I welcome the Minister for Health, Deputy James Reilly, and his officials and Mr. Cathal Magee, chief executive officer of the HSE, and his officials. I remind members that they have absolute privilege and draw their attention to the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable. By virtue of section 17(2)(l) of the Defamation Act 2009 witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they do not criticise or make charges against a Member of either House, a person outside the Houses or an official by name or in such a way as to make him or her identifiable.
Health Issues: Discussion with Minister for Health and HSE
I thank everybody for attending this my first committee meeting on the Government side. I was usually on the Opposition side and while my position has now changed, our health policy has not.
We are facing a very difficult and serious financial situation. The Department of Health and the HSE have to institute cuts of €1 billion this year, with further cuts to be made in the next three years as part of the comprehensive spending review. There is no need for me to go into the history of the matter. Even if we were not facing this terrible economic situation, we could not continue to fund and deliver health care in the way we do. Two years ago we used the entire PAYE tax take of €16 billion to fund the health service. Clearly, that is not sustainable. With an ageing population - Ireland is not unique in Europe in this regard - everybody is on the same page with a view to moving more services from hospitals to the community. We must place greater emphasis on prevention and early intervention. If we were to keep going at the current rate, health spending would increase to €37 billion by 2020. This fact was contained in a report by VHI when it examined the demographics. The total tax take this year will be €35 billion which puts the figure given in perspective.
Treating chronic illness accounts for 70% of all health resources. Some 66% of emergency admissions and 80% of GP consultations are related to chronic illness. Some 70% of preventable deaths are caused by two factors, both eminently preventable, smoking and obesity. What is the solution? We need fundamental reform of the system. The programme for Government includes the most radical health reform plan in the history of the State for which in the general election we received a very clear mandate from the people to pursue. We have started that process. We have made changes to the board of the HSE and appointed Mr. Martin O'Connor to set up the special delivery unit which will be the agent of change in addressing waiting times in emergency departments and inpatient and outpatient waiting lists. This is no small body of work. It requires improving information technology and processes. I am very glad to say much work has been done in this regard by the clinical teams in the HSE. Many hospitals have plans prepared.
I am sorry to interrupt the Minister, but I have to inform him that there is a vote in the Dáil.
I will conclude my opening remarks quickly.
A great deal of work has been done, but more remains to be done. There is a real need to advertise for clinical leaders in general practice. By the autumn we will have a very clear roadmap showing where we are going and how we will get there. What we will achieve is the provision of a single tier health system based on universal health insurance. An underlying principle is treating the patient at the lowest level of complexity that is safe, timely, efficient and as near to home as possible. It is also about changing the way we budget for hospitals. Instead of giving them a block budget, we will give them money as they treat patients, in other words, the money will follow the patient in order that the patient becomes central. It is also about changing the way hospitals are organised by putting in place a trust model and ensuring a clear and secure future for smaller hospitals. Much greater emphasis will be placed on prevention, in which funding will be invested. We will no longer pay mere lip service to it.
We are facing a number of very difficult years and have a huge challenge ahead of us. However, I have absolute faith in the country, the people and our ability to face that challenge and turn it into the greatest opportunity we have ever had to reform the health service and bring equity and fairness to the health system and society generally.
We will reconvene. Is the Minister happy to continue?
I concluded my opening remarks and am happy to answer members' questions.
I welcome Mr. Magee and invite him to comment.
Mr. Cathal Magee
I thank the committee for the invitation to attend and we look forward to working with and extending to the committee every co-operation and assistance in its work. I am joined by a number of my colleagues: Mr. Liam Woods, our national director of finance, Ms Laverne McGuinness, the national director of integrated services, and Dr. Barry White, the national director of our clinical strategy and clinical programmes. In attendance and available to the committee are Mr. Brian Gilroy, our national director of integrated services, Professor Garry Courtney, a national acute medicine programme lead, and Dr. Una Geary, a consultant in emergency medicine and our national lead on emergency medicine.
The committee requested information and replies on a range of issues prior to this meeting. As it will have received written replies to all of its questions, I will confine my opening remarks to a number of key areas.
These are challenging times in our health care service. Demand for services continues to grow year on year and is exceeding our capacity. At the same time, we are implementing almost €1 billion in budget reductions in 2011. The financial results for May show total expenditure of €5.256 billion against a year-to-date budget of €5.061 billion. The reported variance of €195 million, 3.8%, is reduced to €170 million after adjusting for post-service plan reductions by the Department of Health. The budget continues to be €58 million short of planned levels as a result of further reductions in the budget for demand-led schemes, which occurred in the publication of the Revised Estimates of the Vote in February 2011 following the approval of the service plan on 21 December 2010. The deficit in the Primary Care Reimbursement Service had increased to €50.1 million by the end of May.
Also by May, hospital deficits grew to €120.6 million. It is clear that, after five months of data, some hospitals will run into serious cash flow problems unless the measures they have taken to reduce costs are effective. Hospital deficits are being exacerbated by shortfalls in income billing against target and, in some hospitals, activity levels are up considerably compared with previous years. Hospitals will be obliged to bring activity back to plan in locations where service plan targets are being exceeded. In this regard, each hospital and region is implementing a comprehensive cost remediation programme.
In community-based services, expenditure in a number of care groups is running ahead of budget. Child care is the most significant of these, with a year-to-date deficit of €28.7 million, representing 67% of the community deficit at the end of May. Child care is forecast to have an overrun of up to €50 million if demand and service activity is maintained at current levels.
Pay is contributing significantly to the overall deficit at the end of May. Given the scale of the financial challenge, a decision has been taken to pause current recruitment except where critical vacancies arise. Agency staffing has been highlighted as a major cost driver in 2011. The position at the end of May has improved, with the full year forecasted growth in agency costs reducing from €31 million to €23 million in May. The HSE continues to focus on and accelerate its full delivery of the cost reduction programme to reduce the current financial deficit.
Activity continues to grow across the majority of HSE services, placing considerable pressure on our resources. The position in May 2011 compared with the same period in 2010 is as follows. Emergency admissions increased by an additional 4,689 in the first five months of 2011 over the same period last year. The number of inpatient and day case treatments have increased by an additional 14,323, some 2.6%. General practitioner, GP, out-of-hours contacts have increased by an additional 50,000, some 13.9%. The number of individuals covered by medical cards has increased by an additional 120,000, some 7.8%. An additional 51,932 individuals have been issued with cards since December 2010.
As the Minister stated, the committee will be aware that the programme for Government committed to the establishment of a special delivery unit in the Department. Under the leadership of Dr. Martin Connor, it will initially focus on reducing trolley waits in emergency departments and cutting inpatient, day case and outpatient waiting lists in the health services. Dr. Connor has also been appointed to the board of the HSE and a dedicated committee of the board has been established to support the unit in its work.
Central to all of our decision making and planning is to ensure that our hospitals and all the services they provide are safe and comply with the appropriate clinical standards. By statute, hospitals and the services they provide are regulated by the Health Information and Quality Authority, HIQA, which has set out clear recommendations in its reports on Ennis and Mallow general hospitals in 2009 and 2011, respectively. Its recommendations determine clearly what is safe when delivering care in hospitals of that size. We are required to implement the HIQA recommendations to ensure the standards of care delivered in smaller hospitals are as high as possible and that the type of care provided is appropriate to the clinical setting and to the needs of patients.
An implementation process has been established. This process involves all of the relevant national clinical leads in critical care, emergency medicine, acute surgery, acute medicine and the ambulance services. The clinical advice of the national clinical leads is consistent with and reinforces the HIQA recommendations for smaller hospitals. The clinical programmes have also identified the need for certain activity to be transferred from larger hospitals to smaller hospitals, including day case surgery and certain types of medical patients. This is essential to ensure there is adequate capacity in larger hospitals to cope with the lower volume, higher complexity cases that need access to regional services.
The HSE recognises that changes to the role of smaller hospitals must be accompanied by a commensurate development of our ambulance services. In recent years, the HSE has invested significantly in the training of ambulance paramedic staff and the number of advanced paramedics has increased from 14 in 2005 to 220 today.
This year, the HSE identified a potential shortage of junior doctors and put in place a range of proactive measures to deal with the situation. The non-consultant hospital doctor, NCHD, workforce stands at 4,660. As of yesterday, data collated from individual HSE hospitals indicate that 191 posts are vacant, although many of these posts are filled by locums. This follows the appointment of 259 NCHDs recruited via the HSE's centralised recruitment process. In particular, the sourcing of highly trained NCHDs from Pakistan and India will alleviate shortages in the system, as set out in our detailed answers to questions. Working closely with the Minister and the Irish Medical Council, provisions have been put in place to provide for the registration of these doctors on the medical register. They will be provided with two-year contracts and will work in posts registered on the new supervised division of the medical register. Approximately 300 of these doctors have applied for visas and more than 128 are already in Ireland.
This concludes my opening statement. My colleagues and I will take whatever questions the committee might have.
I welcome Mr. Magee's officials and staff.
I welcome the Minister, the chief executive officer and the officials from the HSE and the Department. The public is concerned about a number of key issues relating to the reconfiguration of hospital services. Everyone accepts there is added pressure on hospital services and their delivery because of budget constraints and increased public demand, but there must be local input into discussions on how services are reconfigured. The health boards were abolished and the HSE was established, with the Government, through the Department, providing policy direction that the HSE's independent board would implement. That in itself removed the delivery of health services from the political domain in the context of everyday decision making by the HSE. One could equally argue that there was a strong democratic deficit and public representatives, political parties, lobby groups and communities had little say in how they would protect their services and how services would be delivered in their communities. In recent times we have seen reconfigurations on foot of HIQA reports on Ennis and Mallow. Therein lies a difficulty because HIQA has not recommended that hospitals be closed; it has pointed out there are deficiencies and potential risks to patient safety in some cases. There are two ways to address that: to close hospitals unilaterally and transfer patients to larger centres or to address the deficiencies to ensure an increase in patient safety.
There is palpable anger about Roscommon General Hospital, for example: it is the flagship example of the concern in communities about reconfiguration. The real reason Roscommon General Hospital is to the forefront is because of commitments made on a political basis. If political commitments are made prior to an election and the Minister then does a complete U-turn, having publicly stated that all services would be retained, and if a volte-face of that proportion can be done, every community that did not receive a commitment but that has looked at the HIQA report and its recommendations will be very concerned there will be a massive reduction in services in smaller hospitals. That is clear from the contact that has been made with public representatives and with the media. Places like Mallow, Bantry, Loughlinstown, Navan, Roscommon and other communities are clearly concerned about unilateral decisions being made to downgrade the services those hospitals are providing. They are very concerned that HIQA reports are being used disingenuously to bring forward that policy shift.
The reconfiguration of the health services is another key issue that is coming down the tracks. We await primary legislation to overturn the Health Act 2004. Have there been discussions between the Department, the Minister and the HSE about what form the new health body or authority will take? The Taoiseach commented recently about the incompetence of hospital managers and overruns of hospital budgets, which are issues of great concern to everybody here. The HSE is obligated to address that very serious charge which the Taoiseach made. I am sure the Minister agrees with those comments, so what action has been taken to address hospital management incompetence? I presume the HSE takes this role seriously.
As regards the broader issue of the HSE's abolition, are we to await publication of the primary legislation before the HSE structures are changed or will there be some sort of mechanism in place prior to the publication of the legislation to change that, so there will be a smooth transition as opposed to an organisation being almost in abeyance until the primary legislation is published later this year or early next year, with the restructuring taking place thereafter?
There are huge pressures on the delivery of health care. We have had a commitment to primary care but strong views, almost disagreements, have arisen between the Department of Health, the Minister and the HSE about the provision of such care. How many primary care units have been established? What type of funding will be available in the years ahead?
All political parties and most professional health care providers agree that the delivery of primary care units is a key component in ensuring that health care is accessible locally for as many people as possible and at the lowest cost. That should be a priority for the HSE. I am concerned, however, that because the HSE is to be abolished, we could have a drift in the formulation and implementation of policy. The Taoiseach's statements about incompetence in hospital management must be taken seriously by the HSE. They must be acted upon due to the overruns in hospital budgets. One could argue it is not incompetence and that other issues are involved, but the HSE has an obligation to clarify that.
The Minister was going to carry out a review of the fair deal nursing home scheme, as well as its funding and implementation, and the criteria used for qualification. I wonder when that review will be published.
The Minister stated that a review of protocols would be published concerning the sensitive case of Meadhbh McGivern in the context of transport for a transplant operation. I do not want to make any political comment on that tragic case, but we all agree it should never happen again. Therefore we must put in place resources and protocols to ensure there will be no such recurrence.
I know there will be a quarterly discussion with the Minister and the HSE, but the broader issue of non-consultant hospital doctors is raised every January and July. Up to now it could be addressed in some way, but we are now trying to recruit from abroad because non-consultant hospital doctors who are trained in Ireland are leaving. Does the Department and the HSE think there is a need for a different form of medical education, including proper training and career pathways for non-consultant hospital doctors, so we can retain our own in the first place and then accommodate those who want to come here to experience training and further career progression? We cannot have a system of sustained shortages of non-consultant hospital doctors which are the basic workhorses of the medical service.
I will leave my remarks at that, but five minutes is a very short time. I hope we will have the Minister and the HSE here again in the near future.
I welcome the Minister, the CEO and their support staff. The construction of this engagement on the last sitting day of the Dáil session needs to be addressed. I would hope that the quarterly meetings will be set aside from the normal working days so we will not have the series of interruptions we have encountered this morning.
Time will not allow us to go into great detail but I want to deal with a range of questions I have tabled and the responses I have received. Question No. 38 asked for details of the plans for accident and emergency services in a list of hospitals, including, Roscommon, Portlaoise, Navan, Letterkenny, St. Columcille's-Loughlinstown, Mallow and Bantry, in light of the NCHD shortage and budget cutbacks. I make no apology for mentioning Roscommon at the outset because it is the critical focus at this point. It is part of the long prophesied outworking of the template that applied in Monaghan in my community some years ago. We are now seeing that very black cloud visit other communities, including Roscommon which is very much in focus.
I fundamentally disagree with this centralisation strategy. We have stood up for the retention of acute hospital services, including accident and emergency departments. I absolutely reject the inference that the network of local hospitals across the country is in any way less supportive or concerned about patient safety. It is because of our concern for patient safety that we want to defend local hospital services, specifically in Roscommon.
The figures the Minister threw out have quite rightly been challenged. They alleged a 5.8% mortality rate in Galway compared to a 21.3% rate in Roscommon. This point was well addressed by Senator Crown in the Seanad. The medical consultant Dr. Pat McHugh and Mr. John McDermott of the Roscommon Hospital action committee have thoroughly studied the hospital records for Roscommon. They have come up with the real figures across those years. While there was indeed a situation in 2008 of a 12.77% mortality in relation to heart attacks, the average figure for mortality in Roscommon from 2009 to 2011 was 4.92%. I have to ask where the Minister got the figures. Who compiled those damning statistics? We do not have to ask why they were compiled. They have been a useful tool in arguing the case and defending the Government's position in following through on the former Government's policy of removing critical key services from local hospitals and placing them into larger so-called regional sites.
In terms of the overarching situation, what additional capacity is being provided within the hospital system, with particular reference to the axing of accident and emergency services at Roscommon hospital on 11 July? Will a single additional acute hospital bed be provided to accommodate the displacement of patients from County Roscommon to University College Hospital, Galway and the other hospitals earmarked to act as reception centres for the Roscommon people presenting in emergency situations? It is an absolute requirement that the Minister make a clear statement on this matter. In light of all the information now available, will he take the opportunity to reverse the decision on Roscommon hospital? I note the last sentence in the reply to one of my questions, on page 40, in regard to the hospital states, "There will also be on-site junior doctor cover at night, supervised by a consultant for the first four weeks, as a safety measure." If it is a safety measure, why would it be lifted after four weeks? Let us be under no illusion - GP out-of-hours cover will be provided on the grounds of the hospital, but it will not be part of the hospital configuration or its provision of services to the people of Roscommon.
I inquired about several hospitals in Question No. 38. Is it proposed eventually to turn Portlaoise hospital into a model two hospital? Has the report of the national acute medicine programme been adopted as Government policy? In regard to Navan hospital, assurances have been given on the retention of accident and emergency services for a projected period of months, but what will happen then? St. Columcille's Hospital in Loughlinstown is receiving less attention than some others, but its status is of great concern to people in Wicklow in particular. If the planned removal of accident and emergency services at Loughlinstown goes ahead, will additional capacity be provided at St. Vincent's Hospital to accommodate the displaced patients who would normally have been treated at Loughlinstown? In regard to Mallow and Bantry, does the Minister accept that the impending reconfiguration of pre-hospital emergency care in the HSE southern area will result in a major skills mix deficit due to changes in service delivery rosters? On the basis of the information now provided, Youghal will be left without any ambulance cover.
At Tuesday's meeting I referred to the provision of a primary care facility in Carlow town. When I indicated that the reason St. Dympna's complex was not utilised for the provision of primary care was the restrictions vis-à-vis public private partnerships, the Minister rejected my proposition and denied it was the case. I refer him to a parliamentary reply I received on 14 October 2010 which confirms the situation as I have set out. Will the Minister set the record straight? Despite this information, which I accurately quoted, he dismissed the core problem in regard to Carlow, which sees us paying out €365,000 per year - €1,000 per day - on the rental of private property despite the availability of an on-site HSE-owned premises in the town which would function adequately as a primary care centre. In the context of wastage of public money, there must be a revisitation of this matter.
The Minister of State with responsibility for disability issues, Deputy Kathleen Lynch, stated on 17 June that independent inspections of homes for those with an intellectual disability will now take place and that the Health Information and Quality Authority would anchor that process. This followed on from the "Prime Time" exposé of 16 June. Has HIQA commenced its series of inspections of residential care units for people with an intellectual disability? Will the Minister provide us with a progress report in that regard?
I intended to ask a question on the fair deal scheme but, unfortunately, I am out of time.
I welcome the Minister, Deputy James Reilly, Mr. Cathal Magee and the accompanying officials. Following our questions to the Minister at Tuesday's meeting, Mr. Magee has dealt with the issue of funding in some detail. As I said on Tuesday, the reductions in funding, which amount to some €1 billion this year, are being presented as a fait accompli, as if there were no choice but to impose cuts to this extent. I reiterate that, in fact, there are choices. The choice made by this Government and by its predecessor is to exempt very wealthy people from taxation. The wealthiest 5% in this State have ownership of some €250 billion in assets but pay no wealth tax, unlike their counterparts in some European countries and in certain states in the United States. These people should be obliged to show some patriotism by funding, through a wealth tax, the various services, including the health service, which are now under threat. Unfortunately, the Government has chosen to exempt these people from additional contributions while reducing services to those requiring health care and to the poor and less well-off.
The reconfiguration of hospital services has given rise to frustration and anger throughout the State. The HSE policy of centralisation and specialisation is not appropriate for this country. It may well be relevant in densely populated urban areas in other countries, such as London, Manchester and other large cities, but it is entirely inappropriate to Ireland. It has been suggested that smaller hospitals are less safe and provide less value for money. On the contrary, a considerable body of independent, professional, international study proves that smaller hospitals offer a better quality of care, provide better access for patients and families and do so on a more cost-effective basis. In the case of Roscommon, it will take one hour and 21 minutes to bring patients to Galway, one hour and 18 minutes to Sligo, one hour and 30 minutes to Castlebar, one hour and 12 minutes to Mullingar, 57 minutes to Tullamore and 44 minutes to Ballinasloe. Moreover, these are door-to-door times and do not take account of the time required to pick up and deliver patients.
I share Deputy Caoimhghín Ó Caoláin's concerns regarding the misrepresentation of statistics on death rates at Roscommon hospital as compared with Galway. If there are deficiencies in particular locations, there is always the option to improve services to bring them into line with the required standards.
I wish to comment on the position regarding mental health services in the south east, particularly those in south Tipperary. The HSE is proposing to close inpatient psychiatric beds at South Tipperary General Hospital. This proposal is, of course, at variance with the policy under A Vision for Change. When does Mr. Magee intend to implement the recommendations of the Hillery report, specifically those which relate to the appointment of an independent facilitator? The report was published some time ago and in it Dr. John Hillery was scathing of management. However, we are still awaiting the nomination and appointment of an independent facilitator. Will Mr. Magee confirm when it is intended to publish the Shanker report which deals with the same area? A commitment was given to public representatives and Oireachtas Members in March that this report would be published within a month but it has still not seen the light of day. I request that the CEO, Mr. Magee, provides a definitive statement with regard to when the report will be published.
Will Mr. Magee also provide details on the type of consultation in which the HSE engages in respect of services? I raise this matter as a result of a particular proposal that was made overnight, and in the absence of consultation, in respect of the closure of the acute psychiatric unit at South Tipperary General Hospital. In the past ten days, HSE officials visited a high-support hostel at Mount Sion in Tipperary town and informed the staff and patients that the facility is to close before the end of the year. Will Mr. Magee confirm the current position in respect of this matter? Will he clarify that a decision to close the hostel has not yet been taken and that there will be full and proper consultation before any such decision is made?
There have been reports in the media of late in respect of the fair deal scheme. This is a matter with which most members would have been dealing on an ongoing basis for their constituents. What is the current position regarding the fair deal scheme? What funding is available to the HSE to allow it to implement the scheme? Will any funding that is available last for the remainder of the year? How many people will require funding under the scheme during the coming period?
I am seeking details in respect of the promised abolition of the HSE. The executive's abolition is a development which many of us would welcome. I opposed its establishment on the basis that it is unaccountable and that it excludes input from ordinary citizens, local public representatives and Oireachtas Members. I am of the view that the abolition of the HSE should be dealt with as a matter of urgency.
That concludes the statements from the spokespersons of the various parties and the Technical Group. As stated earlier, 39 questions were submitted in advance by members and we are now going to take contributions from those members who received replies. I will take contributions from members in groups of three. In the first group will be Deputies Keating, Naughten and Maloney.
If the Chairman proceeds in that way, the Minister and the officials will be obliged to provide a massive number of replies at the conclusion of the meeting. Would it be possible for the Minister and the CEO to respond to the points raised in the opening statements of Opposition spokespersons?
If that it what members desire, it is fine with me.
It might be of assistance to those members who submitted questions in advance and who wish to pose supplementaries.
I am just conscious of that this meeting has been running since 11 a.m. and that some members have not yet had an opportunity to contribute. If it is acceptable to Mr. Magee and the Minister, I would be happy for them to respond to some of the questions posed by Deputies Kelleher, Ó Caoláin and Healy. Perhaps the Minister will begin.
That is no problem. Deputy Kelleher referred to local discussions. I do not believe there was too much discussion regarding Monaghan hospital when the Government led by his party closed it. We are not closing down any hospitals. There is no question, however, that some services have been obliged to change. The Deputy's assertion that a massive reduction in the number of small hospitals is planned is not correct. The future of small hospitals is secure. The type of work they do will be different, it will be safe and an expanded range of services will be on offer.
I acknowledge that a commitment was given which I was not able to keep. Not keeping a commitment is far different than breaking promises. I refer to the numerous promises the Government led by the Deputy's party broke. Our predecessors in government did not just break their promises, they also broke the country. That is why we are in the current financial mess.
Deputy Kelleher referred to the discussions taking place in the Department regarding the future of the HSE. Those discussions are ongoing between me, the Department and the HSE. The Deputy also made an assertion in respect of management. I accept that problems exist and that there are major gaps in the context of management. That is a matter which must be addressed and I am sure Mr. Magee will see that this happens.
We face a major challenge, namely, continuing to deliver services and care while instituting the changes that are so necessary. It is clear that throwing a great deal of money at the health service has not resulted in its being fixed. In such circumstances we must try something different and that is what the Government intends to do. Our policy relates to reform and changing processes. With me is Dr. Barry White, national director for clinical strategy and programmes, and he will address some of the issues raised in this regard.
The Deputy is confused with regard to primary care units. We have primary care teams and centres but I am not quite sure what he means when he refers to primary care units. There are over 300 primary care teams and it is generally accepted that approximately one third of these are functioning in the way they should, one third are in the process of getting to that position and the remaining third are only commencing operations. We will continue to try to make progress in respect of primary care. Given that it is such an important aspect of how we believe health services should be delivered in future, this is a priority for us. This is the first Government to appoint a Minister of State with specific responsibility for primary care.
Deputy Kelleher also referred to the review of the fair deal scheme. I certainly stated that I would be reviewing the scheme but I never stated that I would publish the results of any review. Our examination of some of the confusion surrounding the funding arrangements continues. It is important to state, however, that there is no question of any misappropriation of funds. All the money was spent on care of the elderly but it is the manner in which it was spent, the sources from which it was taken and issues relating to what the Department intended and what actually happened that are being examined. There are several different reporting systems within the HSE in respect of finance and these must be streamlined. The existing system makes following what occurred more difficult. However, I am sure Mr. Woods will address that matter.
The review relating to the transplant transport situation is extremely serious. HIQA is currently in the middle of that review and it should supply the Department with a report two weeks from now.
Deputy Kelleher also referred to non-consultant hospital doctors, NCHDs, and the career path relating to them. I accept he was not present but I dealt with this matter at the meeting of the select committee two days ago. The issue in this regard is very clear. This is not just a case of setting down a clear career path: we are also concerned with the way in which people are treated by those who are senior to them. As stated previously, we will be putting in place, through the special delivery unit, SDU, a protocol relating to behaviour towards one's peers, one's juniors and one's patients. That protocol will be a first and it is long overdue. We are also establishing a patient safety authority to cater for the needs of people who feel they may not have been well treated. A great deal of work has been done in respect of that matter.
I will now deal with the issues raised by Deputy Ó Caoláin. We will defend services but we want them to be safe. In respect of smaller hospitals, there has been too much discussion about what has left them and not enough attention on what should go into them. We have had meetings with doctors and we are considering a basket of 24 different procedures and conditions that can be treated in smaller hospitals. The focus on the potential in this area has not been sufficient across the system. I have in the past been critical of the failure to transpose islands of excellence across the system. That is not unique to Ireland. A report published in 2006 highlighted the same issues in respect of the NHS. That is a challenge we intend to meet because smaller hospitals in some areas have already shown the way forward and others are developing new ways of doing business or extending surgical procedures. The team in Mallow, to which Deputy Ó Caoláin referred, is examining ways of expanding day surgery to 23.5 hour surgery, as well as the range of conditions that can be treated in the smaller hospital. That is a model I support and it can be transposed across the system.
The Deputy also referred to Loughlinstown. I will ask Dr. White and Dr. Geary to address the issues that arise in regard to additional services. It takes an ambulance seven minutes to travel from Loughlinstown to St. Vincent's hospital. The service will be much improved and safer, and it will allow Loughlinstown to focus on a myriad of other conditions and procedures.
In regard to Navan, the emergency department is secure for the next six months to one year, at least. There is not enough capacity at Our Lady of Lourdes or Blanchardstown to allow any changes at Navan while maintaining safety. That is not to say we will not continue our efforts to make the situation safer and there may be further rationalisation in the future.
Mallow and Bantry are two very different hospitals. Bantry is geographically isolated, with 60 miles of landmass to the sea beyond it. Clearly, a different approach will be required in respect of it. As I already noted, Mallow is investigating alternative ways of doing surgery and expanding the services it provides. Discussions are ongoing with staff and doctors, within the hospital and outside it, and it would not be helpful to interfere with the process at this point.
I will ask the HSE to respond to the Deputy's contention that Youghal does not have an ambulance. He also asked about Carlow and the response I gave to a recent parliamentary question in respect of public private partnerships.
Do not forget Roscommon.
I will speak about Roscommon in detail because everybody is interested in that issue.
That is right.
In respect of Carlow, I ask the Deputy to study the Official Report for my exact response and the replies to parliamentary questions he put to the previous Government. I will revert to the issue.
I will refer the question on disability and the independent HIQA inspection to the Minister of State, Deputy Kathleen Lynch, and ask her to respond to the Deputy in writing.
I will deal with Deputy Healy's questions before speaking on the issue of Roscommon. The Deputy asked about wealth taxes and suggested that a considerable amount of money can be collected. This Government is committed to a fair taxation system. The marginal tax rates have increased and we will widen the tax base but nobody believes there is a pot of gold to be found.
The Deputy stated that the reconfiguration planned for our hospitals is not appropriate to a small country. There is certainly a need for reorganisation and buckets of evidence support the claim that high volume hospitals have better outcomes for particular types of procedures. There is a basket of at least 24 different procedures that can be carried out in smaller hospitals and I might speak further about them later.
It is not true that the automatic response from this Government is to close hospitals down as soon as HIQA reports that they are unsafe. We will seek to make the facility in question safe but in certain situations the low volume of patients treated means it is not possible to do so.
In regard to mortality statistics in Roscommon, I was clear about this issue when I spoke about it in the Dáil. HIQA made its recommendations on the emergency department at Roscommon long before the aforementioned statistics were available. They became available only in recent weeks after being compiled by the chief medical officer and deputy chief medical officer at the Department of Health. As further questions may be raised in this regard, I will perhaps ask the deputy chief medical officer, Dr. Jennifer Martin, to comment later. I made it clear that I was referring to acute myocardial infarction, or heart attacks, rather than overall mortality rates when I compared the mortality rate of 5.8% in Galway to the 21.3% in Roscommon between 2008 and 2010. I stand over these figures, as does my Department, and they will stand up to scrutiny because they were supplied through the hospital inpatient enquiry, HIPE, data mix by the hospitals. There may be variables in terms of double or triple checking but it was not the basis for the decision to close the emergency department at Roscommon.
The Minister used the statistics as a significant crutch.
I described them as significant information that would support the decision but I did not suggest it was the basis on which it was made.
An examination of the issue contradicts the Minister's claims.
Deputy Ó Caoláin had his chance and other members are waiting to contribute.
I stand over my Department's figures. We seek to make safe all hospitals. We have not closed any hospital and we do not intend doing so. Different services will be taken from certain hospitals and new services will begin in them. That is a two-way street which will also apply to bigger hospitals. People are right to be concerned that bigger hospitals have been slow to allow procedures to be relocated but that will change. Work will move, where appropriate, from bigger hospitals to free them to do complex surgery and tertiary care. It is akin to sending a ten year old Volkswagen to the Ferrari testing centre for a service when the job done by the local garage is just as good. The Government will certainly not take this approach at a time when we are facing dire economic constraints. We seek to provide our people with the best and safest service possible.
Deputies Healy and Kelleher asked about the fair deal scheme. Funding is available to cover 24,000 people this year and the scheme is open. We cleared 1,200 applications one month ago and have approved a further 1,200 since then. I hope that reassures those who are in need of long-term care. I want a greater emphasis to be put on home help and home care to keep people at home for as long as possible. Regardless of how nice an institution may be or how good the care it provides, people prefer the sense of autonomy and empowerment they get by remaining in their own homes. We have provided an additional €8 million in funding for home help hours.
Deputies Ó Caoláin, Kelleher and Healy asked questions about Roscommon. The issue at Roscommon hospital is very-----
Will either the Minister or the HSE representatives revert to the questions regarding mental health services?
Sorry, yes I will allow the HSE's representatives to come in later. Is that alright? I will deal with the Roscommon issue and I am sure other members also will have questions to ask, which may inform the questions and comment thereon. The situation at Roscommon came to a head very quickly because of the shortage of non-consultant hospital doctors, NCHDs, and HIQA's concerns regarding safety. HIQA was not for moving and it is the regulator and it is independent. I have made this comment previously but when one starts to interfere with regulators, one ends up in real trouble and I have no intention of interfering with the regulator. The regulator is not present today specifically because it would not be appropriate for a regulator to be present today. If this joint committee wishes to talk to the regulator, I suggest members invite it to appear separately. HIQA is concerned with safety and is backed up by international research. It is backed up by an international organisation of which it is a member and I recently met one of its board members from Canada.
Equally, the clinical teams and the clinical leads within the HSE, who are clinicians, backed up what HIQA said. We had a great deal of discussion on how it might be possible to keep the emergency department as it was. I was told repeatedly in no uncertain terms that it was not safe and that it would not be safe to give people the idea that this was a possible destination even if one put in place protocols to allow an ambulance to pass by or even if general practitioners knew not to send people there. Unless one made it clear this was not an emergency department, people would roll up there with chest pains or multiple trauma in the belief they would get a service the hospital was not capable of delivering. This is no reflection on the doctors in the hospital who are excellent workers and people, as are the nursing staff. It simply is that the facilities are not there. One could ask whether it is possible to put in such facilities or, had we all the money in the world, why not do so. Within a short period, that is, a year to 18 months, those doctors would become deskilled because they would not experience the necessary throughput to maintain their skill set. Unfortunately, that is the position vis-à-vis the emergency department.
However, that emergency department is only a small part of the hospital and the rest of the hospital has a bright future. Much work can come to it as many people in County Roscommon travel outside the county at present for procedures and they can be brought back. Much work should be sent back from Galway and there is much work that, with co-operation with Portiuncula Hospital, could be attracted back to both sites. There is a huge amount of different types of services that could be carried out specifically at Roscommon hospital. I look forward to achieving this in negotiations, discussions and consultation with the doctors at the hospital, as well as the general practitioners in the area, and ensuring this happens.
I had a meeting yesterday with some of the hospital doctors and am glad to note they are very much interested and on board to see the theatres there upgraded and to have much greater activity in that hospital. As this is a political setting, I make the point that for years, the previous Government invested very little into Roscommon hospital. I intend to invest in it in a safe way to provide services-----
That is not true actually.
Sorry, Senator Leyden, you are not allowed to-----
That is dead lies.
The Senator will have his opportunity.
We built a new accident and emergency unit.
The Minister, without interruption please.
If one builds a new shop-front without putting in anything behind, one is merely building a shop-front or facade. The Government will invest in it and real changes will be evident, as will much greater activity.
While I will address questions on Louth County Hospital later, I make the point that the amount currently being invested in Louth County Hospital, when compared with investment before the opening of the minor injuries unit and the closure of the emergency department is astronomically greater. There is no question of the future of Roscommon hospital being uncertain. There have been contentious questions as to what will happen if we take away the emergency department and tell everyone it is unsafe. I do not suggest that hospital is unsafe and never did. I stated that having the emergency department there was unsafe. The remainder of that hospital is a fine hospital that needs to be upgraded. It needs and will receive investment and will perform a broad range of work.
However, the Deputy is correct. Were a closure and a change in an emergency department to take place and were numbers to fall and were matters left like that, obviously after three or four months someone would suggest there was no point in keeping open that hospital because no one was going into it. I do not intend to let this happen, which is the reason the Government will expedite the changes that must be made. As I stated, I had a good meeting yesterday with the doctors in the hospital and I intend to progress that as a priority. Members will see the changes ringing in over the next 12 to 18 months. That will be there for people to judge and they will be in a position to state whether the pudding is real or imaginary. I will stand over that. I believe that has answered most of the questions and I am sure there are many others.
The Minister missed a question on the provision of additional bed capacity at hospitals to receive the displaced patients that normally would have been catered to at Roscommon County Hospital.
Sorry about that. While I do not know the position at all the hospitals, I am familiar with the situation at University Hospital Galway, to which two patients were transferred last week. This is the normal volume to go out of Roscommon and consequently, there is no real change in this. As for whether they will be prioritised, because they will come by ambulance and will be triaged on the way in, they will get priority because they are sicker people. That is a reality and I hope this answers the Deputy's question.
It does not do so at all.
The Deputy will have an opportunity at the end of the meeting to come back in again. I invite Mr. Magee to comment.
Mr. Cathal Magee
In the interests of time, I will not cover the territory covered by the Minister. On the issue of competence of managers, I make the point that the reasons for budget overruns are complex and multifactorial. Moreover, they vary from individual hospital to individual hospital. There are legacy issues in some hospitals which in recent years have not been meeting their existing budget plans. There are problems with systems and overall, the financial capabilities and skills in many such hospitals may be less than required. In the annual report the HSE published for 2010, I made a general comment that the necessary infrastructure in respect of structure, information, enterprise systems, management capabilities and processes is not in place within the health system to meet the effective integration and leadership of such a large and complex system. Hospitals are no different in that they can employ up to 2,000 to 3,000 people, can have budgets of approximately €300 million and can have capital investment of perhaps €50 million to €70 million. Such large systems need very well invested executive leadership teams at financial, chief executive and operations levels. There has been under-development and an under-investment in management capability, particularly across the statutory acute system. It is more developed in the voluntary hospitals.
This is not a criticism of the existing people in the system because they do what they can, sometimes with extremely limited infrastructure and poor support. Moreover, they are at levels which perhaps understate the requirement for leadership in such major complex acute environments. In any comparable acute environment, one would have management teams with all the necessary skills in place. There is a strategic issue to be addressed that I have raised with the Minister and the Department of Finance. If we intend to drive value for money in our health system and if it is to be reformed, it will need a major injection of management, financial and information technology capabilities right across the system. This does not exist. However, I point out this is not necessarily a reflection of the people who are doing what they can, often in extremely difficult circumstances and the position in particular hospitals can vary significantly.
On the two issues that were raised by Deputies Ó Caoláin and Healy in respect of Carlow and Youghal, respectively, I ask my colleague, Mr. Brian Gilroy, to make a few comments.
Mr. Brian Gilroy
In the case of Carlow, as the entire premise of the primary care centres involves collocation with general practitioners, in many cases utilising our own premises would not achieve that. The development in Carlow, in line with many developments elsewhere, would see us achieving that and the strategy includes the disposal of vacated premises. That is the intention in Carlow but some of the vacated premises will be put to other uses rather than being disposed of.
The picture is broader in Youghal. In the former Southern Health Board area, a significant proportion of out-of-hours services were provided on an on-call basis. At 2 a.m. across many locations in the south, somebody would have to get out of bed to drive the ambulance. For the past several years we have been working on that issue in conjunction with staff representative bodies and the matter culminated in a ruling from the Labour Court to the effect that we can no longer depend on on-call services. We believe the solution that is now in place is safer because, instead of providing a total of six or eight stations which are unmanned out of normal hours, four vehicles are manned and ready to go at any hour of the day or night. This permits active deployments and while the teams are spread across a wider area their availability is guaranteed. When a team is called there is an active deployment from one of the other teams to cover the gap.
Irrespective of one's views about the service, the cover that formerly existed in Youghal is no longer available. The citizens in that urban area and its wider hinterland are now dependent on a more distant call centre to provide for their ambulance needs.
When I first raised the issue of Carlow with the Minister, I asked him to revisit the requirement to adhere to PPP arrangements for the roll-out of primary care centres. I will make that call again in light of Mr. Gilroy's clarification. It was not a trick question and I am happy to share with the Minister the reply I received last October.
Mr. Brian Gilroy
We are not required to adhere to the PPP approach but it is a requirement that services are co-located with GPs. In some cases we can meet that obligation within our own centres. In many locations, however, GPs do not find it attractive or do not wish to be based in our premises and this is where many of the solutions come into play.
The reply I received stated that it was based on agreed Government policy to develop primary care centres through public private partnerships.
I ask Deputy Ó Caoláin to revisit that issue at a later stage because I want to be fair to other members.
He is referring to the policies set out by the previous Government.
The reply came from the HSE, which has not changed. It is only the face of the Minister that has changed.
In case Deputy Ó Caoláin did not notice, the Government has changed.
The Minister is right, I have not noticed.
Mr. Cathal Magee
I will ask my colleague, Ms Laverne McGuinness, to respond to Deputy Healy in regard to psychiatric services.
Ms Laverne McGuinness
With regard to psychiatric services in south Tipperary, A Vision for Change indicates that we have too many inpatient beds and we have to reduce this number as part of our strategy of promoting a recovery model that is more focused on the community and ensuring that people have a better quality of life. We set out these objectives in our service plan for 2011 and we specifically mentioned a number of facilities which would close, including the acute unit in south Tipperary and St. Senan's hospital. Infrastructural issues have also arisen in a number of buildings because they date back to the 1800s and are no longer suitable for inpatient treatment. We have undertaken to construct a high support hostel and a continuing care centre to facilitate residents, as well as a day hospital, and this is set out in our service plan and capital development programme.
We are trying to allow people to remain at home through the deployment of 124 community mental health teams which can facilitate patients in attending day services as required. Deputy Healy asked about two specific reports and, if he does not mind, I will respond directly to his questions on the publication of the reports by tomorrow, when I have had an opportunity to investigate the matter.
Has Mr. Magee any other comments to make?
I ask Mr. Magee to deal with the question on whether the current funding for the fair deal scheme is sufficient for the remainder of the year. In regard to mental health services, A Vision for Change calls for two 25-bed units in the south east, in Kilkenny and Clonmel, respectively. I am disappointed that a reply is not forthcoming on the two reports given that they have been outstanding for quite some time. We have been given commitments in the past which have not been met and I hope Ms McGuinness will respond to me tomorrow.
Ms Laverne McGuinness
In regard to the fair deal scheme, members will be aware of the difficulties that arose. We have been assessing the level of funding for the scheme and, with effect from 13 May, we paused the processing of further applications to final stage. They have now been reopened, however. We projected a deficit of €36 million if the rate at which applications were being received continued but we have since received a commitment for additional funding from the Department of Health and we anticipate being able to provide the 24,000 places envisaged under the scheme. The issue is being monitored on a monthly basis and we will have funding for approximately 650 places per month between now and the end of the year. Of this figure, 400 are on a replacement basis and are filled as patients die.
Is the HSE satisfied that it will have sufficient funding to operate the scheme until the end of the year?
Ms Laverne McGuinness
We will control the level of funding on a month by month basis. We will provide the service we have for the amount of funding available.
Members of the committee submitted 39 questions and I will take contributions in groups of three, beginning with Deputies Keating, Naughten and Maloney.
I commend the Minister on the significant savings he announced this week in the cost of prescribing and dispensing drugs.
I ask the Minister and Mr. Magee to comment on the decision to impose a full staff embargo because of over-runs. How will this impact on the plans to develop primary care?
Alongside public health nurses, general practitioners, home help services and care assistants, the allied health professionals in the areas of speech therapy, occupational therapy, physiotherapy and community social work - I refer to generic social services, such as bereavement support, trauma, terminal illness and welfare, rather than the specific area of child protection - comprise the primary care programme staff envisaged by the Minister in his plans for radical change in the health service. Does he see merit in moving these professionals from hospitals to the community?
Does Mr. Magee believe the five personnel employed in the Park House unit to answer parliamentary questions are adequate given that the unit administered more than 5,000 questions last year? In order to make this Parliament more efficient, will he investigate this issue and will he comment on it?
I agree with the Minister that we have to make difficult choices. This committee should not forget the appalling legacy we inherited but we are here because we passionately believe in the services we provide. We have a broken economy but we are more than that. We are a people. We are a community of families and I and other members are here to address the situation.
I remind members that we are dealing with members' questions which have been submitted in advance to which we have received written replies. Members' supplementary questions should seek clarification.
I welcome the Minister, Mr. Magee and the officials and thank them for facilitating the invitation I sent on behalf of the committee to come before us today.
I wish to speak to question 13 on page 14 and will not refer to my other two questions. My question concerns small hospitals. As the committee will know I am the first representative from my constituency to speak about Roscommon hospital. I have a number of specific questions and I will ask them quickly.
We have been told about planning in regard to the downgrading of services in small hospitals for a long time. It amazes me that we do not have the medical evidence to support it. The evidence that has been provided on the golden hour is dismal. Any evidence I have seen is very non-committal. Can the Minister clarify that the decision made on Roscommon hospital was purely an issue of safety and not cost savings? Will he commit to carrying out an independent evaluation of the evidence?
I am glad to see Ms Geary is here. She might answer a specific question. The College of Emergency Medicine, which is the regulatory body for the UK and Ireland on emergency medical care, has highlighted the association between distance and risk. Its recent report states: "There is a balance between having large numbers of patients travelling long distances with increased risks and with a small number of finite risks in relation to a small number of patients." It is about to produce a report on isolated rural communities. We should have waited to deal with that report. The college has said that timely access is more important than getting to a specialist centre in the vast majority of cases.
Mr. Magee spoke about safety in small hospitals. Services have been removed from Roscommon on the basis of the HIQA requirements. In a reply to a parliamentary question I received yesterday no one can assure me that the replacement service meets with its requirements. I refer to the ambulance service. On Tuesday of this week Roscommon had no ambulances for four hours. The safety arguments are based on transferring patients to a category 4 hospital for heart attacks and strokes.
The Minister said last week two patients were transferred to Galway University Hospital. Where did the rest go? Last year 428 patients were admitted to the CCU at Roscommon hospital. The Minister said on top of that one patient a day was transferred to Galway University Hospital. That means 12 patients last week should have gone to Galway but did not. The reason for it is that they are being transferred to category 3 hospitals because the capacity is not available in Galway. The clinicians locally are saying that privately but are afraid to say it publicly.
I acknowledge the Minister is committed to putting additional diagnostics and screening investment in Roscommon. That capital investment is very welcome. Limerick Regional Hospital is currently over budget by 26%. Part of that can be attributed to the reconfiguration process based on public comments by medics there. HSE west is currently €94 million over budget. Where will we get the funding to provide the resources to pay for staffing and capital investment? It still leaves Roscommon without a 24-hour accident and emergency service.
The Minister is right. Bantry hospital is unique. There is 60 miles of land mass beyond it. The distance from the door of Bantry hospital to the door of Cork University Hospital is the same as that from Roscommon hospital to Galway University Hospital. The only difference is the people of Cork do not have to deal with traffic congestion which the people of Roscommon do.
I will be very specific in the hope that my colleagues will also have some time. I have two questions on the busiest hospital in the country, Tallaght. If the Minister does not have an answer now I am quite prepared for him to e-mail me. I will allow other people time to speak.
I understand Tallaght hospital got notice of its annual budget in May, yet the budget year runs from 1 January to 31 December. There may be a plausible explanation for that. It would create problems if a hospital did not have notice of the amount of money it had in its budget for the year. It should have notice prior to the beginning of the financial year.
As I stated, Tallaght is the busiest hospital, with the busiest accident and emergency department in the country. Last year in excess of 90,000 patients were treated there. The HSE recently introduced the concept of integrated service areas, ISAs. Tallaght hospital, which is 11 years old, had a catchment area in excess of 200,000 people. That has been increased to approximately 333,000 people. The busiest hospital in the country will become even busier. Is there an explanation for that? It is putting the hospital under great strain. We are lucky because it has great staff which are very professional.
I will deal with the points raised by Deputy Keating. Mr. Magee can also comment on them. There is not a full staff embargo, as far as I understand it. There is a moratorium and there is flexibility within it for key staff such as theatre nurses etc. As I understand it from the HSE, what has been issued is an instruction that even if a hospital is below its headcount and wants to employ someone it has to stay within its budget. The clause relates to budgets and will affect some hospitals more than others.
Deputy Keating also referred to social work therapists. I agree with him 100%. We need many more therapists such as physiotherapists, speech and language therapists and occupational therapists in the community. When we move the focus of operations on chronic illness care out into the community some staff will have to move out of hospitals. We need more staff. One legacy issue, without being overly political about it, has been the disconnect in previous policies.
Young men and women are studying hard to get 550 points in the leaving certificate to get into university and study for four years, but they graduate and there are no jobs in physiotherapy. There are no interim positions for them to allow them to get the additional experience which would allow them to work in the community. We and the Minister for Social Protection, Deputy Joan Burton, are considering an internship programme to allow us to solve this problem and help people move on to the next phase. These bright, hard-working people are currently working in McDonald's or have left the country which is a horrendous waste of talent and resources.
We will need more physiotherapists, speech and language therapists and intervention in the community. We need to move resources around and get the best value out of each one. It has been proved that if a physiotherapist screens all referrals to an orthopaedic surgeon 40% of cases can be dealt with by the physiotherapist and patients do not need to see a surgeon at all. It feeds back into the principle of treating the patient at the lowest level of complexity that saves time, is efficient and is as near to the home as possible.
On Deputy Naughten's question, the decision was based 100% on safety. If money could have fixed the problem it would have been fixed, but unfortunately it cannot. As I said earlier, the future of Roscommon hospital is a priority for me and the Government. I want it to be the exemplar of small hospitals to show what can be achieved. For the people who work there and do excellent work, there will be much more work coming their way. They will be much busier than they were previously. Even though there might have been a drop in people attending that hospital in the past week, we intend to make sure its footfall increases. I will give an example later of other hospitals that have achieved such an increase. One hospital has had a drop from 400 to 350 in attendance at its emergency department but the footfall in other parts of that hospital has increased immensely. A much wider range of services can be given to a much broader group of people. I have said previously that the NTPF will not adhere to the ideological stance that only 10% of its funding will go back into the public hospitals. That is not the case. People with a Roscommon address should be able to have their procedures performed and, if they are safe procedures, they can be performed in Roscommon County Hospital, and that is our intent. People from outside Roscommon may find that a very attractive place to go rather than the hustle and bustle and sometimes chaotic settings that are characteristic of the very large hospitals. That is where the future lies and it is a bright and safe one, and that must be a key consideration.
On Deputy Naughten's question on reviewing the evidence in this respect, I am perfectly happy to have that done. There might be difficulty in agreeing who is independent to do that, but I am certainly prepared to engage in a conversation with the Deputy to see what can be done around that. I must have faith in HIQA. It is the independent regulator and that puts us in the position we are in, unfortunately, from the point of view of the emergency department there. There still will be an active, vibrant hospital there in years to come and people can judge us not only on what I say here today but on what is proposed year on year in regard to timelines for what is to go into the hospital. I will leave it to Mr. Liam Woods to reply to the Deputy's question on the ambulance service.
I will ask Mr. Liam Woods, who is the finance lead in the HSE, to address the issue of Tallaght and the annual budget. The point raised seems valid but I am sure there is an explanation for this. I acknowledge that Tallaght is an extremely busy hospital and that the population for which it is caring has grown. I am glad that someone of the quality of Eilish Hardiman will be the new manager there from next month. That will give the hospital a new lease of life but I put on record that we must examine the unwieldy nature of the governance there. We have a bad history of hospitals coming together and governance arrangements not working. Beaumont struggled for a long time when Jervis Street and the Richmond came together, yet St. James's managed it in an excellent fashion. There are lessons to be learned, and it is about transposing those lessons. I have also laid down a marker that the governance of the new children's hospital must be got right before it starts to function, otherwise we will have all sorts of problems.
Mr. Cathal Magee
I wish to add to what the Minister said about the embargo. There is an employment control framework in place set by the Departments of Finance and Health on the numbers employed in the health system. We are well ahead of meeting requirements in terms of that framework. A this point we are almost 900 posts down on our employment control framework, but we have a pay cost spend which is way ahead of plan. We have made the decision to pause recruitment in areas where budgets are not being met and where we do not have the money to fund posts. We are making exceptions; in other words, it is not an absolute embargo. There are services where there will be a case for continued recruitment. In terms of some of the clinical and strategic programmes and the development programmes in our service plan, we will continue to recruit and to provide support. That applies to many areas, particularly therapists, including speech therapists, where there are gaps and shortages. Therefore, the embargo is not absolute, but we have had to slow down the level of recruitment at a point where the funding is not in place.
With pay budgets on a year on year basis where pay is contracting, the incremental cost, through increments etc., are not being funded. There is a gap between the number of posts we can have in the system and the available financial resources. We simply cannot continue to recruit. We will review it in September when we get a good sense of the pressure points.
On Deputy Keating's question on parliamentary questions, I acknowledge that there have been service problems and delays in replying to questions and in the quality of replies. That has come to my attention across the parliamentary system. We are examining the possibility of consolidating the process in terms of the Department and ourselves. We are putting in place an IT system to track much more effectively. There is a tightening of resources. We do not have an ability to put more resources into this, but we are conscious that major improvement is required and we are working on that.
I will ask Dr. Una Geary to reply to the two issues raised by Deputy Naughten.
Dr. Una Geary
I would like to address Deputy Naughten's question on the Way Ahead document from the College of Emergency Medicine. That college in the Way Ahead points out that the recommendations or statements it makes may not apply equally to Scotland, Wales and Ireland and the document defers to the statement on the organisation and configuration of services that was produced by the Irish College of Emergency Medicine. There is always a careful balance to be achieved between distance and risk. The Irish Association for Emergency Medicine, which represents consultants in emergency medicine here, believes that the most appropriate level of service that can be safely provided in smaller hospitals that do not have the infrastructure or service demand to support a 24 hours a day, seven day a week emergency department is a minor injury unit level of service, but that this must be provided in a network system of care such that patients who have higher acuity and higher complexity needs can receive the care they need in a timely fashion. This is about the integration of the networks of emergency care, involving larger emergency departments, services at smaller units and the ambulance service, as the Deputy pointed out.
On the Deputy's comment on the position of the College of Emergency Medicine on services for remote and rural hospitals, I have investigated this through the chair of the Irish board of the College of Emergency Medicine. The College for Emergency Medicine has undertaken regional structure in the past few years and it has boards in Ireland, Northern Ireland, Scotland, Wales and England. My understanding is that the issue of remote and rural services is only an agenda item on a standing committee at this time and that there is not a report imminent. I am afraid the information the Deputy may have been given may have been inaccurate in that regard. I have clarified that issue with the college.
It also then misled the board in Northern Ireland because it was reported to the Northern Ireland Assembly in February that this report was due.
Dr. Una Geary
I will feed that back to the president of the college in London.
In relation to the golden hour, this concept comes from battlefield triage and treatment whereby it is common sense to say the sooner the patients or people get appropriate treatment, the better their outcomes will be. The golden hour is in a way a shorthand for this. There is nothing magical about an hour. The basic concept is that the sooner one gets the correct level of treatment to meet one's need the better one's outcome is likely to be. It also has been applied in the case of trauma. The key issue is the best possible care that can be provided. Very often this care, particularly in trauma and high acuity medical conditions in the initial stages, is best provided by paramedic staff who work to structured clinical protocols, providing evidence-based care and treating the patients while they are being transported to the centres at which they can receive the high acuity care they need. There are balances to be achieved and not every patient needs to be moved to a large hospital.
The emergency medical programme I am involved with and leading is developing a model of care for emergency services based on allowing as much care as can be safely delivered to be delivered close to where patients live but putting systems in place with the ambulance service to make sure that those who need care of a more complex and acute level can move quickly to where they can get that care and that there are good governance structures in place to ensure the care we are providing is the best evidence based and high quality care that can be provided here.
Reference was made earlier to the lack of evidence and that the evidence is not strong in terms of the organisation of emergency services. A review undertaken in Scotland and a literature search we undertook in our programme agrees with that. There is a paucity of high quality research in emergency services internationally that can give clear direction on how to configure services locally. The papers that exist point to the risks involved in transposing research done in one health care system to another because there are always local considerations that must be considered. In terms of the advice our programme is developing, therefore, we will take the best of the research available but we are cognisant that local issues must be taken into consideration as well.
Does Dr. Geary intend to answer the question on the ambulance service and the travel times in Bantry General Hospital versus Roscommon County Hospital or will someone else answer it? We are supposed to have four ambulances based in Roscommon during the day. We had none last Tuesday, which is contrary to commitments we were given that we would have a proper service that would meet the Health Information and Quality Authority, HIQA, standards. I cannot understand how having a community without an ambulance for four hours meets any standard. Can someone answer my question in that regard?
Mr. Brian Gilroy
I am not aware of the incident on Tuesday to which the Deputy referred but I will investigate it and get back to the Deputy with a report on it. However, huge additional resources have gone into the ambulance service in Roscommon. It comes back to the Deputy's earlier question on whether this is a cost saving measure. It is not. We are spending an additional €200,000 a month on the ambulance service in Roscommon alone but I will revert to the Deputy on the Tuesday incident of which I am not aware.
It is important that if Mr. Gilroy reverts to Deputy Naughten with a reply he reverts to all members of the committee in that regard. It is important that he answers the specific question asked by Deputy Naughten.
Could Dr. Geary acknowledge that there is a problem with capacity at Galway University Hospital and that is the reason the 12 patients have disappeared?
Dr. Una Geary
I am not sure what the Deputy is referring to in terms of patients disappearing.
On average last year one patient a day was admitted to the coronary care unit at Roscommon County Hospital. In addition to that, on average last year one patient a day transferred to Galway University Hospital. As the Minister said in his contribution, two patients were transferred last week from Roscommon County Hospital to Galway University Hospital. The other 12 patients have gone to category 3 hospitals which was the category of Roscommon County Hospital until now. The clinicians in Galway University Hospital are saying privately that the reason they have gone to category 3 hospitals is because they cannot cope with the additional admissions through its accident and emergency department.
Dr. Jennifer Martin
On that, from the outset it was never thought that all the patients would go to Galway University Hospital because where people are living in Roscommon-----
That was the argument that was made.
Dr. Jennifer Martin
-----there were five potential hospitals to which the patients would travel. We have been monitoring that over the course of the week from 11 to 15 July.
In terms of the numbers, 11 patients went to Portiuncula Hospital by ambulance. Six went to the Midlands Regional Hospital in Mullingar, four went to Mayo General Hospital, two went to Galway University Hospital, as the Minister rightly said, and three went to Sligo General Hospital. That is the satellite to which patients are travelling, depending on where they live in Roscommon.
That is not-----
Sorry, Deputy Ó Caoláin, you had an opportunity to speak. You can contribute again later.
Mr. Cathal Magee
A question was asked on Limerick Regional Hospital and on Tallaght hospital that I will ask Mr. Woods to answer.
Mr. Liam Woods
On the question of the timing of issue of budgets to teaching hospitals, and Tallaght hospital specifically, the budgets issued prior to the end of 2010 for the year 2011. I can follow it up for the Deputy but I am not sure what the point is around May but we issue budgets prior to the year end. Understanding the point the Deputy is making it is important people have sight of that as soon as possible. As soon as the budget is through and the Estimate is cleared in the Oireachtas we look to issue budgets.
On the separate point regarding resources raised by Deputy Naughten, based on the timescales indicated by the Minister in terms of additional resources I would anticipate that would be a matter of separate provision in a future Estimate, be it revenue or capital. It is correct that there is a significant financial challenge in the west, as there is nationally. The up to date figure for the west is €44 million in our May report, which is on our website, and a large part of that is an issue within Limerick hospital but there is not a direct connection. If there is specific provision of resources in the Estimate at the end of this year for next year that will be directed where it is intended to go. We have a major challenge in terms of the finances but that has been discussed in great detail.
I will call Deputy Colreavy, Senator Crown and Deputy Dowds in that order. I ask members to be brief and concise.
As always, Chairman, I shall attempt to do that. In case I am subsequently accused of a conflict of interest I should point out that the chief executive officer and I started our careers together in the health services.
You both did well.
I said to myself then, and to others, that that young man would go far. Mr. Magee is very welcome and it is good to see him.
He said you should be concise in the questions you submit.
In terms of setting the context, sometimes we are accused of being confrontational or political in the questions we ask but I would say the three most feared words are health services reform, about which there is widespread public concern. It may be a legacy of the previous Administration but people believed that health services reform would improve primary and continuing care services, therefore, hospital bed numbers could be reduced. The public saw hospital bed numbers being reduced but there was not an increase in the primary and continuing care services. There is deep distrust of Government and of the Health Service Executive among the public and our job is to make sure that public concerns are expressed to Government and to the HSE. We must also act as guardians to ensure this Government does not do what the previous Government did, namely, con the people. That is the context within which I speak.
I welcome Mr. Magee's expression of intention to improve IT services because I am aware from working in acute hospitals that an efficient service in 2011 cannot be run with 18th century record keeping systems. It is the case in many hospitals that the basic core system is a hand written system which is unsafe, costly and should have no place in the 21st century.
On the specific questions-----
Thank you.
-----I got an answer to my question on breast cancer services, orthopaedic inpatient services, diabetic and stroke services in Sligo General Hospital. I understand the answer that has been given on the breast cancer services but before the election this Government promised that the services would be restored. It now says that because of a number of factors, primarily potential patient throughput, the service would be better run in Galway University Hospital. I asked questions in the Dáil to which I did not get an answer - perhaps I will get it here - about private hospitals that run cancer services. Do they require the same level of patient throughput as the public hospitals or is there a different set of HIQA rules, or do HIQA rules apply at all to the private hospitals? Also, could I have an answer on the orthopaedic inpatient services and the diabetic and stroke services at Sligo General Hospital because they were not included in the reply?
Regarding the second question I asked, perhaps I am not good at reading between the lines but could somebody tell me if the capital funding is ring-fenced for the proposed new primary care centre in Ballinamore because that is not clear in the reply? As for the primary care facility for Manorhamilton, County Leitrim, is securing appropriate accommodation the only factor delaying its development? Is funding ring-fenced for it?
I understand I have two minutes.
About that.
Members should then put on their seat belts for two minutes. I welcome the Minister, who brings an unprecedented breadth of experience, not alone of working in the health service but of working in anything when compared with his three predecessors, who had an aggregate of four years in the workforce before they became full-time politicians. I also note the large size of the Minister's delegation, which by my arithmetic is larger than the number of paediatric surgeons in the country at present. While I mean no disrespect to his officials, the Minister must lead. These people are managers and cannot lead and consequently, the Minister must provide the leadership and vision. Historically, the health service in Ireland has lacked leadership because there has been a dysfunctional interaction at the core of its leadership between technically inexpert and inexperienced Ministers and officials, whose principal skill set in getting to where they got was, in many albeit not all cases, their ability to negotiate a bureaucracy. Someone with firm vision is now needed and I believe the Minister has it.
While it is not simply due to the sins of the previous Government but to those of many previous Administrations, the health service the Minister has inherited is a qualified failure. It is neither a Third World system nor a desperate system; it is just mediocre. It is poor by European standards and probably is the worst health system of any modern OECD country. Its central problems are that it is unequal - members understand this and have no need to talk about it - it is highly inefficient and is of poor quality. As for the metrics of this poor quality, I am disappointed that none of the officials has addressed this point. While they talked about changes in processes, information technology and so on, the great big mote in the eye, as opposed to the little splinter comprising the IT system, is that by western terms, Ireland has an unprecedented and unparalleled shortage of senior professional staff both in general practice and more acutely in the hospital setting. Although I will not go into all the numbers, in general we are typically under-provided per head of population in absolute terms when compared with Northern Ireland, a jurisdiction with one third of our population and which, as part of Her Majesty's national health system, already is part of the second worst and most under-provided health system by international comparisons. Consequently, this State has unparalleled and unprecedented waiting times. I am sure the NHS managers wake up every morning and thank the good Lord God for Ireland because if it was not for its health service, they would be on the bottom of every list.
As a result of these dysfunctions and pathologies, Ireland has a strange system that several weeks ago necessitated a sitting of the Seanad. The Members of that House which, contrary to the private referendum I believe the press already has held, has not yet been abolished, debated at some length on a Friday the need for a change in the manner in which young doctors are hired and assessed in order to be in a position to keep the hospitals open on the following Monday. In this process, doctors are plundered from India and Pakistan, two countries with the lowest ratio of doctors per head of population of any country in the world. This is not a new problem and I refer to the really troubling case reported yesterday of a doctor who was recruited according to the old recruitment structures to be an non-consultant hospital doctor, NCHD, which showed that someone who clearly had greatly deficient clinical training experience and competence managed to get through the system. There are major holes in the net and the Minister must plug them.
I must add that the Minister and I have been inadvertently, slightly, gently, politely and respectfully engaged in megaphone diplomacy with each other about Roscommon hospital in the past week or two. I make the point I am not an instinctive "save our hospital" type. I believe major rationalisations in the network of hospital systems must be made both in the country hospitals and in Dublin, where I believe big hospital and big medical school politics, certainly in the area of cancer planning, have thwarted the development of rational systems and instead have bequeathed the wholly irrational structures that are coming out of the national cancer control programme. It is difficult for me to believe the timing of what happened in Roscommon hospital was not in some sense influenced by the emergency staffing levels that were arising in respect of the NCHD crisis. While the Minister and I are both aware of this point, other colleagues should realise it is wholly wrong to depend in any sense on the labours of apprentice doctors to do the job that should be done by fully trained specialists. Were anyone in this room to drop something down the drain, he or she would call a trained plumber. However, were children of anyone in this room to become acutely ill, it would be quite likely he or she would be dealt with by someone who still was learning his or her skill in a specialty in hospital.
Three things must be done to reform the system, namely, it must be socialised, democratised and debureaucratised. I believe the measures the Minister proposes to bring in will address these issues, which is the reason I have been a big supporter of his both before the election and subsequently. The only question relates to timing. When can members expect the move to the system? The current plan that it will be done after the next election is a little like someone looking at his beautiful young wife and promising he will be faithful to her in the second five years of their marriage if the marriage survives the first five years and she does not kick him out. I believe members should commit themselves now, as one cannot adjust around the edges. If the problems of the health system are to be fixed, the structure at the core of the system must be fixed. I urge the Minister to provide timelines within the duration of the current Oireachtas in which the big bang move to a fully insurance-based health model will be implemented based on a mixture of public not-for-profit insurance schemes competing with private insurance schemes, that is, not the Dutch model of which members have heard but the German model.
The question I tabled related to the issue of rent allowance, the payment thereof and the responsibility of the HSE in this regard. I am pleased to note the HSE no longer will have responsibility for it. However, I do not agree it should come under the aegis of the Department of Social Protection as it should be the responsibility of local county councils. The difficulty of getting the HSE to act in respect of difficult private tenants has caused great problems in many private estates around Dublin and elsewhere. It is an example of how unresponsive is the HSE on so many fronts and I regret being obliged to say that. My final point is that, like Senator Crown, I am staggered by the number of staff facing members across this room. Perhaps this points to a bloated administration and while this may be an unfair comment, that is what it looks like.
On Deputy Colreavy's comment in respect of Sligo General Hospital to the effect that the Government promised a return of breast cancer services, I was very clear on this issue before the election. The exact words I used were that the longer it was closed, the more difficult it would be to restore it. When asked what I meant by that, I replied that if it goes for longer than a year it will be extremely problematic whereas if it is for less than a year, it will be possible. It was well over a year and it still remains something that I keep under review. While it is not that I am reviewing it, I keep it under review in the context of all the other discussions members have had on the situation in Galway hospital and the problems concerning beds and the emergency department there. All those matters must be resolved but I am clear about this issue.
HIQA does not have any remit on private hospitals and this is a matter I intend to address because Deputy Colreavy is correct. At present, public hospitals are subject to standards and regulations and the health services are trying to implement them and keep people safe. Such standards and regulations must also apply to private hospitals and HIQA must be given the teeth to inspect, license and shut down, if necessary, hospitals both public and private. This matter is in hand.
As for the questions on stroke, orthopaedic and diabetes services, I apologise that the Deputy did not get the answer he should have received and I will refer the questions to the HSE. Similarly, as Mr. Brian Gilroy is in attendance, I will refer the questions regarding Ballinamore and Manorhamilton primary care centres to him.
I thank Senator Crown for his words of support. I agree more senior doctors are needed. I agree more specialists are needed in hospitals, as well as less dependence on trainees, be they Irish or non-Irish. Of course, the case to which the Senator referred regarding the doctor who seemed to have had difficulty in taking a pulse concerned a European doctor. There are issues in this regard and a rather bizarre situation has arisen in which, because of acknowledgements within the European Union etc. and the right to move, doctors from South Africa, Australia and New Zealand must take a language examination in their native tongue and yet people within Europe who have very poor English can come here without being obliged to take that language examination. This issue must be addressed, will be addressed through legislation and is something I intend to expedite.
To address the dependence on non-consultant hospital doctors, NCHDs, we need to create more of a career path for our and foreign graduates. Many consultants go abroad to train and research opportunities are few here. These issues need to be addressed. I want to create a clear career path for doctors so that when they have completed their specialist registrar phase and one in four becomes a consultant, the other three can operate as senior clinicians, independent and answerable to a clinical director. This will be negotiated with the colleges and various stakeholders to be introduced next year. I hope the message from this committee goes out to those excellent specialist registrars that there is a place in the health system for them and consider staying next year.
I am fully committed to our plans to expedite universal health insurance. If anything the past several weeks have taught me, it is better to under-promise and over-deliver rather than vice versa. It remains the case that universal health insurance will commence during this Government’s term but may not be bedded down by a second term.
Mr. Cathal Magee
There are three clinicians and three national directors with me as chief executive today. That is all that I can account for.
Is that to intimidate us?
Mr. Cathal Magee
They have attended today out of respect for the committee and to deal with the wide range of issues that can come up. This arrangement can be kept under review.
Mr. Brian Gilroy
The funding for Ballinamore community nursing unit is in place and is in the capital plan. I need to get more details about the Manorhamilton primary care centre development.
Mr. Cathal Magee
We have not got a solution yet for the problem with the location for the Manorhamilton facility.
I welcome the HSE delegation to today's meeting. They made their stamp which means they are serious about getting the country back up and running.
The Minister and Mr. Magee referred to home care. Is there a standard for home care? The waiting times for older people for eye patient and orthopaedic clinics are not acceptable.
I am new in politics. The big issue I have I noticed though is the importance of communication and trust. What is the plan to communicate to people what needs to be done to the health system, whether it is good or bad news? We have a clean slate now but we all need to work together.
Will the Minister state what is the future for the Louth County Hospital? Will additional outpatient clinics be provided in the area?
I welcome the Minister and the delegation from the HSE. These are the people who need to attend this committee and meet members.
Some of my questions about funding for the Jack and Jill Children's Foundation have already been answered. It was stated there would be no additional funding for the Jack and Jill Children's Foundation and other organisations. What other organisations will be affected by this?
The foundation focuses on home and respite care for children with special needs and to give families a bit of time for their other children. It gives parents that little space to spend time with their other children which makes it an important organisation. I note on 18 July sanction was given for a payment of €75,000 from the national lottery towards the cost of employing a special nurse for a full year in the foundation. Will funding be provided for the following year?
We will have to suspend the meeting as there is a vote in the Dáil.
Deputy Byrne was to ask a question but had misinterpreted the Chairman's ruling. I call Deputy Byrne to ask a brief question.
I understood the Chairman was dealing with the questions individually but he is not.
No, speakers are being banked in groups of three.
A statement was made about €8 million extra going to home help. On what type of services will this be used? Will it go towards extra hours or to support people who have had their hours reduced? How will it be distributed?
I would like an update on long-term stay beds in Inchicore, Dublin 8. Brú Chaoimhín Nursing Home closed with the loss of 110 beds and a number of those patients have been transferred to Inchicore to take up what should have been 50 new beds. The agreement made between local representatives and the board of St. Michael's Estate was that 7% of the beds at the former site of the CBS school would be allocated to people living in the area. However, this does not appear to be happening. People to whom I have been speaking in recent days believe staff being transferred from Brú Chaoimhín Nursing Home to Inchicore will get transfer money. How many staff are being transferred and how much money will they receive for transferring?
I asked for an update on mental health services, in particular on the allocation of resources towards suicide prevention. At a time when suicide is a leading cause of death among the 15 to 34 year old cohort, with 527 suicides in 2009, 486 last year with a further 127 deaths of undetermined intent, and anecdotal evidence suggesting this year's figures may exceed these, I found the response I got unsatisfactory and disappointing.
The response is unsatisfactory because the information contained therein is meaningless and was presented in an incomprehensible fashion. When I was local authority member, I was a member of the board of the HSE South consultative forum. I believe the Chairman was also a member.
Yes.
I felt the language being used by the HSE South consultative forum was designed to obscure rather than to clarify matters. At present, there is a crisis in the HSE South consultative forum as many local authority members are threatening to resign for this reason. The language being used by the HSE in response to formal questions is unsatisfactory. Will the Minister speak to somebody in the HSE to ensure when we request information that it is valuable and will illuminate rather than darken the topic at hand?
The response is also disappointing, and I hope it does not demonstrate that the HSE is giving a lack of priority to what I think is a national crisis. The national strategy for action on suicide prevention is called "Reach Out" and has 96 recommendations, the full cost of implementation of which will be €60 million. However, in the letter I received, one of the responses the HSE outlined is an allocation of €1 million to ensure the further roll-out of all elements and all recommendations of Reach Out. If this is the level of priority that the HSE gives to this most serious of topics I am extremely disappointed. It is almost disgraceful.
What go unmentioned are the cuts to some suicide prevention initiatives, including the suicide information and support system in Cork which costs €75,000 a year to run. It has identified an emerging cluster of suicides on the north side of Cork city where 18 young men died in a period of two years. If not for this system, the cluster would not have been identified, but its funding of €75,000 was cut in February. It might be reinstated at some point, but it is not working now.
I ask the Chair's forbearance. Funding for several other suicide prevention initiatives that I will not identify due to time constraints has also been reduced. I will make it my business on this committee to give suicide prevention and suicide awareness my highest political priority. I hope the Minister and the HSE will share my ambition.
Deputy Fitzpatrick raised the issue of the regulation of home care. The Health Information and Quality Authority, HIQA, plans to introduce regulations.
The clinical teams are putting in place a new initiative in respect of orthopaedic clinics. This should improve the units' efficiency and increase the number of procedures performed, which will have an impact on outpatient waiting times. We need to screen orthopaedic referrals to ensure they cannot be dealt with by physiotherapists in the first instance. Such screening has been successful elsewhere. Dr. White will discuss the specifics of the orthopaedic initiative.
The point on communication and trust was well made. For us, it is a major concern that we communicate what plans are in place and when they are agreed and that we deliver on them so that there can be trust and people can judge the timeline of events. Once agreements are reached, we intend there to be clear timelines for what is to be done, particularly in respect of smaller hospitals, including Roscommon hospital.
In many respects, the Deputy's hospital in County Louth is a shining example of this. When its accident and emergency department closed, 400 people were presenting to it every week. There are 350 people attending the minor injuries unit every week. In 2009, the hospital did not have a care of the elderly service. There have been 388 venesections for haemochromatosis this year to date. In 2009, 535 of these procedures were carried out, a number that is expected to increase to 1,783 by the end of 2011. No colposcopy procedures were carried out in 2009, but 3,083 were carried out last year. The number of surgeries increased from 3,416 to 3,659. The number of radiological examinations increased from 534 to 1,519 last year and is expected to be more than 3,000 this year. The number of outpatient sessions at Louth County Hospital increased from 933 to 974. The number of colonoscopies is expected to double next year. Cataract surgeries are planned to begin in the last quarter of this year, with 1,000 cases dealt with in the following 12 months.
This is the sort of future smaller hospitals have, performing a range of services safely that are only available in large hospitals. We intend to ensure that Roscommon hospital is an exemplar in this regard as well.
Deputy Catherine Byrne asked about the Jack and Jill Children's Foundation, but I am not privy to the information on where the extra nurses will be assigned. We could ask the foundation on the Deputy's behalf and revert to her. The reference to other organisations is an expression of the fact that, unlike in previous years, we do not have money to spread around.
I will let the HSE address the question on the Bru Chaoimhin community nursing unit and residential hospital directly.
I share Senator Gilroy's concern about suicide. I agree that the language used could be clearer and we can discuss the matter internally. Regarding the issues of mental health and suicide in particular, we have had many discussions. When I attended yesterday's North-South Ministerial Council, my co-chair Mr. Edwin Poots, MLA, the Minister of Health, Social Services and Public Safety, also expressed a great deal of concern regarding these matters. We will consider cross-Border initiatives and how to invest further money in researching why this problem appears to grow year on year. My answer to the committee was clear, in that suicide rates increase by 0.8% for every 1% increase in unemployment.
It is a related factor, but it is not the entire reason.
I agree. We can address this issue. We should be concerned with the quality and clarity of answers, not their length. Mental health is a broad area and many issues relating to it have been raised. I am sure members could discuss them in more detail with the Minister of State, Deputy Kathleen Lynch, who would happily attend a meeting of the committee. This is her area of responsibility and the Government is committed to addressing the issue of suicide and, as I told the Minister, Mr. Poots, yesterday, investigating its cause. We have little knowledge about why people commit suicide, why it is often so impulsive and what can be done to intervene. Deputy Keating, who was present earlier, is a member of the board of Pieta House, which provides a wonderful suicide prevention service for people who are in trouble. We support its work and are discussing how best to progress it.
I do not want to give a short answer, as the issue requires a longer and more detailed response. Perhaps the Minister of State will appear before the committee to discuss the matter.
Dr. Barry White
I will address the question of orthopaedics. For members who are not aware, we have established a range of clinical programmes, the purpose being to bring front line clinicians - nurses, general practitioners, hospital specialists and therapists - into a space where they can define how services are to be delivered using ground-up rather than top-down solutions. In this context, we are proactively focusing on the fact that it is more about improving services in their existing environments than it is about transferring services, although that issue has arisen in respect of the role of smaller hospitals. There are many opportunities and a requirement to improve services.
We have a range of approximately 30 clinical groups led by specialists, including Dr. Geary, Professor Courtney and a number of GPs, therapists, nurses, etc. The question of outpatients is being addressed. In this respect, innovative proposals have been made by the physiotherapist specialists, orthopaedic surgeons and rheumatologists on how they can deliver a significant reduction in waiting lists. In accordance with our proposal, we are recruiting and deploying physiotherapists to build capacity to the point at which 24,000 new orthopaedic and rheumatology patients who are currently on waiting lists can be seen as part of an overall governance structure with orthopaedic surgeons and rheumatologists. I hope this proposal will be up and running by the end of the year.
As Senator Colm Burke must attend a vote, does he wish to ask his questions now or when he returns?
I must attend the vote.
I will allow the Senator in when he returns.
Ms Laverne McGuinness
There are two parts to Deputy Catherine Byrne's question on the community nursing unit in Inchicore. First, the staff of Bru Chaoimhin have not been and will not be paid additional travel expenses for moving from one location to another. Under the Croke Park agreement, it is mandatory that staff either redeploy voluntarily or be compulsorily redeployed within a radius of 45 km. There is no truth in the suggestion that staff would be paid. At the time, we hoped there would be sufficient Bru Chaoimhin nursing staff available to open a number of other nursing units, but this has not been possible due to retirements and the moratorium. The staff moved to the new unit in Clonskeagh. We now have a similar position with the new unit in Inchicore and across Dublin and mid Leinster we are looking at a number of nursing homes that do not meet HIQA requirements. One of these is St. Brigid's in Crooksling, and there is a view to closing that or taking a large number of patients out and moving them to new facilities. We are still at the discussion stage and the plan has not been fully finalised. We hope to open it by the end of the year, when the new primary care centre is open there as well.
With regard to the 7% figure agreed locally during the development of St. Michael's Estate, it was signed off by local managers that people living in the area would have access to the unit. That seems to be gone now.
Ms Laverne McGuinness
This is all at a discussion stage and not fully signed off, particularly regarding closures and where the cohort of patients will come from. It was originally thought that this would be a new unit rather than a replacement unit.
It is a replacement unit.
Ms Laverne McGuinness
Yes, which means it is not additional capacity. We will work with the Deputy on this.
Mr. Brian Gilroy
I will return to a question from Deputy Naughten that we did not respond to. We trawled the control room in Castlebar and from midnight on Monday to midnight on Tuesday there were 14 calls, all responded to without issue. At all times in that period there was an ambulance with full crew in Roscommon town and a medical team in a rapid response vehicle in Roscommon town.
I ask Deputy Flanagan to be brief.
I thank the Minister and officials for attending. I will return to the mortality rate relating to myocardial infarction, MI. On 5 July the Minister stated there was a 21% mortality rate in Roscommon hospital in these cases, based on a study of over three years of hospital inpatient enquiry, HIPE, data. As far as I understand, the MI deaths in Roscommon hospital are not categorised in the HIPE data, so the Minister could not have used them to validate his mortality rate of 21%. How did he get those figures?
From detailed analysis of MI admissions to the coronary care unit in Roscommon, taking the worst possible scenario the mortality rate was 8.63%. There is a caveat and it should be noted that the age profile of most deaths are people in their 80s and 90s, as County Roscommon has the highest percentage of older people in the country as per the census.
With regard to the "golden hour", I will quote Dr. David O'Keeffe, the HSE clinical manager for Galway and Roscommon hospitals, who stated:
We stopped believing in the "golden hour" a long time ago. It is not about how quickly you get treatment but about where you get it.
In an interview on ShannonSide Radio it was stated by him that patients had a window of four and a half hours to get the correct care rather than an hour. We will have to check the figures regarding the lack of an ambulance in the area for four hours. I discovered that we must check such facts twice before we believe what is said.
There should be fair comment. Such comments should not be made in here. These are the Houses of the Oireachtas and the official came in to clarify the matter. That comment is not suitable for this committee or these Houses.
That is fair enough. We understood that fact to be correct and if it was, this window of four and a half hours would not be enough.
With regard to stroke services, Dr. Ronan Collins in Tallaght Hospital has indicated that the HSE has created the wrong impression for stroke victims and argued that the distinction must be made between people suffering from heart attacks and stroke. He points out that it is not accurate to suggest patients in rural areas have up to four and a half hours to receive appropriate treatment if they suffer from a stroke.
Comments have been made by the HSE and the Minister with regard to trauma cases. Major trauma cases as specified in the research were always transferred to Galway University Hospital by blue light ambulance. The only trauma cases brought to the accident and emergency department at Roscommon hospital were head trauma injuries, where a CAT scan is done and forwarded to Beaumont for review by a consultant, who would decide on appropriate action. Such action would include either a transfer to Beaumont or Galway.
With regard to low volumes and lack of safety, it was our understanding that people would be rotated in order to gain experience, leading to a greater degree of safety. On the issue of distance, does the Minister think it acceptable for the people of Lucan to travel the equivalent distance after getting a heart attack or stroke? People in Lucan would have to travel to Ballinasloe on roads much better than those we are expected to travel. How can he view such a process as safe?
I do not care where the accident and emergency department is as long as I can get to it in good time. It is quite clear that I, my family or my neighbours could not get to the accident and emergency department in Galway - or elsewhere - on time. As a result I will fight like a dog to ensure we keep the services we were promised at a time when people were trying to harvest votes.
I add my thanks for the Minister and all the officials coming before the committee. I am not intimidated by any of them and they are very welcome. I have two brief questions, one for the Minister and the other will probably be dealt with by Dr. Barry White.
I thank officials for the update on the non-consultant hospital doctor recruitment process, which although clear contains an element I do not understand. We can consider many of the smaller hospitals which are topical and none of the vacancies in them has been filled. Is that because when people apply for those positions they do not actively seek to go to those hospitals? If that is so, what is the reason?
The Minister is aware that for a long time I have been working with a support group called Dignity for Patients. I acknowledge and thank the Minister for the very kind grant that was recently approved which allows the office to stay open. Has further consideration been given to the inquiry that is so desperately sought? The people need clarification and have been seeking the truth for many years. They want to be believed.
Portlaoise was mentioned earlier and I did not address the issue. We have Professor Courtney with us and rumours have abounded arising from comments attributed to him that there is a plan to remodel the facility to a model 2 hospital. That is not the case and it is not Government policy. He can address the committee if it is suitable. I mentioned that HIQA does not have a remit in private hospitals but we intend to give the authority teeth to inspect such facilities. It would be extraordinarily rare for a hospital to be closed down and I meant to indicate that unsafe services would be closed.
With regard to Deputy Flanagan's comments, the myocardial infarction deaths statistics I referred to were collected from HIPE. Dr. Jennifer Martin will deal with that. He raised the "golden hour" and the issue of rotating doctors. I will ask Dr. Una Geary to deal with that issue. He mentioned the four-and-half-hour window with regard to stroke and specifically comments attributed to Dr. David O'Keeffe, and I will ask Dr. Barry White to address that matter.
The Deputy mentioned that trauma cases do not go to Roscommon hospital. As I mentioned earlier, it is not that an ambulance will go to the hospital with multiple traumas, as it would not, or that GPs would send multiple traumas there, as they would know better. The issue concerns other people who have accidents and suffer multiple trauma who do not know any better; if they are told an accident and emergency department exists in Roscommon, they would turn up with families and others expecting to be treated when that is impossible.
With all due respect, there will not be too many people with multiple traumas turning up.
That is fair enough but a specific issue was mentioned and I addressed it. I will address Deputy Doherty's question on dignity for patients, Dr. Michael Shine and abuse of patients.
Many people have suffered as a consequence of not being able to have this issue aired in public and I have discussed it with the Attorney General. Notwithstanding the reports to date, I have the agreement of the Attorney General that we will, following the referendum on the Abbeylara judgment, have an Oireachtas committee inquiry to investigate fully this issue when the committees have restored their rights to compel witnesses to attend. I hope that will address the outstanding issue and give people the sense that justice will be done. Justice will be done in the courts in any event but this matter goes beyond that. I will ask Dr. Jennifer Martin to clarify some points on statistics.
Dr. Jennifer Martin
I want to clarify a point about the analysis led by the Chief Medical Officer's division in the Department, namely, what we calculated, how it is calculated and why it is expected that other rates quoted would be different from what we calculated. The Minister referred to the 30 day in-hospital mortality rate for acute myocardial infarction, otherwise known as heart attack, for a three year period from 2008 until 2010. This is an indicator we chose to look at because it is part of the OECD health care quality indicator project and is being examined widely internationally. The aim of the analysis was to examine the value of using a hospital patient inquiry system as a means of examining variation in care. Regarding the source of the data, as raised by Deputy Flanagan, we used the HIPE system and its data is provided by the hospitals to the ESRI, where it is validated. It is untrue to say that acute myocardial infarction or heart attack is not recorded, in fact, it is one of the better recorded diagnosis within the HIPE system. Also, as mortality is the outcome, we are examining whether this is a better recorded outcome unfortunately, within the HIPE system.
Regarding the indicator, acute myocardial infarction was chosen because it is an OECD measure and there are no other well-defined indicators of cardiac outcomes. This is why there is confusion and we fully expect other people have made different findings. As Deputy Naughten has clarified, the data source within Roscommon hospital covers all cardiac patients. We welcome people checking data in more detail. Acute myocardial infarction is one of the very serious cardiac events that end up in hospital. Less severe events also end up in hospital and are captured in that cardiac patient bundle. Also, the patients examined were in the coronary care unit, which includes all the other heart patients that are not heart attack patients. This may involve cases such as pneumonia and other medical conditions that are not counted in this analysis-----
Someone has a mobile phone switched on.
Dr. Jennifer Martin
-----and explains why this is also a valid subject to examine but is not comparing like with like.
Can I ask-----
No, Deputy Naughten had a good hearing and other members have indicated that they wish to speak. I am trying to be fair to everyone.
Can Dr. Martin provide us with the raw data, which would provide the clarity we need? We are all examining different sets of figures.
Dr. Jennifer Martin
The hospital can examine the raw data.
We have that figure and the mortality rate is 8.63% based on the HIPE data and the hospital figures.
Dr. Jennifer Martin
We can enable the hospital to examine its data within the same calculation. The disparity is in the calculation, not the data.
Can the HSE not send us the data and show us how it came to the calculation?
Deputies have received latitude from the Chair and Ms McGuinness wants to contribute. We have been here since 11 a.m.
I have all day.
I have also but I want to be fair to other members who have been here all day and who want to raise other issues.
Dr. Una Geary
I wish to address Deputy Flanagan's points and his questions. My comments on the golden hour are in keeping with the approach of Dr. David O'Keeffe. There is nothing magical about an hour, the concept is getting the treatment one needs and the appropriate level of care as early as possible. That is what Dr. O'Keeffe was referring to in his comments. Regarding the stroke issue, the 4.5 hour timeframe relates to the commencement of thrombolytic or clot-dissolving drug, which a small number of patients receive after a stroke and it reverses the effects of stroke. It can stop patients being paralysed. Dr. Ronan Collins subsequently clarified his comments to say that the important point was getting to the commencement of treatment for stroke in an appropriate care setting. Patients with strokes may deteriorate and become unconscious and ideally they should be managed in hospitals that have 24-7 critical care. It is important that patients who suspect they have a stroke call an ambulance as per the national guidelines, and are brought to centres that have the facilities to manage them and give them this important treatment, requiring clinicians with expertise and 24-7 access to CT scanning and 24-7 access to critical care, should the patient need that level of care. There may have been some trauma bypass in that region but the trauma bypass system in place is the national trauma access protocol, which is a standard protocol agreed by the national ambulance service and the emergency medicine programme and which is applied in the midwest. I harp back to the fact that it is about getting patients who need high acuity care to the right place.
Regarding the rotation of doctors, historically it is true that some hospitals have been more attractive than others from the perspective of trainee doctors. This may relate to the training available on-site, the infrastructure, the complexity of specialties available on-site and, in my specialty of emergency medicine, the number of consultants present to do the everyday supervision of work and on-the-job training. The programmes try to address this issue in conjunction with the training bodies by linking smaller hospitals with larger centres so that staff rotate. This makes all the hospitals as attractive as possible for training. In the same way that different levels of clinical care are provided on different sites, different components of training need to be available to junior doctors on certain sites so the smaller hospitals with more ambulatory care will be sites for training for junior doctors in those aspects of their careers. It is a question of organisation, structure and reforming how we are training our junior doctors. That will take some time to evolve to a standard and a system with which we are entirely happy. We are addressing that.
I thank the Minister and the officials for giving so much time today. My questions are specifically about the non-consultant hospital doctors. I received a detailed response in respect of vacancies, which refers to assigned candidates who are in Ireland or have confirmed flights as of 20 July 2011. Of the 236 people about whom we are talking, how many are in situ and working in hospitals? If they are not in situ, how long will it be before they are? We heard time and again today about the number of people exiting the Irish system. Is there a system in place to do exit surveys of the people leaving the Irish system? Is there a programme to deal with that? Have we done any research on the reasons junior doctors are leaving Ireland or leaving the Irish system and to identify the real problem areas so that we can try to keep people here?
I received an e-mail from a junior doctor who has worked for five years in Ireland. The doctor said that after about five years of doing the rounds, he felt ready to seek completion of training and sought the opinion of respected senior colleagues. He said he was encouraged to go for it and he did so. However, he was surprised to get feedback that he was too experienced for the specialist registrar scheme. That person went to an agency and the HSE is now paying a far higher price for the services of that person because he is now employed through the agency scheme as opposed to having a post.
I wish to raise the centralised applications system. I received a letter from a consultant, dated 7 June. He said he traditionally had ten to 15 applicants for single posts over the past three to four years. He went on to explain the difficulties he has had this year. He is very critical of the centralised process for job applications and said that they are either ignored or fobbed off with extremely brief e-mails indicating that the HSE is just about to advertise. He said that when they pointed out that it had overlooked their service and its posts about six weeks ago, which was six weeks before 7 June, they requested that they be permitted to advertise and recruit locally but they were refused such latitude.
I got feedback from specialists in smaller hospitals who felt the centralised system had not worked for them. They were not told in early June that there were not people to fill the junior hospital doctor posts in their hospitals and that if they had any contacts they should come back to the HSE. They said there was no direct consultation with them. There may be consultation with some local management but that information may not necessarily have been fed back.
The final issue I wish to raise is doctors who fit the European Union criteria and come from within EU member states. Last night I received a text from a consultant saying that a senior house officer, just taken on in a hospital, could not put up a drip. That is the reality. People from coming from outside the EU must go through an assessment procedure but there is a different procedure for people coming from within the EU which does not appear to be working. Could those issues be dealt with?
I am not a member of the committee but I thank the Chairman for allowing me to ask questions.
The Senator's speaking time is limited.
I appreciate that. Does the Minister realise the upset in Roscommon as a result of the commitments given? I do not know whether he has read the letter since he wrote it-----
It is not relevant.
It is relevant. The Minister is here and I am asking him if he read the letter since-----
I am not going to have a fight with the Senator.
Okay. All I am saying is that the Minister gave a commitment and he knew the situation in which we were economically and yet as a former president of the IMO-----
That is not relevant to the work of the committee today.
It is my only opportunity. The Minister will not come to the Seanad in order that we can question him on this issue.
We are not in the Seanad; we are at the Joint Committee on Health and Children.
Okay. Is the Minister aware that he changed the whole election process in Roscommon?
That is not relevant to what we are discussing today.
The biggest upset currently, besides what has happened to the 24-7 accident and emergency service, is the statements in regard to the professionals in Roscommon. Dr. Pat McHugh is the outgoing consultant there. I think Dr. Martin spoke when I was in the Seanad for the vote. Those figures have caused a great deal of upset in Roscommon because they are retrospective justification for the decision the Minister made. HIQA never came to Roscommon and I do not know whether it will at all.
I understand the medical assessment unit is closed for two weeks due to holidays. What is the exact situation with the medical assessment unit in Roscommon General Hospital? The Minister will appreciate that by not having an accident and emergency service, it will reduce the number of admissions to Roscommon General Hospital. There is no format to admit patients who are gravely ill. I will leave it at that, although I wish I had more time.
I welcome the opportunity to engage with the Minister, his officials and the HSE. I wish to put on record my appreciation and acknowledgement of the excellent work done by the health service and the excellent care provided. We hear about the negatives quite often but we do not often hear about the very positive outcomes. From time to time, this negativity affects staff morale. Nurses, doctors, clinicians, therapists and social workers are working very hard in the health service to try to deliver as best a service as possible. Sometimes the system overtakes them, which is something we need to address.
I wish to ask about the roll-out of the national cancer care strategy, specifically in regard to Waterford Regional Hospital which is in the constituency I represent. I understand it is the intention to develop an oncology unit there and a 20-bed palliative unit for the south-east region. As the Minister and the officials know, Waterford Regional Hospital serves a region with a population of approximately 450,000. I understand it is the only region in the country which does not have a residential palliative care unit. The local hospice movement has already raised €2.5 million and a site is readily available on the grounds of Waterford Regional Hospital for the development of a palliative care unit. If a brief progress report could be given to me today and perhaps a more detailed one could be provided afterwards, I would certainly appreciate that.
In regard to residential care for the elderly, St. Patrick's Hospital suffered the closure of St. Brigid's ward. At the time, almost two years ago, the HSE committed to the building of a new 50-bed unit. I attended a meeting where the regional manager of the HSE committed to that, subject to capital funds. Has the proposal moved on? This is a very important area of care. There is a gap in services not only for Waterford but for Wexford, south Kilkenny and south Tipperary. I hope some progress can be achieved in that regard as commitments have been given.
A number of cases have been brought to my attention of young children who require speech and language therapy. They require urgent early intervention but cannot access services. Is any effort being made to address resource issues in this area? I hope that as our economy improves, the embargo on resources in our public services will be lifted. I certainly hope that areas in our health services will be the priority as soon as the embargo can be lifted. Given that children need early intervention in the speech and language therapy area, this should be prioritised. I will be interested to hear the HSE's comments on that.
I had a meeting at 2.30 p.m. which can be put back but I have another meeting point at 3.30 p.m. which I cannot put it back.
I hope we will be finished by 3.30 p.m. because we have been here since 11 a.m.
I am happy to take questions and I will come back to the committee. Senator Colm Burke's questions were mostly directed to the HSE, so I will defer to it. I accept Senator Terry Leyden had attend a vote but I had addressed the issues. I made it very clear that this was not a reflection on the staff at the hospital. The facilities are just not there for them to do the job. We cannot have catheterisation laboratories and all the things we require to get better outcomes. The issue of the figures was addressed comprehensively by Dr. Martin and we stand over them. As I said earlier, when some were not present, this was not the basis for the decision on the emergency department, as these statistics became available later.
It was stated that HIQA had not visited the hospital concerned, but I have been given to understand it visited a number of small hospitals and does not think it appropriate to visit each and every one, in order to be concerned. The officials from the HSE have visited several times and they are in agreement with HIQA. Perhaps, as has been suggested earlier, HIQA will come before the committee, if invited.
May I make some general comments because there are many from County Roscommon at this meeting? The future of Roscommon County Hospital is important. It is an important hospital and we must look to the future and plan on building up a range of services to meet future demands, similar to the services available in Louth hospital. Other facilities could be made available through more co-operation between Portiuncula Hospital and Roscommon County Hospital so that we maximise the level of work we can take away from the bigger hospitals, in Galway and Dublin. It is not appropriate for people to attend the larger hospitals for services that can be delivered safely and conveniently in hospitals like Roscommon County Hospital. It is important to get the message out that the medical assessment unit operates from 9 a.m. to 5 p.m. Monday to Friday and, having spoken to the physician in charge yesterday, GPs can refer patients to the unit if they are concerned about them. There was some confusion about the medical assessment unit, people had started to talk about the unit being closed and GPs not knowing if they could refer patients to it.
I ask the HSE to respond to Deputy Paudie Coffee's question on the 50-bed unit, the report on palliative care and speech and language therapy.
Ms Laverne McGuinness
On the question of non-consultant hospital doctors, 146 doctors arrived yesterday and more will arrive this morning. We know that more than 236 doctors have booked flights. The balance will change every day in the next week or so as more junior doctors arrive from India and Pakistan.
There are waiting lists for speech and language therapy and in order to address them we have put in place some improvement programmes, whereby speech and language therapists instead of seeing patients, particularly children, individually see them in groups and work on training the parents to see if they can help at an intervention level. Speech and language therapists are not subject to the moratorium and when a vacancy occurs as a result of a retirement, the person is replaced, however they are not replaced when on sick or maternity leave. Efforts are being made at a clinical level to manage the service and increase productivity by specifying the number of patients a therapist should see during the day and getting children to group sessions, where appropriate.
Professor Garry Courtney
I will address Senator Colm Burke's questions. It is unacceptable that a doctor who is employed cannot take a post or put up an intravenous line. The Minister introduced a measure in the Dáil that develops a structured practical clinical assessment for doctors. Prior to this that did not exist, so the new law has brought in a much improved assessment so that doctors will be tested on practical issues.
This person took up duty on Monday.
Professor Garry Courtney
The Senator is correct. The President signed the Bill into law about a week ago. There is a week of statutory consultation and the new exams will start on 2 August 2011. As my colleague, Ms McGuinness said, the doctors arriving from India and Pakistan must sit these exams. From 2 August, there will be a new way of examining doctors starting to work in this country and this will be a much safer system. The law also allows for continuous mentoring of these doctors so that they will receive follow-up support. With regard to the overworked specialist registrar, if the Senator can give me details after the meeting, we can provide career advice.
Senator Burke made an excellent suggestion, when he asked why Irish doctors are leaving the country. I am glad to say that the HSE and the college of physicians are engaged in a study to find the reason that increasing numbers are leaving and if there is a problem with what they see as the future in this country. If that is true, we need to improve training, the career structure and guarantee jobs as well as acknowledging the importance of a work-life balance.
On the question of centralised recruitment, I accept the HSE had to deal with an issue but the feedback I am getting is that while it worked for some hospitals, others felt they were left out of the loop. It was flagged up too late for them. Hospitals and hospital management have their own contacts with junior hospital doctors but they were not allowed to use that system this time around.
Professor Garry Courtney
I am a supporter of centralised recruitment as I think it is necessary. I think mistakes were made this year because it was brought in quickly. Some hospitals advertised earlier than others and that gave them a competitive advantage but, that will not happen next year. I would like to see centralised recruitment maintained. It succeeded in recruiting 250 doctors of the shortfall of 450, so that was reasonably successful in addition to the 150 to 200 doctors from India and Pakistan who will staff the system. We are actively discussing nationalised centralised recruitment with much more local involvement and a regional bias and that will address the issues.
Thank you.
We will deal with Deputy Coffey's questions.
Mr. Brian Gilroy
In the case of the community nursing unit in Waterford, we are currently carrying out a review in conjunction with the Department of Health about our future involvement in long-term care of the elderly. The HSE funded new community nursing unit developments are on hold.
With the level of investment required for the Waterford Hospital development, a team was brought together in January 2011. Funding of the development will be based on a cost benefit analysis and this will feature in future plans.
I am not a member of this committee and I thank the Chairman for allowing me to make a brief contribution.
I was following the proceedings on the monitor and noted the reference to Portlaoise hospital, which is in my constituency, and I wish to put a question to the chief executive officer of the HSE, Mr. Cathal Magee. I acknowledge the work that the Minister for Health and the HSE did in procuring the team of doctors that will lead the team in the accident and emergency department on a 24 hour, seven day basis. There was concern in the community and among management and staff in the hospital about this service and I am grateful, on behalf of the people of Laois, that the matter was resolved. Within 24 hours of the change in rotation and the new doctors taking up their positions, I was alarmed to read in the Leinster Express an exclusive interview with Dr. Garry Courtney, in which he stated that he is implementing “Government policy” and that Portlaoise hospital should be a so called model 2 hospital. He further stated that in the acute medicine programme, the hospital cannot have an accident and emergency service. My questions to Mr. Magee follow: what assurance will he give the people of County Laois, who have expressed deep public annoyance following Dr. Courtney’s exclusive interview in the local newspaper? On whose authority was Dr. Courtney speaking? Did Dr. Courtney engage with the local general practitioners, or the local hospital prior to this exclusive interview and does he realise the alarm and damage he has caused by virtue of this article, not only throughout County Laois but throughout the midlands? Staff morale at Portlaoise hospital is at an all time low. The good reputation of the hospital has been damaged consistently by the HSE, and in particular by the remarks of Dr. Courtney. When he is dismantling the services at Portlaoise hospital, what will happen to the 2,500 mothers who give birth in this hospital on an annual basis? What services will be available in a model 2 hospital, given that there is a paediatric unit and an obstetrics and gynaecology unit in Portlaoise hospital? This is a hospital that performed 42,000 procedures in the accident and emergency unit last year. I want to know where these people are going under the Courtney plan. They will not go to Nenagh because the services have been decimated or to Cashel because the services have been removed. Naas hospital remains a conundrum because it gets great remuneration for performing fewer services than many hospitals in the region. I ask Mr. Magee where the 42,000 people will go and where the 2,500 births will take place given that the recent trolley count shows 1,145 people are on trolleys in Mullingar hospital for six months of the year and more than 1,000 in Tullamore hospital.
The Deputy has made a good point.
This is really serious. This is even if the rapid ambulance service, to which Professor Courtney refers, is put in place. We have been down this road before. The people of County Laois will not accept HSE commitments and promises to provide an ambulance service that is wholly insufficient as present, much less any commitments. I want Professor Courtney to retract the content of his article in which he said "busier hospital but services to go". When he does this without consultation with the hospital and the general practitioners and with no reference to the consumers of the service - the people in the area - people are concerned.
I thank the Deputy.
I would like this article retracted or else that the HSE issue a reassurance which may not be sufficient given the widespread damage and alarm caused in respect of a sensitive situation.
Mr. Magee indicated he wished to speak.
Mr. Cathal Magee
Earlier in the year there was real concern around the non-consultant hospital doctor resource process which could have had significant impacts for Portlaoise hospital. In that process the clinical teams and clinical leads across the midlands hospitals tried to work out the configuration solutions or what contingency plans could be made to deal with the potential risk associated with the staffing issue. As is outlined in the answers to the questions, particularly Question No. 13 from Deputy Naughten, it is indicated in the report that the risk in Portlaoise hospital is being managed in accordance with the HIQA recommendations and in accordance with the clinical leads but there are issues around the volumes and complexity of surgery which are under review.
I will invite Professor Courtney himself to comment on the article. Much work is being done by Dr. Barry White and our director in charge of quality and safety issues on the future configuration for the midlands hospitals. It is quite complex. The mix of services across those four sites is unique and, therefore, there is no easy solution to how best to configure services and how best, in the longer term, to comply with the HIQA recommendations. I do not think there are any immediate dramatic changes planned for that hospital.
In regard to Professor Courtney, we have in the past year and a half got huge co-operation from our clinicians to take leadership positions in trying to shape and help reform our health system. Some Deputies spoke about the problems of reform. The most positive thing happening across the health system is that for the first time in our health system - though not unique elsewhere - our clinicians are stepping forward and taking leadership roles to try to blueprint what are the best pathways of care across all the key disciplines. Dr. Barry White leads a programme where there are 30 major clinical programmes under way, all led by clinical and multidisciplinary teams. Those clinicians are stepping up and trying to have a public debate on what represents the best care practice, best clinical standards, best health care system, best use of resources and best configuration.
Professor Courtney has been a hugely influential consultant working across the system, travelling at weekends and at night to every part of the country to try to have a dialogue with GPs and local hospitals around these issues. He has been enormously respected. Professor Courtney can explain for himself the context of the interview and, perhaps, I will ask him to do that. It is important when clinicians step up and are willing, with no recognition or thanks, to take leadership positions to try to shape our health system and deal with some of the problems, that they are understood and respected for that.
Professor Garry Courtney
I thank Mr. Magee. I never heard of the Leinster Express. I never gave an interview for it. There was no exclusive interview. It may be there but-----
Professor Courtney's photograph is on it. I find it quite extraordinary that he does not know anything about it.
Allow Professor Courtney to reply.
Professor Garry Courtney
I never posed for a photograph for the Leinster Express. What often happens with newspapers is that people Google a photograph - there is one out there somewhere of me - and download it. I think that comes from an interview where I spoke to the Deputy and a number of Deputies and Senators from the Laois-Offaly area, in the Department of Health. I was asked to come in by the HSE to explain the issue of the clinical care programmes and, in particular, the acute medicine programme. I thought we had an extremely good discussion. The week before we had a very good discussion with the HSE and Deputies and Senators from the Dún Laoghaire constituency about St. Colmcille’s hospital. What happened then, after the interview with members of the Oireachtas, was that one member went to the newspaper and gave quotes that I had said at the meeting. I have no problem with that so long as they are accurate.
I would have a problem if I were you.
Allow Professor Courtney to reply.
The article states-----
Allow Professor Courtney to reply and I will give the Deputy the right of reply at the end.
-----that Professor Courtney told the Leinster Express-----
If the Deputy allows Professor Courtney to respond I will give the Deputy the right of reply at the end.
Of course.
I appreciate that.
Professor Garry Courtney
Obviously that may have led to the confusion. What we were trying to do was not to denigrate any hospital or pick on any hospital, we have been speaking to many hospitals and have visited almost 30 hospitals. I did not intend to do reputational damage to Portlaoise hospital. I did not put it on a HIQA list of ten hospitals. What we were trying to do was explain how a hospital, Portlaoise hospital or any hospital, can adapt itself to the future of the acute medical programme. That was actually the only intention.
I thank Professor Courtney.
I would ask Professor Courtney to apologise to the people of Laois for scaremongering. Is Professor Courtney now saying he did not give an interview at all? If I was him, I would contact the editor of the newspaper immediately.
Mr. Cathal Magee
I think Deputy Flanagan heard what Professor Courtney said. Professor Courtney said he did not give an interview.
He did not give an interview.
Sorry-----
When will Professor Courtney contact the editor of the Leinster Express?
That is not a matter for the committee today. Professor Courtney has given his reply.
Mr. Cathal Magee
I said at the outset that we should show due respect to clinicians who are giving of their time and effort to try to shape and blueprint the future clinical services for our health system. Professor Courtney is present to assist the committee in its deliberations. He is saying he did not give an interview and he also explained the context that it may have emanated from meetings within the Department with some delegations. I suggest, through the Chair, that Deputy Flanagan reconsider what he has said to Professor Courtney, given that Professor Courtney said he did not give an interview.
Professor Courtney has given his reply to the committee. In fairness to Professor Courtney-----
I am not going to prolong this debate.
I thank Deputy Flanagan. He asked-----
I request a meeting with Mr. Magee.
Professor Courtney did say here that he did not give the interview. The record of the House should be used as a means of recording what he has said.
I require a meeting with Mr. Magee on this matter and I want to see the HSE apologise to the people of Laois.
That may require a different forum.
With due respect, I point out that perhaps Deputy Flanagan's dispute should be with the Leinster Express and that he ask it to express an apology if it has attributed an interview which did not take place. Let us have calm, fair play and justice.
To be fair-----
We have had one person tell us precisely his view of the situation and in natural justice we will allow the Deputy get the other side of the argument. Then, perhaps, we can have a calmer discussion around the issue. I am sure the Deputy was listening earlier when I made it clear that it is not Government policy that Portlaoise will be a model 2 hospital. Portlaoise has obstetrics and paediatrics, and anaesthesia cover and has a bright and essential future in the hospital network. As the Deputy rightly points out, it is on a major motorway. I hope we can return to the calm of the meeting we have had to this point.
We have two more questions. To be fair, Deputy Flanagan, Professor Courtney did say here that he did not give an interview.
I will take it up with the newspaper anyway. It will be on the record.
Professor Garry Courtney
What I was saying was that a member who was present at the meeting gave an interview, I presume, to the Leinster Express and, to check on that, a reporter phoned me when I was in the outpatients department and asked me some questions about it. It was not an interview; I just clarified an issue that was mentioned.
I apologise for not being here earlier; I was tied up with other matters in the Chamber.
The issue of the flow of information to public representatives may have come up already, if it has, let me know and I will stop. As an example, I am facing an issue at the moment regarding the reconfiguration of ambulance services in the southern region. I know this was mentioned earlier. I am facing a public meeting about this in Youghal on Wednesday. The word on the street is that the ambulance is being withdrawn and replaced with a first responder car. It is a very emotive issue and people are angry and upset about it. I have little information to go on and I could be at the meeting on my own. Is it possible that representatives of the ambulance service who are making these decisions could attend such a public meeting and explain what is happening?
The dissemination of information about such local issues to local representatives on the ground leaves a lot to be desired. There is much room for improvement. For instance, at present, we have not had a meeting of Oireachtas Members in the southern region for quite some time. When those meetings are held, they are held in private. I request that the possibility of holding these meetings in public be considered, so that the press can be present and people can be informed by the press about the proposals and deliberations. With the kind of meeting I am facing on Wednesday night, I am left swinging in the wind. I was the last person to be informed about this proposal - I know it is only a proposal at the moment. With a little information, this could have been avoided. We want to assist in bringing positive developments and proposals to people's attention, but if we are not informed and are left swinging in the wind, we cannot do that. We then end up in a situation in which we must defend something or try to maintain the status quo. It is important that this is done.
As I have the floor, I will ask the witnesses to consider this perception that an ambulance is being completely withdrawn from a town that is a good bit away from a hospital and replaced by a car. It is hard to explain to people because it is an emotive issue.
I welcome the Minister, Mr. Magee and his team. The budget overrun being experienced by the HSE at the moment is primarily a result of budget overruns in particular hospitals across the country. One example is Letterkenny General Hospital, which is representative of other hospitals that are experiencing this situation. Last year, the Letterkenny General Hospital budget was €103 million and it had an overrun of over €4 million. This year it is expected to keep to a budget of €95 million. The Minister's policy is that all hospitals must stay within their budgets. What that means is that in the second half of this year, Letterkenny General Hospital and other hospitals will be experiencing severe difficulties. Patients who are waiting for treatments will have to wait and will not receive those treatments. In Letterkenny hospital, the vast majority of treatments provided are non-elective and the vast majority of its budget currently goes towards such treatments. The elective side will be the one that gets cut. That means that people who are waiting for hip replacements, joint replacements and so on will not get those treatments and will continue in chronic pain.
When hospitals are given their budgets, what agreement is made with the HSE in terms of expected treatment outcomes? The Minister has taken a tough stance in insisting that hospitals must stick to their budgets. What assessment has been done by the HSE with those hospitals that are currently experiencing budget overruns as to why this is happening and what the Minister's policy of forcing them to stick to their initial budgets will mean for patient treatment? In my own region, many patients will be suffering and continuing in pain as a result of this policy. The second part of this year, undoubtedly, will be a difficult time.
With regard to the issue of non-consultant hospital doctors, which has been putting severe pressure on hospital services over the last number of months, how many NCHDs would have been coming on stream this year if we had had a 100% take-up from doctors who were trained at Irish universities and who stayed in the country? How many such doctors are currently in the Irish hospital system?
In reply to Deputy Stanton, the issue of the ambulance was addressed earlier with Mr. Gilroy. However, I appreciate the Deputy's point and I think it is reasonable that there ought to be better communication about these issues, particularly for public representatives in the area, who must try to communicate these messages to their constituents. I have no reason to disagree with the Deputy about the question of holding these meetings publicly and allowing the press to be present in the gallery. I do not see any problem with that. I ask the representatives from the HSE to respond to the request to consider sending a representative to the meeting. I will not ask Mr. Gilroy to go over what he said already. To be fair to the other members of the committee, we will send the Deputy a note so that he is up to speed.
I know Deputy McConalogue is a new Deputy, but the party of which he is a member is not a new party. The overruns he alludes to and the shortage of NCHDs in hospitals are not things that have developed in the last few months. These have been a cause of pressure for years - years during which the country was governed by his party. We have taken extraordinary measures to address these problems. We had a discussion earlier on, when Senator Crown was here, about the over-reliance on doctors in training, as opposed to trained doctors. We should not have such a reliance on those doctors but should have more trained specialists. We have addressed that through the proposal to create a specialist associate consultant grade, which is something we are discussing with the colleges and universities and other stakeholders.
Letterkenny General Hospital is a very important hospital which does excellent work, and I am examining why its designation is such that it does not get the same income from private beds as other large hospitals. That should help in terms of its budget and its income. However, I must address the core issue of the Deputy's point, which is that hospitals are being asked to stay within budget. They must stay within budget because there is no money. Without wishing to remind the Deputy of why we have no money, I will just leave it at that. We have no money. There is no further money. There is no cavalry coming over the hill. We have to live with what we have and within the budget we have. We have to do more for less and work differently. I have already commented on and commended the excellent work done by the clinical teams within the HSE which are starting to address this. The special delivery unit, of which Dr. Martin Connor has been appointed head, will be a major agent of change. An analysis is being carried out of what goes on in our emergency departments and what happens in the first 48 hours after admission of patients to our hospitals. There are major efficiencies to be achieved. However, these efficiencies will not result in savings; they will make things more efficient and enable more patients to be treated.
I have been clear with the hospitals through the letter that was sent out by the Secretary General, which also went to Mr. Magee. They signed up to a budget and to a service level agreement. The days of not living up to those agreements are over. They must stay within budget and deliver the service level agreements to which they signed up. They cannot continue any longer with what we have had for the last ten years, which is the lámh amach at the end of the year with a request that we give them more money or they will cancel the most sensitive operations. We all know that game went on. It is over. There is no more money than what we have put into health. When one considers that €16 billion of taxpayers' money, or the entire PAYE take two years ago, went into health it is not sustainable and we cannot continue in that vein. We have to change the way we work.
Mr. Cathal Magee
I take note of what Deputy Stanton said on the consultation process. We will try to deal with the local situation in Youghal. I want to add to the comments of the Minister on Letterkenny General Hospital. Its activity in the current year is growing. Its day cases are up 9%, inpatient cases are up 3% and emergency presentations are up 4.3%. It is dealing with a much higher volume of activity than last year.
Its run rate on costs is flat, year on year, but we had plugged into the plan a 6.5% reduction in the acute budget this year. Acute budgets across the hospital system were cut by between 6.5% and 7%. We protected mental health, disability and certain services under the Government policy direction on cuts of 1.8% or 1.9%. The acute system had to take a cut of 7%.
In Letterkenny the same amount was spent during the first half of the year as was spent last year but it is not dealing with the 7% adjustment. Its activity is above what was planned. The hospital will have to work on remediation plans, such as slowing down the volume of activity and trying to get back within budget.
We are working within the region on various issues. It has had particular exposure to agency and locum costs. We hope, if the current non-consultant hospital doctor recruitment from India, Pakistan and elsewhere happens as planned, we can save money in the second half of the year by having an increased number of staffed non-consultant hospital doctor posts and remove the more expensive locum and agency costs.
We acknowledge the issue. The hospital has a reduction of 6.5% to 7% to deliver each year and is struggling with that.
Mr. Magee said there seems to be efficiencies in the hospital this year but in order for it to get back within budget, treatments will be cut at the end of the year. Apart from some further cost savings it can try to make, it will ultimately mean that fewer treatments will be done in order to get back within budget.
There needs to be more assessment done between different hospitals to determine why they are running over budget. It may not be because of efficiency issues. Letterkenny operates quite well. Other hospitals may not be as efficient as they should be. We are probably being treated unfairly, which ultimately results in patients not getting treatment.
Mr. Cathal Magee
The Deputy is correct. The situation in each hospital is different. Equally, the difficulty is each hospital thinks it deserves special treatment. The overall budget situation for the acute system requires a cut of 7%. It is more difficult for hospitals which overran their budgets last year but I do not think that is the case in Letterkenny. The run rate is currently about the same as last year but it has not met its reduction of 7% and will have to make that up.
In our service plan commitment we committed to the Government and the Minister the same levels of service and activity as in 2010. Letterkenny is outperforming that target in terms of volume and will have to slow down on its volumes. It will have to try to take whatever measures it can locally to get back on plan. It is no different to any other hospital and we will work in support of Letterkenny to try to deliver its budget and have the minimum impact on services.
That ends the formal question and answer part of the meeting. I ask Deputies McConalogue, Ó Caoláin and Healy for very brief closing remarks.
I will be brief. I thank the Minister for appearing before this committee for the second time this week. He could choose to come back but that would not be constructive. I thank Mr. Magee and his team for appearing before the committee. They have very busy schedules. The meeting has been very constructive. I, along with the other members of the committee, look forward to further engagement with them. It is to be hoped we can deal with some of the key issues. Undoubtedly we are in a very difficult six months for health this year. We will need a lot more engagement.
As a health spokesperson who has been here for four and half hours I want to acknowledge the responses of the Minister, the CEO and their colleagues and I am very grateful to them. I am discomforted by some of what they said but I acknowledge their intent. Deputy Coffey earlier rebuked those who have ordered a negative view of our hospital and wider health service. There is no better example than the statistics that the Minister has cited in regard to Roscommon hospital.
In 2008 there were 47 myocardial infarction patients, 60 acute angina patients, six myocardial infarction deaths, no angina deaths and a mortality rate of 5.61%. In 2009 there were 46 myocardial infarction patients, 45 acute angina patients, two myocardial infarction deaths, no acute angina deaths and a mortality rate of 2.2%. In 2010 there were 46 myocardial infarction patients, 63 acute angina patients, four myocardial infarction deaths, four cute angina deaths and a mortality rate of 7.34%. Those are the facts and figures.
If one also examines and takes into account a fair comparison between Galway and Roscommon one will find that the overwhelming number of those who died were aged in their 80s and 90s. That would not be the same ratio in regard to the profiles of people presenting in the statistics vis-à-vis Galway.
I am concerned today and wonder if the Minister and CEO are aware that this morning or late yesterday evening the Irish Nurses and Midwives Organisation served notice of intention for industrial action at Cavan General Hospital. I am anxious to know what steps the Minister and CEO will take to ensure there is an immediate intervention to establish talks to avoid any deterioration of that developing problem.
The hospital is already trying to cope with hugely overstretched conditions, which is the kernel of the nurses' complaint. I ask the Minister and CEO to undertake to address that matter and if they would be kind enough to respond to me at the earliest opportunity in that regard.
I thank the Minister, Mr. Magee and his officials for coming before the committee and for their responses. The Minister and the HSE have indicated there is no money, a term the Minister has used on numerous occasions. I repeat my point that this country is one of the wealthiest in the OECD. The problem is that income distribution in this country is completely skewed in favour of a small percentage of very wealthy people who have been exempted by this Government and the previous Government from paying their fair share in tax towards the provision of services such as health and education.
Having listened to the various speakers today I am not convinced that the policy of centralisation and specialisation which the HSE, the Minister and the Government are pursuing is correct. It is ill-conceived, inappropriate and not relevant to Irish conditions. It is not at all relevant to the situation in Roscommon. I do not believe that the transfer and removal of emergency services from Roscommon is evidence-based. It is significant that the Department of Health refused to make the statistics on mortality available to the committee.
I raised the issue of non-consultation by the HSE earlier in regard to acute psychiatry services in Clonmel and a high-support hostel in Tipperary town. It was evident in Roscommon and is now evident in Portlaoise. Unfortunately, the HSE goes about its business by deciding on a policy and then attempts to drive it through without consultation or simply goes through the motions. This will have to change and there will have to be full consultation with all stakeholders, including the public.
I wish to make two brief comments. I know something about hospital management as I was a manager for 21 years in a previous existence. I accept the need for competent and qualified management and indeed, the need for various support systems for that management. However, the issue regarding hospital management raised by the Taoiseach and again by the Minister here today is a red herring. It is impossible for hospital managers to deal with a situation where budgets were cut in 2009 and 2010 and again this year while at the same time maintaining or increasing throughput but with fewer staff. Hospital managers, by and large, are in a most invidious position.
I request Ms McGuinness to revert to me on the two issues I raised regarding the Hillery report and the Shanker report and also the position regarding Mount Sion high support hostel in Tipperary town.
I invite the Minister to make his concluding remarks.
I will also address some of the issues raised. I thank Deputy McConalogue for his contributions. Deputy Ó Caoláin has put on record certain figures which he considers to be fact. The record of the House and the record of today's meeting will show the facts of the figures from the Department of Health. The contention that there is a refusal to share those figures is not so because these figures will be published and-----
The Minister without interruption.
-----the Deputy will have his opportunity.
Obviously the INMO action is very recent although the exact nature of it is not available to me at the moment but I will revert to the Deputy, as will Mr. Magee.
In reply to Deputy Healy, I respect people's beliefs but that does not mean I accept them nor that they are based on fact. I will not reiterate what I said earlier about the idea that there is a secret pot of gold somewhere that we have not found-----
It is there in the CSO statistics.
I must also point out that hospitals must stay within their budgets. Everyone else in the country knows and feels the effects of the economic recession and everyone is trying to manage with less. Hospitals have to do the same. They are not being singled out for any particular treatment, if members will pardon the pun.
I thank the Chairman and the committee members and Oireachtas colleagues for contributing to today's debate and proceedings. I understand the passion and the emotion associated with hospitals and why Members of the Oireachtas are so committed to them and support them. However, we are now constrained by budgets and we must always put patient safety first. I have said before and I reiterate that I will be straight. I will tell members when it is down to money and when it is a case of a budgetary constraint and I will also say when it is a case of safety.
I thank my officials in the Department for attending and also the HSE officials, both medical and non-medical. They are here not to intimidate anyone but to inform us all. If they were not in attendance, the meeting would be far poorer.
The Government has embarked on a significant reform agenda in all areas and not just in the area of health. We have tough decisions to make in the area of health and we will take them. We will not flinch; we are not for turning. We will turn the health service around to ensure the service provides a safe place to be treated and a source of pride to those who work in it.
I thank Mr. Magee and the Minister for their attendance and also I thank the officials from the Department and from the HSE for their attendance. The officials have added to the meeting and if they were not in attendance, members would have been critical of their absence. It is important to acknowledge they are not faceless bureaucrats and they have made a valuable contribution to the meeting.
Since we abandoned the old health board system there has been a failure of communication between the Department of Health and the HSE and the local service providers and public representatives. Today has been a very valuable exercise in how communication can be a two-way process. We had a very good and a civilised debate. We may not have liked the answers but we got answers. As the Minister said, it is important to put patient safety at the heart of everything we do.
I thank members for their patience and their contributions.