JOINT COMMITTEE ON HEALTH AND CHILDREN debate

Health Issues: Discussion

Chairman

I welcome the Minister for Health, Deputy James Reilly, his officials and Mr. Cathal Magee, chief executive officer, HSE and his officials. I remind members that the Minister and Mr. Magee will give opening statements. They will be followed by the party spokespeople, Deputies Ó Caoláin and Healy who will have five minutes each. I will remind them after four minutes that they have one minute remaining and then other members will get an opportunity to join the debate. Written answers have been given to members who tabled questions for answer today and they will be allowed to ask a supplementary question. The Minister has informed me that he must attend a Cabinet meeting at noon so he will leave around 11.45 a.m. and will be replaced by the Minister of State, Deputy Shortall, for the remainder of the meeting.

I remind everybody to switch off their mobile telephones. By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence you are to give this committee. If you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise nor make charges against any person(s) or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

I welcome the Minister for Health, Deputy O'Reilly, and I ask him to make his opening remarks.

Minister for Health (Deputy James Reilly)

I thank you, Chairman, and members of the committee for providing me with this opportunity to brief the committee on our position on a broad range of health issues and to discuss the Government's intentions for the radical reform of the health services.

I would first like to say a few words on the financial crisis, which the Government is tackling head on, and the resulting challenges for the health services. Now more than ever, the Government must press ahead with major health sector reform. I have often said before that if we were not in this financial morass, we would still have had to change the way our health services operate, because they would have broken the country eventually. However, the challenge for the foreseeable future will be to deliver accessible, high quality, safe and equitable health services to those who need them, when and where they need them, within a climate of significantly reduced and further reducing public finances. Ageing populations, the growing burden of chronic disease, life-style related risk factors, rising costs, increasing public expectations and rapid medical and technological advances all contribute further to the challenge of providing sustainable health services.

I and my Government are determined to create a single tier health system for Ireland. We have not wavered from that goal. Indeed, we were determined to change the way the system was financed even before the introduction of universal health insurance. The current system of allocating block grants to hospitals is outdated and inefficient, and we must move to a sophisticated system where money follows the patient, and which pays hospitals and doctors on the basis of what they actually do, while also putting in measures to ensure that budgetary discipline is maintained.

One of the areas in which health spending is increasing is that of drugs and medicines. Public expenditure on drugs provided to patients under the GMS and other community drugs schemes has rocketed over the past decade. The year on year increase is among the highest in Europe. In 1998, we spent under €400 million. Our annual expenditure on drugs in 2010 was just under €2 billion.

While committing to the delivery of a safe, higher quality health service, there is also a need to ensure that these services are delivered in the most effective and efficient manner. Given that approximately 70% of health costs relate to staff, this area must be the focus of co-ordinated and sustained efficiency initiatives. While the numbers employed have fallen and savings have been made, I believe there are still significant opportunities under the Croke Park agreement for services to be provided with less staff and lower payroll costs. Part of this means working differently and changes in rosters. Members have heard me speak of this before, without identifying any specifics, but I am happy to go into that later during questions.

I would like to address briefly the reconfiguration of our smaller hospitals and to reiterate my previous statements confirming that there will be no hospital closures, either as part of reconfiguration or due to budgetary measures. The framework for the development of smaller hospitals is well progressed. In particular, it will specify what services will transfer to them from the larger hospitals, with full regard for all health and safety issues, as highlighted by the HIQA. Closely aligned with this initiative is the ongoing work of the special delivery unit, which is tackling hospital inefficiencies, especially waiting times and waiting lists, as well as our emergency department problems. The resources of the National Treatment Purchase Fund have been refocused to align with the work of the SDU and to allow for the progressive improvement of the performance of our hospital system.

I have said in the past that if people were perturbed by the furore over what has come out of smaller hospitals, there will be an even greater furore from the bigger hospitals when we start taking stuff from them and putting them back into the smaller hospitals. We are determined to do that and that is what will happen.

The HSE's clinical care programmes represent a highly significant and progressive development in our health services. These programmes have developed care models which are centred on the needs of patients and the achievement of improved outcomes for the Irish population. The implementation of these programmes will require extensive co-ordination and arrangements across service areas and regions, from GPs practices to tertiary care acute hospitals. There will be clear lines of accountability at individual service, regional and national level. Dr. Barry White is here with us today and he can take questions as the clinical lead in that specific area.

Some of the initiatives undertaken have already yielded considerable savings. There has been an initiative in Cork where five theatres have yielded savings of €2.5 million, and this only represents 5% of theatres in the country. The scope for savings in the improved work practices in our theatres is considerable and we intend to pursue that.

I would like to inform people of the reality of the situation. There has been much speculation about what might or might not be in the budget. I do not intend to add to that speculation and I certainly do not intend to speak about what is in the budget, because nothing is agreed until everything is agreed. The Cabinet is still discussing and preparing the budget. However, I wish to inform the committee of the following. Having started the year with a €70 million overrun in hospitals - a wild overrun in the first three months of hospital activity -and with a request to save €1 billion out of the system, we will end up having nearly achieved that, with possibly up to €300 million of a deficit. We are working very hard to minimise that.

I wish to put things in perspective. Demand led schemes will cost us around €160 million. This is as a result of new people on medical cards, increasing drug prices, newer drugs, and an ageing population. Even if we found some way of preventing cancer at this stage, the problem is already there and it is growing. Unfortunately, we are facing ever-increasing numbers of people with cancer, as they live longer. On top of all this, we have an EU directive on agency staff, which means that they have to be given the same terms and conditions as permanent staff. There is a huge cost in that. The 2% increase VAT may cost our Department over €50 million. New sick pay arrangements have been mooted but have not yet been accounted for in the Department. We do not know what it will cost us, but it is in there and we have no extra money to deal with it. We have to deal with the normal increments in pay.

We face a huge challenge. This is going to be the most difficult year yet for the health services. There is absolutely no question about that. My Department and the HSE are striving to ensure that the impact on patients is minimised and that front line services are maintained, but there is no doubt we are facing huge challenges in the coming year.

Chairman

Thank you. I now ask Mr. Magee to make his presentation.

Mr. Cathal Magee

Good morning Chairman and members of the committee. Thank you for the invitation. I am joined by a number of my colleagues. Ms Laverne McGuinness is the national director of integrated services. Dr. Barry White is the national director for clinical strategy and programmes. Mr. Liam Woods is our national director of finance, Mr. Brian Gilroy is national director of commercial services, and Mr. Sean McGrath is our HR director.

The committee requested information and replies on a number of specific issues prior to this meeting. Members will have received a joint written response to these issues from the HSE and the Department of Health. Therefore, my opening remarks will be brief.

Activity continues to grow across the majority of HSE services, placing considerable demand on resources. The position as of September 2011, compared to the same period in 2010, shows the following. Emergency admissions have increased by an additional 4,559, or 1.7%, in the first nine months of the year. The number of inpatient and day case treatments is up by an additional 20,861, or 2.1%. Out of hours contacts for GPs are up by an additional 55,461, or 8.5%, compared with last year. The number of individuals covered by a medical card in September is 1,701,951. An additional 86,142 individuals have been issued with a medical card since December 2010.

Increased service activity levels place considerable pressures on available resources and capacity within the system. As the Minister has stated, we will continue to face significant financial challenges until year end, particularly in areas such as child care, acute hospitals and community drug schemes, based on the demand for services. Health service staff resources at the end of October stood at 104,065 whole-time equivalents. This represents a reduction of 8,706 whole-time equivalents since staff numbers peaked in the health system in September 2007. The HSE and the organisations funded by it are operating well within the current approved employment ceiling of 105,622. The recruitment embargo will remain in place, for funding reasons, until the end of the current calendar year.

I wish to provide the committee with information on our clinical care programmes which are led by Dr. Barry White. All health care systems face the challenge of balancing the priorities of access to and the quality and cost of care. Despite the financial and resource challenges, it is essential that we continue to address these priorities and focus on solutions to improve access, quality and cost. The national clinical programmes which have been established in conjunction with the respective colleges provide a powerful vehicle to empower front-line clinical staff to develop and implement solutions. I will highlight a number of areas in which significant progress is being made.

The acute medicine programme was established in 2010. It is clinically led and provides a roadmap for how services should be delivered to patients in a far more efficient and safer way. It centres on up-front rapid assessment, earlier diagnosis and treatment by consultants and the associated multidisciplinary clinical teams. It is being rolled out in conjunction with the emergency medicine programme and the work of the special delivery unit established by the Minister. A number of sites are at an advanced stage of or have already completed implementation. One such site is Cork University Hospital where the acute medicine unit, led by consultant staff, opened earlier this year. By year end, in excess of 3,000 patients will have been treated at the unit, of whom 25% who would previously have been scheduled for admission to inpatient beds are now able to go home within 24 hours. This has been associated with a significant reduction in the requirement for hospital beds for these patients and also gives rise to a far safer and better experience for them. Similar work is under way at 18 sites across the country. It is hoped this work will, subject to the availability of resources and funding, be well advanced in 2012.

The surgery programme, to which the Minister referred, is jointly established with the Royal College of Surgeons and focused on improving bed utilisation, surgical theatre productivity and ensuring safer surgery procedures. An example of this is evident in orthopaedic surgery. As a result of the surgery programme, a significant increase in same day of surgery admissions has occurred and there has been a doubling of the rate nationally since July. The largest of the orthopaedic facilities - Cappagh Hospital - now has a 90% same day of surgery admission rate. This initiative has also resulted in a 20% reduction in average length of stay in hospital for these procedures.

Stroke care is another extremely important area in which significant advances are being made during the current year. Four stroke units have opened this year at the Midland Regional Hospital, Mullingar, Cavan General Hospital, Wexford General Hospital and Roscommon County Hospital. A further five locations are scheduled to open during the next six months - a number are actually due to open in the next three months - including Cork University Hospital, Mercy University Hospital, Cork, St. Vincent's University Hospital, Limerick Regional Hospital and Our Lady of Lourdes Hospital, Drogheda. By mid-2012, 28 acute hospitals will have operational dedicated stroke units. Extensive work is also under way among front-line clinical staff to ensure all patients admitted with stroke will have access to consultant expert input for emergency stroke thrombolysis on a 24-7 basis, regardless of where they are admitted. We anticipate this initiative will be in place next year.

The HSE aims to have established 12 ambulatory care services by mid-2012 for three of the commonest health conditions - chronic obstructive pulmonary disease, COPD, heart failure and epilepsy. Through an approach targeted at complex cases, this initiative aims to reduce mortality and save in excess of 200 beds. In addition, a range of other clinical care programmes are under way and at various levels of development in both primary and secondary care throughout the health system. All of these programmes are clinically led and focused on improving safety, quality and access and reducing cost to the Exchequer. However, additional resources will be required in 2012 for these programmes to be executed in an effective manner.

I take the opportunity to acknowledge the work and contribution of our clinical leaders and the multidisciplinary teams of doctors, nurses, allied health care professionals and managers in developing and delivering the solutions to which I refer, despite the resource constraints and challenges. The manner in which clinicians are taking leadership roles in re-engineering and restructuring services is one of the real positives in the health system. This is an extremely welcome dynamic. It may be worthwhile for the committee to receive a more detailed presentation on the scope and scale of the national clinical programmes, under Dr. Barry White's leadership within the HSE, some time in the new year.

Chairman

I thank Mr. Magee. The committee may well take him up on his offer of a more detailed presentation on national clinical programmes. I remind members that they have been provided with a timetable of speaking times and that this meeting will conclude at 1 p.m.

Deputy Caoimhghín Ó Caoláin

Cuirim fáilte roimh an Aire agus an phríomhfheidhmeannach.

This meeting is taking place in the wake of another which has received an amount of public attention in the past 24 hours. I refer to the meeting involving the Minister and members of Fine Gael and the Labour Party. The key issues which the Minister brought to the attention of those present at said meeting were deliberately leaked - by whomever - as part of what I would view as a softening up process in advance of the introduction of the budget on 6 December. This is an extremely serious matter because the threatened cuts signalled - we do not yet know what will happen on 6 December - would utterly devastate the public health service. It is clear the cuts are all targeted at the old, the sick, the vulnerable and families on low incomes. Those to whom I refer are the ones who will suffer most.

We do not know whether cuts as extensive as those threatened will actually be imposed in the budget. However, they have been described as three years worth of cuts rolled into one. That certainly appears to be the case at this juncture. Regardless of whether such cuts are actually introduced in one budget or across three, they will be equally devastating. The Minister and his colleagues in the Cabinet must realise that this deliberate process of leaking is causing fear and anxiety throughout the country. We are contemplating a situation where serious cuts and changes will be made to health delivery systems. I see what is happening as part of an elaborate game being played both among Ministers in the Cabinet, between the component parts of the coalition - namely, Fine Gael and the Labour Party - and between the Cabinet and the media.

What is taking place is extremely sad to witness. Make no mistake, the recession with which we are coping is extremely bad and challenging and has given rise to increasingly deep depression among the people. The activities of the Minister and his Cabinet colleagues may lead to people stating on budget day that, "It was not as bad as we expected." However, they should not count on this happening. The current process of cuts was begun by Fianna Fáil, as we all acknowledge and recognise, but it is continuing under the current Administration's stewardship. The cuts are hurting people and damaging the public health service. That is a matter to which reference must continually be made. Further health cuts will worsen an already serious situation.

Any attempt to impose an annual charge of €50 on medical card holders and increase prescription fees would be seen as an attack on the most vulnerable. Prior to the general election, the two parties now in government pledged that they would ensure free GP care for all during the lifetime of the current Dáil. A commitment in this regard is included in the programme for Government, on which the two parties signed off.

The threatened closure of care homes has commenced. Evidence of this is contained in this morning's newspapers. The Minister stated there would be no hospital closures, but he was referring to the acute hospital network. There have been closures of hospital facilities in which care for older people was provided. There is ample evidence of such closures happening in the recent past and it appears the process of closures is continuing. People see this as a retreat from the provision of nursing home care for older people by the HSE, the Department and the Government. The latest victim of the HSE axe is St. Vincent's Hospital in Athy with the closure of 24 beds following the closure of 26 beds previously. In the past month we have seen the closure of a 32-bed facility in Abbeyleix, 28 respite beds in County Tipperary, 30 beds in Shane in County Laois and 89 patients displaced with the closure of St. Brigid's in Crooksling, County Dublin. In the case of the nursing unit in Abbeyleix and St. Brigid's, the HSE had carried out extensive works to those facilities only for us now to find they are to be closed. The Minister should call a halt to these closures. This is a hugely worrying development. The is fear that there is an unspoken policy at the back of this, that the Minister and his Department with Government support, hatched with the HSE because the retreat continues. He need not point to HIQA reports. HIQA did not recommend the closure of any of these facilities, rather it has pointed towards specific and required improvements that should have been carried out. These older people should have the certainty of remaining within a facility that has become their home in their later years of life.

There are several points I could make but I hope other communities will take a lead from the spirit exemplified on our television screens and elsewhere by some of those older people and older people who stood up to Governments in the past over the proposed cuts in medical entitlements vis-à-vis the provision of medical cards for all those over the age of 70. Older people in nursing home facilities have had the courage to come out in their wheelchairs and say to the Minister: “I will not leave”. That is the spirit that is needed. I urge people across the country to follow that example, to show that tenacity and to say to the Minister and his colleagues, “this won’t wear”.

Deputy Seamus Healy

Before dealing with other points I wish to ask the HSE officials a specific question related to a meeting of the committee in July of this year at which I requested a date for the publication of the Shanker report. I and my Oireachtas colleagues were advised in March of this year that this report would be available within a month. I raised this issue at a meeting of the committee in July and was informed by a letter from Ms McGuinness that the report would be available shortly. Today is 24 November and apparently the report is still not available. I raised the issue again at a meeting of HSE officials in south Tipperary last Monday week and they were unaware of the situation and said they would check it for us. Could the Chairman get confirmation on whether this report will be published and, if so, when it will published, and an exact date for its publication? Issues that we raise here and responses to them go to the heart of whether meetings such as this one are of any value. We need a specific answer to that specific question before the end of the meeting.

Chairman

I agree with the Deputy. I hope Mr. Magee will answer that question when he replies.

Deputy Seamus Healy

I agree with what Deputy Ó Caoláin said but I also want to make a further specific point. The Minister talked about reality and moneys available but the Government is making choices that are basically in favour of very wealthy individuals and against very poor people - low and middle income people and social welfare recipients - who use these services. These are deliberate choices being made by the Government and it is not the case that there are no choices.

Recent reports by entities that are part and parcel of the financial capitalist system clearly prove that this is a very wealthy country and that the distribution of wealth here is completely skewed in favour of a very small number of individuals. Merrill Lynch recently published a world data report of high net worth individuals and in the teeth of the recession in 2009 and 2010 that report found that those individuals increased their wealth by more than 7%. In regard to Europe, the same trend is found, with there having been an 8.2% increase in such people's wealth in 2009 and 2010.

The position in Ireland is made clear by Credit Suisse in a report it published in October of this year. The wealthiest 1% of people in this country own 28.1% of the wealth and the wealthiest 5% own 45% of the wealth. These are the findings of people who are at the heart of the financial establishment. Furthermore, the Central Statistics Office shows that in 2009 and 2010 these very wealthy individuals have increased their wealth by €46 billion. This is in the teeth of the recession when low and middle income people and social welfare recipients are being hit with austerity of all kinds. Very wealthy people here increased their wealth by more than €46 billion in 2009 and 2010. There is no taxation of these people - they do not pay tax on their wealth or assets. If they were living in some other European countries or some states in the United States, they would pay a wealth tax. Surely the Minister and the Government should ensure that these people who are not paying their fair share in contributing to the economy should be made do so through the taxation system through the introduction of a wealth tax. Even from their own perspective, they should do so from a patriotic point of view when they see their friends, neighbours and citizens of this country being hit with every kind of austerity. There are choices but, unfortunately, to date the Government has made choices in favour of wealthy people and against people who are on low and middle incomes and social welfare recipients.

On medical cards, we know about the kite the Minister has been flying in recent days but I ask him and the HSE when is it intended to increase the income threshold limits that apply to medical cards? They have not been increased since January 2006. While there has been a significant increase in the number of medical cards issued, particularly to people who have lost their jobs - some 350,000 in recent years - people in lower paid employment find it difficult to manage, given that these limits have not been increased since 2006. The Minister told us he would abolish the prescription charge but it appears he will increase it not by another 50 cent but by €1.50 or €2.00. When will that charge be abolished?

I welcome that stroke units will be opened in the various acute hospitals. Mr. Magee might outline the position in regard to rehabilitation units that are linked to stroke units. What proposals, if any, has the HSE in regard to those?

Deputy Charlie McConalogue

I join other party spokespersons in welcoming the Minister, Mr. Cathal Magee and his staff from the HSE and the officials from the Department. This is a difficult time in which to manage the health service and in trying to deliver health services in the same way as previously and it is probably more difficult for this Department than for many other Departments.

I wish to focus on a number of issue which I hope the Minister will be able to address. First, I wish to raise the proposed charge for those with a medical card. That would be a retrograde step and would put pressure on people who can least manage it. I hope the Minister will be able to clarify the position and avoid such a charge in the upcoming budget.

The National Treatment Purchase Fund ceased this year, shortly after the Minister took office. I wish to address how the special delivery unit is working. Is it delivering for the patients who need it? I am sure I am no different from other members who receive representations from patients. In my case, I receive a great many representations from people in pain who are waiting for orthopaedic operations. Up until the start of this year, these patients would have been able to be treated under the NTPF and they would have seen the light at the end of the tunnel. The best case scenario now for those with whom I am dealing is having to wait for over a year for their operations. People seem to be taken in rotation as opposed to on the basis of the severity of their condition. Anybody who is waiting for an orthopaedic operation is in a fairly severe position. Since the cessation of the NTPF, these patients have nowhere to go and are living with chronic pain while they wait for their operation. Many of them who are unable to wait and have scrimped pennies together in order to have their operation as a private patient because they can be operated within a month. If they cannot go privately, they have to wait for over a year. That is a very serious situation.

Finally, I wish to raise the issue of community hospitals with the Minister and the chief executive of the HSE, Mr. Magee. The HSE has sent a report on community hospitals to the Minister for Health, suggesting that 12 such hospitals have been considered for closure, with the loss of 840 beds. In County Donegal, community hospitals in Carndonagh, Buncrana, Ramelton and Lifford are mentioned. We know there are financial pressures on the Department of Health. I do not want to cause alarm in any way so it is important the Minister clarifies the position. If there is no threat over these hospitals, which play an invaluable role in the community, especially the four community hospitals in Donegal, the proposal must be knocked dead immediately. I ask the Minister to deal with that matter.

Chairman

I thank the party spokespersons for their opening remarks and they will have an opportunity to make a contribution at the end of the meeting.

We will take contributions from three members at a time and then ask the Minister and Mr. Magee to respond to them.

Deputy Robert Dowds

Will the Chairman clarify if the Minister is dealing with the questions we have submitted?

Chairman

Yes, the questions from members.

Deputy Robert Dowds

The first question I submitted relates to consultant numbers in different hospitals. Unfortunately there is an error in the question, in that St James's Hospital has been omitted and I am interested in those figures as well. The main reason I submitted this question is that there is concern that Tallaght Hospital is not getting sufficient financial cover for the number of patients it has to deal with. Since submitting this question, another point has emerged through conversations with GPs in the Clondalkin area, in that there seems to be an element of a turf war between Tallaght hospital and St James's Hospital. In the Clondalkin-Lucan area people tend to go to both hospitals, but there seems to be an attempt to direct people from Clondalkin towards Tallaght, even if the best specialist is not available in that hospital. What is the situation? I have followed this up by tabling parliamentary questions in the past few days.

There is a concern as to whether Tallaght hospital is getting sufficient financial cover, while recognising that the new CEO of Tallaght hospital is doing an excellent job with the resources she has. It is possible that neither the Minister nor Mr. Magee may be able to answer the question about what appeared to be the attempts to direct people towards Tallaght, if they happen to be from the Clondalkin-Lucan area. That is not always appropriate as many people have been in the habit of going to St James's. I tabled parliamentary questions on this issue in the past day or two.

The second issue I raised refers to specialist treatment for Hunter's syndrome. This relates to a case that I had to deal with earlier in the year - I will not give names - but I felt the family and child were treated very badly by the HSE. Plenty of notice was given, the relevant approaches were made by the Irish consultant who was dealing with the case and the family were left hanging on trying to find an answer to whether they would be given HSE support to travel to Britain to see the particular specialist, as there is no specialist that can deal with that syndrome in Ireland. People in that situation should receive clarification on whether they will get that cover. In the case I dealt with, the family were not told until the last minute, which is shabby behaviour. People should be treated with care and dignity.

I now raise the response to question No. 16 which I submitted, concerning a residential youth centre which was established in an area. In fairness to the residents of the road concerned, there were no significant objections but various problems have arisen since then, some of which are acknowledged in the answer. Given that this is in a residential area, I ask that every care be taken to see that it works effectively for those in care without causing problems to people in the neighbourhood.

Deputy Catherine Byrne

First, I want to record my dismay and lodge my objection with the Chairman regarding this meeting. Four minutes is an insufficient amount of time to give anybody to respond to questions and comments that have been made this morning. I have been in attendance for up to six hours at some of these committee meetings. This is probably one of the most important meetings of the Joint Committee on Health and Children between now and the budget and to be confined to four minutes to cover questions and make comments is unfair and unjust.

I am disappointed with the comments of Deputy Ó Caoláin for whom I have the greatest respect. I am a member of the Government parties and I do not play games. I have not spent 13 years in politics playing games and I do not intend to start now.

As for the only colleague from the Fianna Fáil Party who is here, and who represents the previous Government, shame on him for making such comments. The reason we are in this position is because of the mess, the overspending and the no-tomorrow spending of money of the Government of which his party was a member.

Chairman

I remind the Deputy that we are on questions.

Deputy Catherine Byrne

I do not need to be reminded.

My problem with this is that if there are to be cuts, we all must share the burden. Those who should not carry the burden are the nurses, the occupational therapists, the health nurses in the local offices and those who face the public on a daily basis, such as the staff sitting at reception where people are going in for operations and day-care procedures.

In the past three days, I have received a number of complaints. For instance, a person arrived from Tipperary yesterday to a hospital in Dublin to be told that the operation was cancelled that morning. They heard about it when they arrived at outpatient department. Something must be done. Those are the kind of people I want protected in the HSE.

I mean no offence to any of the managers attending this meeting, many of whom I have known well over the years, but it is not their jobs that are on the line. It is those of the poor young staff in Tallaght Hospital who are working in administration and are trying to make a wage and keep their homes over their heads.

I submitted questions Nos. 17 to 19, inclusive. I may not have time in my remaining two minutes to adequately go through them, but I want to refer to the presentation that was made in 2008 and 2009 on the Inchicore framework plan, which was presented to public representatives, including myself, the local community and members of the board of St. Michael's Estate.

I do not take credit for many things in my life, but I do take credit for the fact that the CBS school in Inchicore was handed over to Dublin City Council, and then to the HSE, to build a 50-bed nursing unit for community care nursing. As part of that presentation, which was made by three persons, all of whom have either retired or moved on to greener pastures from the HSE, there was a clearly written statement that 18% of the beds would be ring-fenced for the elderly from the local community in Inchicore. This is in connection with question No. 17. There were to be 50 extra beds to cover community care units across the city. We were told three months ago that Brú Chaoimhín in Cork Street was closing and now, in reply to my question, I am told Crooksling is closing and the 50 beds will be taken over. I want to know where, in this report, there is a statement referring to respite beds. Some 18% of them were to be given to the local community. I have a few comments to make on this but I might not have time to do so.

This commitment was made by the HSE to the people of Inchicore, Bluebell and Kilmainham and the only reason the grounds were given over by the CBS at the time was to provide this facility to facilitate the local community. Why were the people of Inchicore misled regarding the 50-bed unit and what can be done by the CEO of the HSE and the Minister to reallocate 18% of the beds to the local community?

I will bring the Deputy back in at the end. To be fair, the timetable has been agreed, not only for this meeting but for the meetings since I became Chairman. All of the members had a role in the setting of the meeting. In fairness, the Minister made the request today because he must go to another meeting and he has another meeting afterwards. That is why the meeting was at 10 o'clock and why it has been set for three hours. There are 22 members of the committee. We seek to be fair to all members and the Chair is impartial.

Deputy Denis Naughten

I welcome the contributors. I have a couple of brief questions about issues that I raised at the last meeting on which we are still waiting for follow-up.

The Minister spoke at the last meeting on the mortality rates for patients at Roscommon General Hospital and other hospitals around the country. When will that report be published?

Also at the last meeting, we discussed the possibility of an independent assessment of the information and research on the golden hour or golden hour and a half. Has the Minister make any progress on appointing someone to carry out that assessment?

My next point is a follow-up to the last meeting. Would someone clarify who made the decision on the closure of the accident and emergency department at Roscommon hospital? I was informed, subsequent to the meeting here, that no written management directive was issued on the ending of services at Roscommon hospital by the HSE. Who formally made the decision in that regard?

If I could focus on the three questions that I tabled for today. First, on Question No. 4, as the Minister will be aware, following the closure of the accident and emergency department in Roscommon, it was replaced with one additional ambulance and one additional advanced paramedic. At the same time, there is a chaotic situation at Galway University Hospital and Dr. John Barton in Portiuncula Hospital has stated that the accident and emergency department there is unsafe due to the numbers going through it. Would the Minister consider opening the accident and emergency department at Roscommon hospital in exceptional circumstances if staff were requested to do so, either by a paramedic or a GP, where there is a life-threatening situation, for example, someone with internal bleeding? That situation has arisen recently and, sadly, that individual is no longer with us. The staff are on-call on a 24-7 basis.

Second, the Minister has heard of a proposal regarding a dedicated air ambulance to be based in either Roscommon or the midlands. Its cost is approximately the cost of one additional ambulance but it would cover the region of the west and the midlands. I ask the Minister if any progress has been made in that regard. The difficulty is that if there is a serious incident in Roscommon, the advance paramedic is taken out of the catchment for three and half hours plus. The HSE is considering a plan to base an air ambulance service at coastal locations but, as the committee will be aware, that is where the accident and emergency departments are already located. Surely it would make more sense to base it in the midlands to service the areas where accident and emergency departments are closing.

I refer to question No. 5, which I tabled, on the reconfiguration of long-stay hospitals. As the Minister will be aware, there are six facilities within my constituency that have dedicated beds for my constituents. These amount to approximately 5% of the total number of facilities in the country, yet we have a population of almost 2% of the country. The difficulty is that my constituency has a high dependency ratio. It is reported that St. Patrick's Hospital in Carrick-on-Shannon will lose ten beds, along with a bed reduction at Roscommon County Hospital. I ask the Minister to clarify the position on these closures rather than allow selective leaks. It makes more sense to explain precisely what is happening in regard to management of long-stay beds. This has become a weeping wound over the three or four months since the regional director of operations initially spoke about reconfiguring long-stay hospitals.

My final question pertains to the impact of budget cuts on local services. I welcome Mr. Magee's announcement on the stroke unit that is to be developed at Roscommon County Hospital. Work is under way on upskilling front-line staff to treat thrombosis on a 24-7 basis. How does Mr. Magee envisage this happening given that the hospital's doors are locked at 8 p.m., and why did he not refer to this announcement in his detailed response to my parliamentary question? While reference is made to stroke facilities in Ballinasloe, there is no mention of such facilities in Roscommon.

Deputy James Reilly

I will take the questions in the order in which they were asked. If I miss anything, I ask members to remind me. I am pleased to be accompanied by Mr. Paul Barron, Dr. John Devlin and Ms Geraldine Fitzpatrick, among others, who will help to answer questions. This session is about sharing information and we are happy to facilitate members in this regard.

Deputy Ó Caoláin spoke about hospital closures. I have made it clear that no hospital will close. Community nursing units will be rationalised and that is unavoidable. To be accurate, the 28 beds in Abbeyleix have not closed, although there is a plan to close them. I met representatives from Abbeyleix yesterday on foot of a request from Deputy Charles Flanagan and we had a useful discussion. I intend to investigate certain aspects of the proposals put forward by community representatives and check on the veracity of some of the figures that have been suggested by the HSE. That matter remains in abeyance.

On Deputy Healy's question, I ask the witnesses from the HSE to comment on the Shanker report. As he indicated that he asked about it at a previous meeting, I am sure they will have something to say about it. I also refer the question on stroke units to Dr. Barry White.

In regard to increasing the limits on medical cards, there is a plan to increase the population covered by medical cards and early next year we intend to extend them to holders of long-term illness books. We are in a financial morass, however, and not only is the cupboard empty of cash but it also contains a heap of bills. We are trying to maintain services against a background of reduced budgets. A broader discussion on finances belongs properly to a different committee. I am here to discuss health issues, although I accept the budgetary situation is having a huge impact on health services.

Deputy McConalogue asked about charges on medical cards. A number of options have been put on the table and I am not going to comment on them until we have clarity on our budget. However, this is an option we will strive to avoid.

For the purpose of accuracy, the National Treatment Purchase Fund was not discontinued at the beginning of the year. It has not yet been discontinued. Its purchasing methodology has changed and some of the money is being used in different ways, including on funding the initiatives that have recently been put in place in emergency departments at our most troubled hospitals. Comprehensive plans are being drawn up for each of the high risk hospitals and the special delivery unit will be conducting a similar diagnostic investigation in Galway to the one it did in Limerick. We have put in place an initiative on waiting lists, and hospitals have been told that patients should not have to wait longer than 12 months for a procedure. At the end of this year, any hospital that has a patient waiting longer than 12 months will have to subtract from its budget the money to treat the patient elsewhere. Nearly all the hospitals are coming up to speed in that regard but one or two are problematic. The one that is most problematic clearly needs a new management structure. We are investigating our options in this regard.

In regard to orthopaedic initiatives, a money follows the patient system has been put in place based on same day admissions. This has resulted in significant improvements in efficiency. At Navan hospital, where previously nobody was admitted on the day of procedure, 80% of patients were being admitted on the same day when I last checked. This initiative saves a considerable number of bed days. The numbers in Navan are not huge but Cappagh, which is the busiest orthopaedic hospital in the country, has improved same day admissions by more than 45%. That alone has saved us nearly €6 million. This progress demonstrates the results that can be obtained when the right clinical programmes are put in place with appropriate levels of support.

The community nursing unit sector is currently under review. We face three constraints, namely, money, the moratorium and the standards HIQA requires these units to meet. I do not think members want people to live out their last days in facilities that do not meet adequate standards. Particularly in respect of Abbeyleix, I am investigating ways of working with the community to address the issues that arise.

In regard to Deputy Byrne's comments, I do not want to see a situation whereby people who need long-term care are sent miles away from their communities to wither on the vine. We want them to be cared for as close to their communities as possible and we will do all we can to achieve that objective. I recognise that many of the people who live in these facilities have formed relationships and regard them as home. We want to keep people together, with their permission.

I ask Dr. White to deal with the question by Deputy Dowds on Tallaght and turf wars because he is familiar with both hospitals. The governance issues in Tallaght, regarding which HIQA has written to me, were serious and I am glad they have been resolved. They had gone on too long and were undermining the entire process. If we do not get the governance right in Tallaght we will face an awful mess in the national paediatric hospital. In June we directed the hospitals to keep within their budgets. They are responsible for their budgets because they signed up to them. They need to be mindful to stay within budget when making cuts because they will have to defend them. Otherwise, there will be consequences. There is a consequence there because the board has gone. That is a serious consequence.

With regard to HIQA, what is sauce for the goose is sauce for the gander. If HIQA insists for safety reasons on closing the accident and emergency department at Roscommon County Hospital, as it did, I will follow that direction, as I did. Equally, if it says the governance of a hospital is problematic and is undermining the functioning of the hospital and that it needs to be addressed, I will do that too, and I did. Whether it is a big hospital or a small hospital, or indeed any other facility, if HIQA comes in with strong recommendations and serious concerns about the undermining of patient care, we will act without fear or favour.

Deputy Catherine Byrne mentioned the people from Tipperary. I was not aware of that but I will certainly ask my officials to talk to the Deputy afterwards. That is utterly unacceptable. It is bad enough to be ill and anxious without having to travel miles only to be sent home again. That should not happen. As far as I am concerned, that is an issue to do with the management of the organisation, and it will be addressed.

Deputy Byrne spoke about Jean Murphy, from her constituency. I fully accept the point about people being looked after in their own communities as far as possible. Potentially, there are beds in Hollybrook nursing home. We will engage with the HSE and the Deputy in this regard. We will have to reach an arrangement whereby beds are available for local people in the local facility.

Deputy Naughten asked when the report on mortality rates at Roscommon hospital would be published. I might ask Dr. Devlin to talk about that because he is closer to the issue than I am. However, we are keen to have the report published. At the moment, we have no update on the independent assessment of the golden hour, but I will be in contact with the Deputy about that.

Reopening the emergency department at Roscommon hospital would be utterly impossible. It would not make it safe. That is part of the problem. We have been considering the Deputy's other point about the air ambulance proposal since early last June. A proposal was put to us by a charitable group. Since then, another proposal has been made by a group from Roscommon, and we have also been working with another group. There are three proposals on the table, and I hope to have news about that shortly. It is in everybody's interest that we have a rapid response for people who are critically ill, that we have an integrated system and that everything works together, so that we do not have ambulances turning up at the same time as the helicopter and the fire brigade. We are improving the ambulance co-ordination, and I hope to have news about that shortly.

The Deputy mentioned St. Patrick's.

Deputy Denis Naughten

What is the number for day cases?

Dr. Barry White

Sorry Deputy-----

Deputy Robert Dowds

They made a complaint and that was rejected. The HSE did not even accept that they were making a complaint - it was very unsatisfactory.

Mr. Cathal Magee

I will investigate that. The comments in regard to Clondalkin were well made and we have raised that with the directors. We accept the issue of the sensitivity for the local community.

I believe Deputy Byrne has left. Deputy Naughten asked about the accident and emergency unit. That is the subject of legal correspondence. The decision on Roscommon accident and emergency unit was a matter for discussion at the board meeting of 23 June. The following day there were meetings with the Minister and departmental officials on that issue: that is the process. It is the subject of legal correspondence with us, but that is the formal answer.

Chairman

We have a slight difficulty in that the Minister has to leave and the Minister of State, Deputy Shortall, is not available. The Minister has indicated he is willing to come back in early January if we agree to adjourn.

Deputy Caoimhghín Ó Caoláin

If we have a short period of time, the opening statements by spokespersons do not provide an opportunity for questions. Will the Chairman accommodate supplementary questions?

Chairman

The list I have includes Deputy Fitzpatrick and Senators Cullinane and Burke, followed by Deputies Colreavy, Conway and Moloney. I will take Deputy Ó Caoláin in the third group. Other people have been waiting to speak. I did not know this would happen until now. I ask Deputy Fitzpatrick to be brief.

Deputy Peter Fitzpatrick

I thank the Minister and HSE for coming before the committee. I come from a completely different angle. My philosophy is that one's health is one's wealth. One can have all the money in the world and everything one wants, as Steve Jobs had, but money cannot buy one life. All the people of the country want is the best service when they go to hospital. I have asked a lot of questions over the last eight months. I liked some of the answers and did not like others. The most important information I got from the Minister and HSE is the truth.

I have raised the issue of overcrowding in of Our Lady of Lourdes Hospital in Drogheda. In fairness, Dr. Martin Connor came in and did his job. He provided over €700,000 to help hospitals. I also asked if Louth Hospital in Dundalk could help Our Lady of Lourdes Hospital and in fairness the clinics in Dundalk are improving. The Minister made a statement that no hospital would close, which is fantastic and means an awful lot to the people in my area.

St. Joseph's Hospital in Ardee and the College Hospital in Drogheda are two of the hospitals named in the list this morning. They are two very important hospitals. All I am asking for is the truth. Can the Minister tell us if they are going to close? I do not believe in scaremongering. From day one the Minister has told the truth. People might not like it. Out of the entire Cabinet, the Minister probably has the hardest job. I ask him to help us.

Senator David Cullinane

Question No. 27 refers to the need for an integrated oncology unit on the grounds of Waterford Regional Hospital. Where does that sit with the current national cancer strategy? It is to comprise a cancer care unit, a critical care unit, palliative care, radiology and replacement single bed hospital accommodation. It is much needed for the south east, a region of nearly 500,000 people. The unit is not in the current capital programme and if it does not proceed where does that leave the Minister's national cancer strategy?

My second question concerns the need for a community nursing unit on the grounds of St. Patrick's Hospital in Waterford. We had a discussion earlier on community nursing units and Mr. Magee made the point that no decision has been made on existing ones. When making decisions I ask that regard be given to areas where beds were removed from existing facilities. St. Brigid's ward in St. Patrick's Hospital in Waterford was closed, which resulted in the loss of 19 beds. A 50 bed community nursing unit is needed to replace beds that were taken out of the system. I ask that the issue be addressed when the Minister is making decisions on capital spending in this area.

Deputy Caoimhghín Ó Caoláin

On question No. 2 regarding bed closures, nowhere in the Minister's answer is an upfront admission that the recruitment embargo has led to bed closures and closed hospital wards, but it is there implicitly. I refer to his statement that a significant proportion of the overrun is due to the continued dependence on agency staff and overtime. Overrun in hospital spending is linked to the bed situation.

Why is there a continued dependence on agency staff and overtime? It is because the Minister and the HSE continue to pursue the false economy of the recruitment moratorium. Some 3,100 nursing and midwifery posts have been lost. We have to come to a point where patient safety and care is not being compromised every day in terms of front-line service providers. In my view there is a deficiency in that response.

They will be dealt with at the next meeting of the committee.

Deputy Catherine Byrne

When will that be?

Chairman

We will discuss the date after this meeting.

Deputy Caoimhghín Ó Caoláin

Will the Minister arrange for written responses to our questions to be supplied promptly following this meeting?

Chairman

I will allow the Minister and Mr. Magee to reply if there is time.

Deputy James Reilly

It is now 11.45 a.m. and I have to go to the Cabinet meeting. I want to answer as many questions as possible very quickly. The cottage hospital, as it is called, is a community nursing unit but St. Patrick's is a different case. In answer to Deputy Fitzpatrick, it is one of the hospitals under consideration and there is no question or doubt about that. However, no decisions have been made. My Department and I want to do our own review. There has to be rationalisation and there is no point in me saying none of these community nursing units will be closed because some of them will close, without doubt.

Deputy Peter Fitzpatrick

What is the position regarding St. Joseph's in Ardee?

Deputy James Reilly

I will come back to the Deputy. I do not have that information with me. Senator Cullinane referred to inequality in Waterford. I think Mr. Gilroy can answer that question for him and he might send Senator Cullinane a written response. Deputy Ó Caoláin asked about the moratorium and rationalisation and the cost of drugs. Those questions will require some response from Mr. Barron who will be able to provide the accurate figures. As regards mental health services, I am not familiar with the acronym PWDI.

Deputy Caoimhghín Ó Caoláin

People With Disabilities Ireland.

Deputy James Reilly

I will come back to Deputy Colreavy regarding his questions about the mental health services and I will send him a written response, expeditiously. Deputy Flanagan asked about Roscommon hospital. Let there be no doubt, I had discussions with HIQA and it was made very clear to me that it would be unsafe to keep it open. If the Deputy wishes to discuss the semantics of who said what - I am sure he does not wish to do so - I tried everything to keep it open. We even talked about a shopping list of what would be required, by the consultants themselves, to make it safe but this was not possible to achieve. Even if we had the money to do it, I was told that within time, the staff would become deskilled and we would be back to square 1. I recall the Deputy was at a meeting in the Department and I believe Tracey Cooper, the head of HIQA, was also at that meeting and she made the situation very clear. It was a HIQA recommendation and I wish to put that on the record of the House. I will write to the Deputy as he requests.

Mr. Cathal Magee

I thank Deputy Fitzpatrick for his comments. We will seek to use Dundalk as it has been very successful over the past 12 months in how it has adjusted to its new role in the network. Any work that can take the pressure off Drogheda and which can be handled in Dundalk will be supported. The Minister commented on the community nursing units and I have made a broader comment. The units to which the Deputy referred are part of that review process but no decisions have been made and these will depend on funding and budgetary circumstances.

I will ask Mr. Gilroy to reply in writing to Senator Cullinane's question. Deputy Ó Caoláin referred to the staffing issues and the issue of agency workers and he is correct. The resourcing issue is a significant issue which is affecting the viability of our community nursing units. A total of 90% of the costs of running a community nursing unit are staffing costs. The total in the acute system is 72%. If significant numbers of staff are leaving the system, then the staffing budget disappears. In fact, funding is not provided for the use of agency staff. As there is no budget for them, this leads to a deficit. The resourcing issue in long-stay nursing care is a staffing issue and it is also an issue to do with capital and quality and standards. However, resourcing is the key issue because of the figure of 90%. The areas under most pressure in the health system are the areas of high dependency on staff resources. Broadly speaking, the overall health system is 50-50, pay and non-pay, but there is a big spend on drugs and on payments to private providers. In the case of residential care and disability services, the cost split is 90% staff costs and 10% other. Therefore, these are the services whose viability at local level is most impacted by the moratorium and the employment control framework.

The employment of agency services is not a solution but a stopgap measure to deal with staffing shortfalls. It is not budgeted and is leading to deficits. That is what is forcing the consolidation of units that are less than viable in terms of the number of residents and the unit costs. In the case of the latter, we are paying €1,800 per patient bed day as opposed to a private cost of €850. In that situation, the imperative as to the effective use of resources dictates our approach.

We are making progress in this area. The facility in Ballincollig is a good example of where we built a new unit and outsourced its operation while retaining it under the management of the HSE. That has reduced operating costs from €7 million to €5 million. We may have to be very innovative in finding solutions which retain the viability of these units.

Deputy Caoimhghín Ó Caoláin

Having direct employees providing the service at the coal face is the most cost effective approach.

Mr. Cathal Magee

Chairman

Members will be allowed the opportunity-----

Deputy Denis Naughten

The Minister said there would be a cut to the budget of Galway university hospital before the end of the year. The Chairman is not allowing me to seek clarification on that and on the issue of investment in community nursing units. I am seeking clarification on these issues, based on comments made by the delegates. I did not interrupt during the contributions, but I am seeking clarification now.

JOINT COMMITTEE ON HEALTH AND CHILDREN debate - Thursday, 24 Nov 2011

Health Issues: Discussion

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Dr. Barry White

Dr. Barry White

Dr. Barry White

Mr. Cathal Magee

Dr. Barry White

Dr. Barry White

Dr. Barry White

Dr. Barry White

Dr. Barry White

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 24 Nov 2011