place? The numbers cited at a recent local briefing — Professor Drumm's colleagues immediately behind him were in attendance — do not match the population to provision ratio. When will the situation return to normalcy and child and adolescent psychiatric services be available to all families that need them?
I thank Deputy Ó Caoláin. Perhaps Professor Drumm could respond in writing to the Deputy's questions. Mr. O'Brien must leave the meeting at 1.30 p.m.
If Professor Drumm could give a brief response to each question, I would be delighted.
Out of courtesy to Mr. O'Brien, who was asked to attend until 1.30 p.m. but who has not had an opportunity to respond to any question, perhaps he could address the priority questions. I apologise to him. If Professor Drumm has to leave, the committee would understand, but perhaps he could correspond with Deputy Ó Caoláin.
That is a harsh ruling.
Commitments were given.
I remind the Chairman of our conversation, which I took on board. I did not ask any questions about cervical screening because I was asked to leave them until the end.
Yes.
My colleague will ask questions on my behalf. I apologise, but I must attend a vote in the Seanad.
Mr. Tony O’Brien
Were it helpful, we could attend a further meeting.
We could do that.
Mr. Tony O’Brien
We might have a higher billing.
We would appreciate it.
Mr. Tony O’Brien
I am conscious that all of the questions were asked by members who are no longer present. While I am happy to deal with them——
If it suits Mr. O'Brien, we could arrange to reconvene at an early date to discuss matters in greater detail.
Mr. Tony O’Brien
That might be better.
Can we ask simple questions, such as when will certain areas be provided with BreastCheck services?
Mr. O'Brien has been in attendance for a long time.
I understood that we would be able to ask them, for which reason I did not ask earlier.
Yes, but arrangements were made with Mr. O'Brien to allow him to leave by 1.30 p.m. In fairness to him, he sat through all of the debate and he and his team have been patient. With his agreement——
If he has definite news on rolling out BreastCheck in those counties that do not yet have the service, could I get it in writing?
Yes. We can make arrangements for an early meeting to discuss outstanding issues.
We are interested in, for example, finding out when the roll-out of cervical screening in Munster is expected.
I thank the Minister, Professor Drumm, Mr. O'Brien and their officials for attending the committee and updating it on these important health issues. It has been an informative meeting.
The committee will adjourn until 3 p.m. on Tuesday, 24 June when we will meet Dr. Margaret Kennedy, the Brothers of Charity and the HSE. I thank everyone for their co-operation.
The joint committee adjourned at 1.35 p.m. until 3 p.m. on Tuesday, 24 June 2008.