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Joint Committee on Health and Children debate -
Thursday, 12 Feb 2015

Quarterly Update on Health Issues: Discussion

I remind everyone that mobile phones should be switched off or left in airplane mode as they interfere with the broadcasting of proceedings.

We have received apologies from the Minister for Health, Deputy Leo Varadkar. Owing to aviation connectivity issues, he has been unavoidably delayed. He hopes to be here, although he may not be able to make it. He will, however, endeavour to answer outstanding questions from members today or at a later date. It is important that we acknowledge this is a quarterly meeting which is set in stone and of which the Minister is conscious.

I welcome the Minister of State at the Department of Health, Deputy Kathleen Lynch. I also welcome from the Department of Health Mr. Jim Breslin and Ms Tracey Conroy and from the HSE Mr. Tony O'Brien, director general; Ms Laverne McGuinness, Mr. Pat Healy, Mr. John Hennessy, Dr. Áine Carroll, Mr. Liam Woods and Ms Angela Fitzgerald. I thank them for coming.

In advance of the meeting members submitted written questions. It would be appreciated, therefore, if they asked questions, rather than make Second Stage speeches. The objective of the meeting is to allow an engagement between the committee and the HSE and the Department on key health care issues.

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. If, however, they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They 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 should not criticise or make charges against any person or an 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 they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I invite the Minister of State to make her opening remarks.

My opening statement is not very long. I am glad that the Chairman explained that the Minister hopes to be here later when I am sure he will be anxious to address the joint committee.

I thank the committee for the invitation to attend. I am joined by officials from the Department, including Mr. Jim Breslin, Secretary General; Ms Treacy Conroy, assistant secretary - acute hospitals; Ms Grainne Duffy, disability services division; and Mr. Barry Murphy, services for older people division. I am also joined by Mr. Tony O'Brien, director general of the HSE, and his colleagues.

Members have been informed that the Minister has experienced a flight delay on his return home from a meeting at the European Parliament. He will try to join us as soon as possible and will speak about some wider issues. I will cover those within my brief.

The budget for the health service in 2015 shows a modest increase – the first such increase in a number of years. As acknowledged by the Minister and the director general of the HSE, it will not allow us to address every priority in the current year, but it will allow us to make a start. As we see the fruits of the rebuilding of the economy emerge, I look forward to further sustainable increases in the health budget in the years to come which, together with reform, will allow us to address the deficiencies in key services.

The Minister and I have published our priorities for 2015 which set out an ambitious but achievable set of goals. They include introducing universal GP care for children under six years and older people over 70. Detailed discussions are proceeding with the Irish Medical Organisation with a view to rolling out these initiatives in the second quarter of the year. It will be a matter for individual GPs to agree to provide these services. I cannot presume agreement, but I hope the main body of general practitioners will see this as an important opportunity to secure more investment in primary care services and introduce a more preventive focus, in particular in children's earliest years.

The budget provides an additional €10 million for the fair deal scheme. These resources have already allowed waiting times for funding under the scheme to be reduced from 15 weeks in October to 11 now. This is an important initiative for those awaiting a placement from the community, but it has also contributed to a reduction in delayed discharges from hospitals, with numbers down by more than 100 since December.

Demographic factors mean that there is significant ongoing pressure on the fair deal scheme. A review of the scheme is being finalised and I will bring the findings to the Cabinet. As well as improvements to the operation of the scheme, it is likely to highlight the ongoing funding requirements to further reduce waiting periods and the need to simultaneously invest in community supports to avoid older people having to be placed in residential care, where at all possible.

Other priorities for 2015 include reducing the cost of medicines to patients and the taxpayer, building on price reductions and a successful introduction of reference pricing. I will also publish a review of the Mental Health Act which will contain recommendations on how this ground-breaking legislation can be further improved to support the rights of those suffering from mental illness. Before the end of the year, subject to planning permission, we will commence work on the new national forensic mental health service campus at Portrane. The Central Mental Hospital in Dundrum has a very professional body of staff, but its facilities are from another era. Their replacement has been long promised and we will embark on making this a reality with the new development.

On disability services, the national service plan provides for a planned approach to school leavers and emergency placements. We will further implement the registration of facilities with HIQA and the comprehensive change programme to modernise services and ensure standards of care are consistently of high quality.

The director general will now make his opening remarks to the committee.

I welcome Mr. Tony O'Brien, director general of the HSE. I thank him and all of his staff for the work they do on our behalf in hospitals and primary care centres. I also acknowledge the tremendous work being done in the health system.

Mr. Tony O'Brien

I thank the Chairman for those remarks which are very much appreciated. I also thank him for the invitation to appear before the joint committee. My colleagues have been introduced by him, but I point out that Mr. Liam Woods is here for the first time in his capacity as director of the acute hospitals division on an interim basis.

Mr. O'Brien means that he is returning to us.

Mr. Tony O'Brien

He is returning to the committee but for the first time in his capacity as director of the acute hospitals division on an interim basis.

Fair enough.

Mr. Tony O'Brien

Prior to the meeting the committee requested information and replies on a number of specific issues and will have received a written response to each of them. We will obviously be happy to deal with further issues that arise.

The service plan for 2015 was published by the HSE on 27 November last, following ministerial approval. The budget to which it relates provides for the delivery of health and social care services within a funding allocation of €12.13 billion, plus an additional €35 million for mental health services. This represents a welcome but modest increase of €115 million in funding. It is the first time in seven years that there has been an increase, not a decrease, in funding. This has allowed the health service to allocate more realistic budgets to hospitals and community health care organisations which puts the health service on a more sustainable footing.

The allocation of more realistic budgets brings with it a requirement for greater accountability to ensure services are delivered within the budget provided. To help to achieve this, we have put in place an enhanced governance and accountability framework which set out clearly the responsibilities of all managers to deliver on the targets set out in the service plan against the balance scorecard. There are a number of core requirements under the accountability framework, the most notable being the introduction of a formal performance agreement with me, as director general, and each of the national directors and cascaded throughout the system.

Emergency department attendances have increased by 5.6%, at 63,123 attendances over the past five years, standing at 1,182,842 in 2014, and with 2014 alone seeing a rise of 2.5% over the previous years. In addition, patients attending emergency departments are now generally more unwell and more likely to require admission than in the past, which is due in part to an increase in the number of frail elderly patients attending. In 2014, there were 6,614, or 1.7%, more admissions from emergency departments compared to the previous year, which equates to 550 more admissions each month. That does not include the cohort of 52,437 patients who presented at acute medical assessment units and medical assessment units during the course of the year.

As previously discussed with the committee, the pressures on emergency departments over the past number of weeks are not new or unexpected. Based on the trends I have outlined, significant action was taken prior to and after the Christmas period to plan for a surge in attendances and admissions. Some €25 million was provided to alleviate the problem of delayed discharges this year and an additional €3 million spend in 2014 was fast-tracked in November and December as part of the winter pressures plan. This enabled the early release of an additional 300 Fair Deal approvals in addition to the routine 700 places each month.

In addition, the following actions have been taken. During December, 165 additional transitional care beds were funded and targeted at hospitals in the greater Dublin area to facilitate egress from acute beds. A further 424 transitional care beds were commissioned nationally up to 27 January in order to move patients whose acute episodes of care had finished. All short- and long-stay public beds are being prioritised to support discharge from acute hospitals. A further 173 short-stay beds are being opened on a phased basis in identified locations during this time of peak demand. Additional home supports were provided, with a specific focus on supporting acute hospital discharge prior to the Christmas period, allowing the discharge of 87 patients from acute hospitals.

The total number of additional home care packages provided to date is 400. Of the €25 million provided, €2 million was allocated to community intervention team services, which are very effective in preventing people from having to attend emergency departments in the first place and allowing for early discharges. The scheme has managed more than 200 patients in the community each day during this time of peak demand.

During December and January, 1,239 people whose acute episodes of care were completed but who remained in acute beds were provided with alternative care more appropriate to their needs. However, a further 1,176 people have been added to the delayed discharge list, which means that the perceived net benefit is small. The number of additional delayed discharges being added to the total weekly list is exceeding the usual intake rate of 100 by a factor of about 1.6, which makes it extremely difficult to sustain improvement. As such, the number of delayed discharges remains high and very challenging, at 745.

The overall position, therefore, remains challenging. The HSE is maintaining a daily focus on this area and is an active partner in the emergency task force set up by the Minister to find long-term solutions to overcrowding. We are also working on developing a detailed plan specifically to address emergency department issues, with a view to a significant reduction in trolley waits over the course of 2015. This is a priority for the HSE and the Government.

On patient safety at Portiuncula Hospital, the review will involve a thorough examination of the delivery of maternity services at the hospital and will include a review of the perinatal care provided to the seven women who were the subject of the preliminary review completed in January 2015. The draft terms of reference for the review have been finalised and are currently being discussed with the families concerned. The investigation team is currently being established, to include two obstetricians - one national and one international - one of whom will act as investigation chairperson, two senior midwives - one national and one international - a patient advocate, a consultant neonatologist and an expert investigator from the national incident management learning team. I can also confirm, in respect of the cases highlighted in the media recently, that the chief clinical director of the Saolta University Health Care Group will meet the families concerned, has met some of them already and will meet others again, with a view to agreeing with them how best a review of those cases should be progressed.

Sometimes, in the midst of the challenges such as those I have described, we can overlook the many things that are improving. During 2014, significant parts of the health system worked very well, with notable improvements over previous years. We continue to meet and exceed our targets for specialist palliative care, with 97% of patients accessing a specialist inpatient bed within seven days of referral and 89% of those receiving palliative care in their own homes. The number of persons in receipt of home care packages is 13,199, 21% above the 2014 target. The numbers waiting more than 12 weeks for a physiotherapy assessment continue to fall and there were 7% fewer people waiting more than 16 weeks for an occupational therapy assessment. With regard to the ambulance service, in 2014, 76% of ECHO calls and 65% of DELTA calls were responded to within the target response times. This compares with 69% and 64%, respectively, in 2013, and comes against a backdrop of an increase in call volume in the order of 4%.

A dedicated GP support line commenced in September to allow closer working between GPs and the HSE, aimed at supporting patients in regard to medical card applications and renewals. The implementation of the expert reports on medical card assessment and processing continues to be a high priority this year. A senior manager has been appointed to lead the process and a number of measures are now under way, as outlined in more detail in the response to question 17 from Senator Jillian van Turnhout. The recent appointment of the clinical advisory group chaired by Dr. Mary Sheehan, who is a GP, represents a significant development in this process and one which adds senior clinical and patient representation to the governance and oversight of assessment of medical card eligibility.

With regard to eculizumab, or Soliris, the HSE has taken a decision to extended access to it to sufferers of paroxysmal nocturnal haemoglobinuria, PNH, and atypical haemolytic uremic syndrome. Due to the exorbitant cost of this drug, which is approximately €430,000 per patient per year, its provision for patients will be on the basis of clinical need. The opportunity cost of the inordinate price demanded for this important drug will inevitably be felt over time in other parts of the health services and will have an impact on our ability to fund other important service developments. We will continue to pursue a more reasonable price for this medicine.

As it is now 18 months since the health service directorate was established as the HSE's governing body to take forward reform, in that time we have made a significant start on re-fashioning the health service to ready it for a post-HSE era. Significant progress has been made towards consolidation of the hospital groups. CEOs were appointed by the directorate in October despite a challenging recruitment backdrop. The community health organisations were designed and progressed, with chief officers appointed to seven of the nine before the end of last year. Health business services have progressed on the journey towards a contemporary shared service platform for the entire health service, providing for the most effective use of resources.

Clarity and transparency on funding and service planning has been brought to each of the five core service domains. Significant progress has been made, as I outlined, in the reform of the operation of the medical card service in the aftermath of the probity debacle. The quality and patient safety enablement programme has been established, as outlined in the service plan, with a distinct and appropriate focus on quality improvement, on the one hand, and quality assurance verification on the other. We are learning from the past in this regard.

A confidential recipient has been appointed as a means of empowering workers, service users and family members to highlight the most serious shortcomings in health services and to rebalance the power relationship between the health service, its users and their representatives. These are important steps in the right direction and the directorate is committed to building upon them, working with Ministers, to ensure that the health service is fundamentally reformed and improved.

I welcome Mr. O'Brien and the officials. I would like to ask Mr. O'Brien and Mr. Breslin about an article in The Irish Times today which refers to the €1.4 billion increase sought last year in the allocation for the budget to provide safe clinical care in our health services.

Reference was made to the debacle associated with probity and medical cards and many other dysfunctional areas. I refer to the budget allocation in the Estimates for previous years, which we knew almost immediately was unsustainable.

I ask Mr. O'Brien to say whether the clinical pressures are generally across the health services or whether there are key areas of major concern. I assume we are talking about patient safety as well as the clinical pressures. When did Mr. O'Brien become aware that this would create significant problems? For example, is he referring to emergency departments or to the Fair Deal scheme? Due to the shortfall in funding, what other areas of health services were identified?

At previous committee meetings Mr. O'Brien stated that while he always sought more funding, this year's budget was realistic. As today is 12 February, how realistic is the budget looking so far in the profiles that are being done? Mr. O'Brien stated that €200 million to €300 million is required for demographic proofing annually. In view of the fact we have €115 million extra, is that before or after demographic proofing of €200 million to €300 million? If it is not, it means we are in a negative situation before we even start the year. Does Mr. O'Brien envisage significant difficulties in the future?

Mr. O'Brien referred to the winter pressures plan. I do not think that plan - if it exists - has really covered itself in glory. It was a reaction to an issue as opposed to a plan. A total of 601 people were on trolleys in emergency departments earlier in the year. As I said at the previous committee meeting and as everyone is talking about, our emergency services are chaotic at the moment. This is not just Billy Kelleher making it up; it is a fact. The HSE's own statistics verify the situation regarding the number of people on trolleys. Clinicians are telling us every day that patient safety is being compromised constantly in emergency departments throughout the country. How does Mr. O'Brien envisage the current budget providing the funds to address this issue? He referred to delayed discharges and the number of people that would have to be moved from the acute hospitals into step-down facilities or home care packages. There has been a slight improvement in the waiting time for approval for the Fair Deal scheme, from 15 weeks to 11 weeks. However, there remain significant pressures on our emergency departments and, as a result, patient safety is compromised and clinicians and front-line service providers are under pressure. How will this translate over the next number of months into an improvement in the situation?

Is the Secretary General permitted to speak? An Acting Chairman indicated-----

The only occasion on which officials are not permitted to speak is during consideration of the Estimates. Those are not my rules, Deputy Kelleher.

That is why we are not able to get at the full truth at the Estimates meetings.

I refer to Government policy on universal health insurance. I have a question for the Secretary General, Mr. Breslin. Is universal health insurance still being actively assessed, costed and verified? What is the Department doing to address and consider that central Government policy?

I have a question for Mr. O'Brien. The terms of reference for the review of Portiuncula Hospital indicates that seven cases are to be investigated. Would it be worth revisiting the terms of reference, considering that more than seven people have come forward expressing concerns about the service in Portiuncula Hospital? Is is possible to expand the terms of reference to cater for other families who have also expressed concerns? I suggest that any investigation should include all those who have expressed concerns rather than holding a subsequent review.

The Deputy has one minute left.

The Chairman is rushing me. It is not often I get a chance to ask questions with such a group of people in front of me.

I have a question for Mr. O'Brien on the more focused issue of consultants' pay and the need to fill a large number of vacant posts. I refer to the remuneration package in the context of attracting or retaining consultants compared to other countries. We are losing some consultants and not attracting others to return. How will this be addressed in the short term?

I refer to free GP care for under-sixes and over 70s and the intensive negotiations with the IMO, which is the GP representative body. The Minister said that not every GP is obliged to take up this contract. The National Association of General Practitioners represents approximately 1,200 GPs, which is quite a substantial number of doctors. Why is the HSE not engaging with an organisation that represents a large number of people who will be to the fore in implementing this policy by delivering the services?

I welcome the Minister of State and Mr. O'Brien and their respective colleagues to the meeting. I wish Mr. Woods well in his new appointment and responsibilities. I thank Dr. O'Connell for his service.

The Minister of State referred to the review of the Mental Health Act which she intends to publish. Will it be published in this year? I ask her to elaborate on the review, which speaks about further improving and supporting the rights of those suffering from mental illness. I refer to those who are not only suffering from mental illness but have had a challenge in terms of their mental illness. The reference to suffering from mental illness suggests a problem that I believe is in the minds of many - the notion that there is no recovery. The reality is that people get better. That is a very important point which is not clear there.

A number of cases have been brought to my attention recently in which people are being clearly discriminated against in terms of their former, existing or prospective employment because they have been open and forthcoming about their experience. I want to know if the Minister of State will include address of that issue in order to further the rights of people who have suffered or are suffering from either depression or some other challenge with regard to their mental health. It is a very important area and I will be addressing it to the Minister of State by other means in the time ahead. I ask her to indicate whether that is something she hopes to focus on in the review of the Mental Health Act.

I have a question for Mr. O'Brien on two matters arising from his opening statement on the subject of the emergency departments. I recognise the range of actions that have been taken to respond to the difficulties that have presented over the past period of many weeks. He referred to actions including additional transitional care beds, a further number of short-stay beds and additional home supports. In my view, there is a glaring omission in this list of actions - which are all essential, and more besides, I would say - but there is no mention in the list of the initiatives taken, or to be taken, with regard to additional public long-stay residential beds. I believe this is crucial in terms of addressing the delayed discharge issue. Many of those in delayed discharge are not able to return home because they are either incapable of looking after themselves or they do not have the familial support or backup necessary for them to cope. They are looking for access to long-stay residential care. Dependence on the private sector is not good enough. We have a bounden responsibility as a public health service to ensure that we are providing as best as budgets will allow, and I accept that.

I mean no criticism of HIQA's observations but it has produced a series of reports which resulted in a reduction in the number of beds in some of our older institutions. Are plans being prepared to increase the number of public long-stay residential beds at settings across the State?

In regard to Portiuncula hospital, the review will include an examination of the perinatal care provided to the seven women concerned. Since we first learned about this cohort of seven women, a significant number of additional individuals have presented with differing degrees of concern about their experiences in Portiuncula. I am told the figure may be as high as 40, although I cannot confirm it. Will the review include those individuals who have since come forward and will the review team have the power to take on board other cases that may present in the course of its work?

I inquired in question No. 7 about consultant posts across the various specialties in our acute hospital network. These posts do not include psychiatry but they do include paediatrics, pathology, radiology, surgery, anesthesia, emergency medicine, intensive care medicine, obstetrics and gynaecology. To cut to the chase, there are a total of 2,314 posts across the board but 325, or 14%, of these are not permanently filled. I acknowledge that a number are currently filled by temporary locum or agency placement but a significant number are still vacant. What steps are being take to address the need for permanent appointments to these posts and what is the expectation in terms of an increased number of posts in the course of 2015? I note that 40 additional posts are signalled but we need many more if we are to put in place a real and attractive career path for those we wish to retain in or attract back to our health system, so they can deliver their specialties and experience to Irish patients.

I submitted question No. 17 on the issue of medical cards for children. Ireland is going to be examined before the UN Committee on the Rights of the Child in January 2016. The NGOs, including the Children's Rights Alliance, will come before the committee in June, along with the Ombudsman for Children and the Human Rights and Equality Commissioner. Article 24 of the UN Convention on the Rights of the Child states:

States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.

My question referred in particular to children with life limiting or life threatening conditions. All of us are aware of the work being done by the Jack and Jill Foundation, LauraLynn and many other organisations. I meet parents who are fighting to get a medical card at a time when they should be with their children. I was particularly distressed and shamed in recent weeks after hearing about the case of nine year old Lucy, who is battling cancer. As a society we are not providing the cards that would allow parents to focus on their child. Lucy's case is illustrative but I am sure there are other such cases. Why are we not systematically upholding the right to health care of children in this situation by ensuring they are not deprived of access to treatment? I am not happy with the response to my question because I do not think we are going far enough on this issue. I hope it is not a case of waiting until Ireland goes before a UN committee before we make any progress but that is usually what happens. Instead of waiting for people from outside of the country to make us do what is right, we should just do it.

In regard to question No.18 on early supported discharge, I have raised this issue on several occasions, most recently under the committee discussions on emergency departments. Everybody seems to agree it is what needs to be done but we do not seem to have any plans to extend it. I will be following up separately on the issue with the Minister for Health.

Question No. 19 pertains to the budget for disability services. The question that arises for me is why it is not being implemented. The programme for Government proposed to allocate 5% for this area. Some 50% of the current budget in disability services goes to five organisations and 80% goes to 50 organisations. The reality is that three quarters of the current budget is being spent on services that are no longer appropriate. We are back to doing what we used to do even though we know more about what we should be doing. Everybody agreed that the situation in Aras Attracta was not on its own. We have to do much more in respect of congregated settings. The answer I received to this question was unacceptable. If it is in the programme for Government and a political priority, why are we not allocating 5% to 8% of the budget to support innovative approaches? The word "innovative" may be a misnomer because I am simply referring to bringing us to the current practice that has been developed in other countries. Why are we not creating a momentum for change so that people have the services they want? I know of one family who adapted their home but because we do not have the necessary systems, they are basically captive in the congregated setting. It is a question of dignity and equality. The best way to deal with the issue is to apportion 5% of the budget for a new way of doing things in order to create momentum over the next three years. I think we would see a huge difference. It is unacceptable to keep delaying. The closure of congregated settings was due to take place from 2018 onwards but that target will not be met unless we do something radical. It makes common sense to allocate 5% to 8% of the budget towards this. I would like a stronger commitment but I think the issue is being blocked in the HSE - I am sorry to say that to Mr. O'Brien. It is a Government priority but I think it is being actively blocked. I do not know what hold the services have, especially those which currently receive 50% of the money, but it is unacceptable. These are people's lives. I would like clear answers on this. I would prefer shorter answers rather than the cut and paste replies I have repeatedly heard on these issues.

A Member

Shorter speeches, even.

I will chair the meeting.

I kept well within my time.

Every member is treated fairly and in accordance with the rules of the meeting. I would be happy to be judged on that.

The Minister of State has the floor and six other people have indicated their wish to speak.

I will try to be as brief and clear as possible. Deputy Kelleher mentioned the fair deal scheme, which I will deal with. Others will speak about the Portiuncula Hospital issue. Both the Deputy and I agree that orthopaedic treatment is a serious pressure point as it keeps people mobile etc. We must deal with it.

We have managed to reduce the fair deal backlog with additional funding, although I fully accept it is not enough. I will continue to pursue the idea that the fair deal scheme should be demand-led and that element should ensure a more structured and planned mechanism so people do not continue in hospital where it is not necessary. I dispute all the time how we deal with ourselves and our needs as we age. It should not just be about long-stay care. It always strikes me that in the three areas where I have responsibility - mental health, disability and older people - I am charged with taking people out of institutions with two areas but with older people, I am almost charged with putting them into institutions. I will get to Senator van Turnhout's point, as I agree with her substantially. There must be a balance but the fair deal scheme must be demand-led. That will take substantial resources, although the country does not have them at this stage. We will have those resources in future.

Deputy Ó Caoláin mentioned the mental health legislation, which I received approximately four week weeks ago. We had other issues to deal with and we will publish it very early in March. The Deputy will be very happy with what the group has formulated. There was no interference and it is a very independently minded group. The work it has produced is incredible. With regard to employment, education and stigma, we must remember that the Mental Health Act is really about detention and treatment, so the new legislation cannot deal with what the Deputy mentioned. We can consider stigma and education of the people in general, rather than people with a difficulty with mental health, as something separate that needs to be enhanced. We need to put a greater focus on such matters. Each and every one of us has done a substantial job with mental health issues and there is no disagreement. Perhaps we need to start having a clearer focus on removing the stigma. We always perceive mental health to be at the extreme end with a "no recovery" model but we all know there is the possibility of recovery. People can have poor mental health and good mental health at different stages in their lives. This will be a substantial improvement. The process is human-rights based and it is geared towards ensuring that when the capacity legislation is published and enacted, it will dovetail with that work. The Deputy will be happy enough when that happens and we will have briefings for the Opposition at that time.

Senator van Turnhout commented on medical cards and the only way we will get to the point where we will not have the hard cases is when we all have medical cards. I understand perfectly where the Senator is coming from and the specific cases which she raised and which we have been working on. The legislation is written not in terms of the convention but family circumstances. If people want to change that, it is a different campaign entirely. Even two specific and recent reviews still tell us that we should not move to a condition-specific process or from the realm which stipulates that it must be based on financial means. These were independent studies.

Senator Crown may know more about this than anybody. The members can take my word, although we may not have said it aloud, that there is no barrier to treatment for cancer in this country, whether one has a medical card or not. It is one great service that has emerged over the past number of years. I give credit to both the previous Government and its predecessor in this respect.

When we have a serious look at medical cards, we know it is not always about medical access, as there may be issues with aids and appliances. We have separated that sector and aids and appliances will not be given according to clinical need. That is important to note. There is a GP card, long-term illness card and the drugs refund card. We are managing to deliver to people who are in the greatest need, although they do not fit criteria. We are managing to deliver to these people a comprehensive medical system, as far as possible without fees.

Is that not being lost in translation? If somebody has a long-term illness card or a GP card-----

A person may have both.

It can be every bit as good as a medical card.

That is being lost in translation. Where is the deficiency in that case?

We have much to do in the health sector, covering such a broad spectrum, so sometimes that type of detail is not communicated properly. I accept that fully. Somebody with a GP card and a long-term illness card is better off that somebody with a medical card because there are no prescription charges. There are facts, and it is not about me making stuff up, as Deputy Kelleher argued. Numbers for discretionary medical cards have gone from over 50,000 to over 70,000. We are using discretion and doing our very best to ensure we help people with significant difficulty. We can all only imagine what it is like to have a child in those circumstances. We are working within the legislation and I am not certain that at this point in the Government's lifetime, that legislation will be changed. Both expert groups that examined the matter have indicated that cards should not be allocated on a condition-specific manner and the process should not get away from the finance element.

It is not that the system is unsympathetic, as it is very sympathetic. We are doing our best. Taking the aids and appliances out of the realm of the medical card is a major improvement. There are people who could not change a prosthetic leg before, as it would cost €3,000 or €4,000, if they did not qualify for a medical card. We must separate such issues and having the medical card as strictly facilitating access to medical services will give us a major advantage.

Senator van Turnhout also spoke about congregated settings. I may be looking at her with a smile on my face because only yesterday I had two meetings about the issue. There is new funding for social housing which is a substantial sum. Senators may think I get annoyed about everything landing in the Department of Health but this is very much an issue related to the Department of the Environment, Community and Local Government and its delivery of housing. We are in discussions with the Minister for the Environment, Community and Local Government, and he is anxious to formulate a proposal for housing that would be delivered through funding from his Department. The support services, which are in the residential settings as we speak, must come out with a person into that setting. It is not a matter of having a house down the road for four people.

It is a bit more delicate and nuanced than that. We are now talking to the Department of the Environment, Community and Local Government about congregated settings, on how we start to de-congregate and bring people into communities with the types of support that they will need. The guy who carried out the Winterbourne investigation told me that the one big worry he had was that people coming out of congregrated settings into communities would become quite isolated and alone. We do not want to make that same mistake. We are in negotiations with the Department. We believe that, although it will not be revolutionary, there will be substantial movement very shortly.

Mr. Tony O'Brien

I will start by talking about Portiuncula Hospital, because a couple of members commented on the mention of the hospital in my statement. The final paragraph on the matter also confirmed, in relation to the cases highlighted in the media recently, that the chief clinical director of Saolta, Dr. Pat Nash, is meeting, has been meeting and is continuing to meet with other families with a view to agreeing with them how best a review of their cases can be progressed.

While the first draft of the terms of reference refers to the seven cases - there has been consultation with the families involved - it is not in any way the case that, based on discussions with those families on the most appropriate way to address their concerns, they are precluded from being part of the review, if appropriate, although it may not be appropriate. For example, it is possible that two of the families of the seven may not wish to take part in this review, and that is their choice. It is also possible that there may be other families who would be included in the review. Some of the cases, or some of the individuals who have come forward, have been involved in losses that go back as far as 35 years, so it may not be appropriate in all cases to include them in this review. Dr. Nash is proceeding sensitively and carefully to make sure the review is comprehensive and appropriate to the individual circumstances.

Is it Dr. Nash who will decide which cases are appropriate?

Mr. Tony O'Brien

Dr. Pat Nash is the commissioner of the review. He will do that in consultation with the families.

There was a two-part question on consultants, one part from Deputy Ó Caoláin and the other part from Deputy Kelleher. The conclusion of the recent talks, and the substantial reversal of the additional pay cut that consultants were subjected to in 2012, is a key contributor to our ability to resume the effective recruitment of consultants.

Deputy Ó Caoláin referred to vacancies. There will always be a certain number of vacancies due to churn, which I think is understood, but that number is abnormally high at present. However, although there have been several hundred competitions that have closed after selecting candidates, in many cases it was not possible to get them into employment until this recent pay issue had been resolved. A significant number of these posts will now be filled on the basis of competitions that have already been completed. In addition, we are now proceeding to advertise other vacancies. There are 30 posts to be advertised this week, and there will be further waves. My expectation is that while there will always be some level of churn-type vacancies, we are now going to see a significant change in the pattern of vacancies. That will bring us up, over the course of the year, to the position that we would wish to be in.

As the Deputy correctly stated, with population change and increasing demands and so on, there are always cases in which we might wish to create additional posts. That will be dependent upon an assessment of priorities, the availability of resources and then the process of a competition. We are limited by the fact that there is a scarcity of supply of specialists in some disciplines. It is not a universal issue, but this is true of certain disciplines. The situation, I think, will change quite significantly in the next short while, and the recent pay agreement is critical to that.

In regard to the broader issue, the Minister of State, Deputy Lynch, has already referred to her assessment that the Fair Deal scheme should be regarded as a demand-led scheme. In fact, in many ways it is perfectly set up to be a demand-led scheme. The problem with it is that there is lots of demand and insufficient resources, and that is a direct result of demographic change within society. Let us be clear that it is a good and positive thing that more of us are aging and that we are living longer - none of us should ever characterise that as a problem - but it does create a need. That need is best exemplified by the fact that as at 29 November there was a 15-week waiting period, beyond the process of financial assessment, to gain access to a Fair Deal bed, and the number of people in that queue stood at 1,937. Due to the measures that I referred to, by the 5 January that waiting period had been brought down to 11 weeks. That does not sound so dramatic, but the dramatic change was that the number waiting had been reduced by 759 to 1,188. Today, the number stands at about 1,234. That is partly because, as I outlined in my opening statement, we are seeing more people going on the list than coming off, even though we are taking off more people than ever. The funding we have applied will sustain the 11-week waiting period until approximately the end of this month. In the absence of additional resources to be applied to that scheme, our concern is that by the end of the year we will reach a waiting period of between 18 and 20 weeks and see 2,200 people on that list. While I do not wish to be alarmist, in many respects, when we look at what is happening in the acute hospital system right now, it could be said that the funding mechanisms and the arrangements for the Fair Deal scheme, as welcome as they are in terms of the benefit it brings to those who gain access, has become the Achilles heel of the acute hospital system. There is a direct correlation between the increase in waiting time and the increase in numbers on the waiting list for scheme, the numbers of delayed discharges in hospitals and the numbers recorded as waiting for admission on hospital trolleys each day. Unless we solve that problem we are going to be in for a very difficult year in 2015. That is not to say it is not already difficult, but it will be more difficult.

In regard to the question of where I see clinical risk, I see clinical risk arising as a consequence of that. This is the direct result of demographic change. In most Western societies which did not experience the type of economic implosion that we experienced a few years ago, when they talk about health cuts they talk about bending the curve of increase of expenditure on health. In Ireland, as of necessity, we have had to contemplate actual reductions in expenditure on health. We need, as quickly as we can - hopefully, the signs of economic recovery will facilitate this - to get back to a point at which the demographic impact can be reflected in a demographic allocation. We have not been there. I regard the service plan as realistic in that it said there would be enough money to hold services as they were but not necessarily enough to meet increasing demand.

The other consequence is that, when faced with the number of people on trolleys that we have, it is an inevitable and unavoidable consequence that access to hospitals for non-urgent elective procedures becomes curtailed. While something may not be urgent, that does not mean it is not chronic. It does have an immediate adverse impact on the person whose admission is delayed and it can mean that over time the person's condition deteriorates, meaning that he or she needs a greater intervention than he or she otherwise would. That is essentially what was referred to in the bones of the question.

Notwithstanding all that Mr. O'Brien has said, we have known about this demographic problem - that we are going to live longer and will have an increased population - for some time. In the past we spent money on health - we threw money into health - yet we still had waiting times in emergency departments, we still had an absence of step-down beds and we still had an issue with routine procedures. Have we learned from that for the future?

I heard what Mr. O'Brien said. I do not want to cause alarm, but let us make no mistake: what he has just shared with us has rung alarm bells in all our heads across this room.

I have six other people who wish to speak.

My point about emergency departments and delayed discharges was not answered. I had specifically mentioned there was no inclusion of a commitment to increase the number of long-stay public residential beds. I do believe that initiative must be an essential part of the package of responses.

I have eight other people who wish to speak.

I will give a brief reply to the question on long-stay beds. I apologise to the Deputy but I should has answered his question. Although the matter is ringing alarm bells, it is something that we have known for some considerable time.

The difference is that we do now know what we need. The difficulty is that we do not have the resources to supply it. For the first time ever we have a very good handle on the situation, what the need is and what the increasing need will be. We have 124 public sector bed units. We are determined that we will not lose any of them and we have a programme in place for refurbishment and for new builds. Mr. Pat Healy could perhaps give more details on Waterford, which is getting a new 50 bed community nursing unit, CNU. That type of development is ongoing and it is not all in the private sector. We cannot afford to lose beds in the private sector either because of the demographic demand. For the first time ever, we know what we need and we know where we need it.

Another factor which comes across from time to time, which I find very disturbing, is that not everyone in a bed awaiting another bed in an acute hospital is an older person. We must get that into our heads as well. The argument takes place that somehow or other we are concentrating on the public sector and at other times on the private sector. The beds are needed and what we should concentrate on is the quality of care. It will be a different type of care for each person. There will be step-down intensive rehabilitation and all the other treatments that are required. We are working very hard to find a solution. It is correct to say that we cannot afford to lose any bed in either the private sector or the public sector.

Mr. Jim Breslin

Deputy Kelleher asked a direct question and given the strictures that have been removed since last week, it is only fair that I respond. His question was on universal health insurance, UHI, and the extent to which the Department is working actively on it. We have staff assigned to that area and they continue to work on it. The commitments the Minister published two weeks ago for 2015 include a number of deliverables in that area, which we are working to try to achieve. A major one is to complete the initial costing exercise on UHI and to revert to the Government with a roadmap for the next steps. As part of that, we have available to us the consultation exercise that was undertaken by the Department on UHI. We are working at present with the ESRI on an initial costing analysis. When we get those two things in place, we will work on a roadmap that will look at a number of steps which have been taken, and a number of further steps that would need to be taken. The Minister will go back to the Government on the matter.

Other relevant aspects of the priorities to that policy are the Minister’s package of measures to increase the numbers with private health insurance as a step along the road and also, as the committee has debated, the universal access to GP services, the first steps which relate to children aged under six and people aged over 70. In short, we continue to work on the policy.

What about the National Association of General Practitioners?

Approximately 2,500 GPs are in the GMS system, which are the people we are dealing with right now. The barriers to entry to the GMS system have been removed substantially and more than 300 additional GPs have been recruited into the system in the past year. It is unclear how many people are represented by each organisation. The other difficulty is that we are at a very critical point in the negotiations with the IMO. We are discussing fee setting, which comes at the end of the negotiations. I will not be making that call and perhaps the Deputy could put the question to the Minister when he comes. I do not believe it would be useful at this stage to have another organisation involved because it is so late in the process. Even though GPs are represented by two organisations, they will make up their own minds on an individual basis on whether they wish to participate. If they decide not to participate, there is very little we can do about it. They are sole traders and they will make their own decisions on the matter. It would not be helpful to get involved in the negotiations at this late stage. The group clearly represents GPs, but it is unclear how many GPs are represented by either the Irish Medical Organisation, IMO, or the National Association of General Practitioners.

Mr. Tony O'Brien

To return to your question, Chairman, if we look at what has happened in the health service in recent years, it is fair to say that across a number of metrics there have been very significant increases in efficiency and productivity in the health system. The average length of stay has been cut very dramatically. Day-of-surgery admission has increased very dramatically. The throughput in the acute medical assessment units and medical assessment units, the numbers of which I provided in my script, show that there is a huge change in the way substantial cohorts of the population are cared for. Despite of the extraction of so many staff, the level of activity is up. The absence rates are down significantly in recent years. They now stand, on average, at below comparators for the National Health Service in the United Kingdom. There are very significant improvements. That is not to say that there is perfection, because of course one never gets to that wonderful state, but this is not the health service that it was seven years ago. What we are describing in relation to the fair deal scheme - we must recall that the legislation was not in place back then - is that it is a self-contained process. The only mechanism by which the health service can provide long-term care for those who have been assessed through a very rigorous process as requiring it, is through a prescribed process from a set amount of money. Even if we had the money, we could not do it outside of that constraint, and should not. In fact, it would be unlawful to do so.

We should not do it anyway.

Mr. Tony O'Brien

It is a specific channel and it is a channel with a blockage in it.

There are nine other members who want to speak.

I did not interrupt but I did not get an answer to my question on the percentage of budget ring-fenced for disability services. I would like to note that.

I will respond to Senator van Turnhout. It is not a “Yes” or “No” answer. I will discuss the matter with the Senator later. It is a bit more complex and we feel that we have found a way around it by the mechanism on which we are now working.

Mr. Tony O'Brien

For the record, I can confirm that the HSE is not obstructing any progress in that direction. The Minister of State can confirm that.

When one talks to people about it, it does not appear to be happening.

I will take the following three speakers in the order they indicated to me – Senator Colm Burke, Deputy Regina Doherty and Deputy Peter Fitzpatrick. Senator Burke has three minutes.

I thank the witnesses for responding to question No. 24. It is the same question that I submitted last September and it is unfortunate that it took six months to get the information I wanted on consultant vacancies. It appears that there are 325 vacancies in real terms. My question relates to subsection (f) of my question which is about the number of retirements expected in 2015. Again, similar to October, I have received an inadequate answer. If one takes it that there are 2,300 posts, one can assume the average consultant will work in the system for approximately 20 years and that there will be 100 retirements in any one year. The details on who is retiring and how we are planning are causing problems. If one offers a job in the morning to someone who is working in the UK, Australia or Canada, the likelihood is that they will not be able to take up the job in Ireland for 12 months. Therefore, we appear to be advertising jobs when the vacancy arises. I ask that we would get a report on how we are going to deal with the matter in the future. I note that in the reply to my question it was indicated that someone will be appointed to put together all of the data. Could we put together information on who is retiring in the next 12 months in order that we can advertise the vacancies long before they arise? It has taken six months to get a response. That is the type of change we need in terms of planning.

One of the other questions I have - I think it was question No. 26 - concerns the appointment of people without interview. I am referring to managerial and administrative staff. In real terms, approximately 1,527 people have been appointed over the past five years without interview.

It was question No. 23.

My apologies. Has a review been carried out in respect of those appointments? The HIQA report on the ambulance service clearly identified that a number of staff appointed did not feel they had the skills to do the job. I do not accept the reply here that 1,527 people were appointed without interview, and that none of them has been identified as not having the skills. I ask that we get a detailed report about what training processes were put in place for those people. We also have 184 people who went up not one, but two grades or more, in that period without interview. We need a detailed response on this matter.

I have two smaller questions before I talk about question No. 16. I welcome the announcement this morning from Our Lady of Lourdes Hospital in Drogheda about the 88 new nurses and the 25 new beds. Is extra money being allocated to pay for those or are they coming out of the specific budget already allocated to the hospital?

I want to publicly thank Mr. O'Brien and the team that was involved in the negotiations for the drug Soliris last week. The outcome must have been fiercely frustrating under the circumstances, but the gratitude of the people directly impacted is enormous. In his statement, Mr. O'Brien described being frustrated by the amount of money that had to be paid and the negotiations with the particular company. It might have been lost in translation but it appeared that his frustration was pointed to the patients, as though they were the cause of potential reduction of other services, and I know he did not mean that at all. He might just clear up the record because it caused a little bit of hurt to some of the patients.

The main thing I want to talk about is the response to question No. 16. I say this with respect, but I am sorry that Mr. O'Brien has to answer it because I would have preferred the Minister to answer the question. This committee had six full sessions on end of life and palliative care and bereavement in Ireland the year before last. The discussions spanned 32 oral and 44 written presentations. It involved a substantial amount of work and commitment from this committee to put 37 recommendations to the HSE and to the Minister. With the greatest of respect, the response we got back was far from reasoned, in my opinion. It did not do justice to the commitment, energy and sincerity not just of the people around this table, but of those involved in the area. I genuinely felt it was a cut-and-paste response, which did everybody a disservice. There were one or two things in it regarding the children's palliative care policy which were very welcome. The medical cards for children and adults who have terminal illnesses are, again, very welcome. However, it did not show any strategic thinking or vision whatsoever in this area.

I want to talk specifically about recommendation No. 15, that palliative and end-of-life patients be given a special patient status to co-ordinate the care. This was rejected on the basis that other medical specialists or patients' groups might want the same thing and therefore we might run into difficulties. We all know the vast majority of money that is spent on care is spent in the last year of patients' lives so it is already costly. Some of our initiatives and suggestions were going to save money. With respect, can I ask the Minister - in his absence - and the officials who are here to come back another day and give the work done due respect by going through the 37 recommendations and discussing them with us logically? There may be reasons some of them cannot be done, but I respectfully ask the Minister to give due regard to the ones I know can be done and to put in place some plans for how we will achieve them together.

There is a higher level of delayed discharges than there was this time last year. I realise it is hard to recruit senior decision-making doctors in some hospitals, and that junior doctors are less experienced when making decisions. What are Mr. O'Brien's plans to deal with this problem of delayed discharges when he has already allocated 300 additional fair deal places and 400 additional home care packages?

The HSE and the Department are working on getting another 200 beds open across the State in the next two weeks. Where is this happening? I believe 500 transitional and community beds have been opened or re-funded. What are their locations and what funding was given?

I also welcome the news this morning about the 88 nurses and 25 beds in Our Lady of Lourdes Hospital in Drogheda. Can Mr. O'Brien give me the plans to deal with the serious overcrowding in accident and emergency units and the trolley situation in the Lourdes hospital in Drogheda, which is one of the worst in the country? Has the HSE got a strategy in place to raise awareness of number of clinics currently available in Louth County Hospital? As far as I and people in the area are concerned, there are still too many people visiting the accident and emergency unit in Our Lady of Lourdes Hospital when they could have gone to the minor injuries unit at Louth County Hospital. I have met with the manager of Louth County Hospital, Louise O'Hare, and with Louth County Council. We are trying to put up signs on both hospital sites, stating what is available and the opening hours, and hopefully that will help.

At the last meeting, we talked about enhancing the services of Louth County Hospital, including the policy on ambulances, extending opening hours, etc. Has there been any progress made on these matters since the last meeting?

I agree with the Minister of State that a medical card is a point of access to medical care. In his report today, Mr. O'Brien stated that he has appointed a manager, which I welcome. Nearly every query I have in my clinic at the moment is to do with discretionary medical cards. We need something done urgently over the medical cards.

The last speaker listed is Deputy Dowds.

I thank the Minister of State, the HSE and the departmental staff for attending. I apologise if the first issue I raise was dealt with while I was out of the room. Could I have an update on the situation regarding the cost of drugs and advances made in reducing that cost, both for the country and for individuals? Second, I have been asked to raise the issue of meningitis by a group involved in this area. Apparently a meningitis B vaccine is available. Could I have an update on the situation regarding the introduction of the meningitis B vaccine to Ireland? Apparently it is two years since it received its European licence. Given that it is an illness that can lead to loss of life, it would be very useful if the vaccine could be provided around the country.

I will hand back to the Minister of State and the officials. Deputies McLellan, Byrne and Moloney are next, and then Senator Thomas Byrne.

I will let Mr. O'Brien deal with the drugs issue. The Chief Medical Officer has just received a recommendation on whether the vaccine should be available on the broader remit. It is not done in other countries to any great extent but we are assessing that recommendation and there will be a decision very shortly. It is not just life threatening, as the Deputy knows, but can result in very severe disabilities, including brain damage.

I ask to be kept informed as to the decision. When the Minister of State says shortly, does that mean in the next month or two?

He has only just received it but he usually makes decisions in a reasonable length of time. It is not something that will drag on forever.

I will ask Mr. O'Brien to deal with the savings in respect of FEMPI and the drugs.

Mr. Tony O'Brien

Mr. Woods will address issues relating to Our Lady of Lourdes hospital and Mr. Hennessy will address the palliative care and cost of drugs issues.

On the 200 beds referred to by Deputy Fitzpatrick, these are opening on a phased basis. Some of them are already open and others will open within a week or two, all based on recruitment profiles. There will be 16 beds opened at the Clontarf unit; 25 at Cuan Ros; 25 at St. Vincent's, Fairview; 25 at Ballinasloe; ten at Farranlea Road, Cork; four at Heather House community nursing unit; five at the Ballina District Hospital; six at Sacred Heart, Castlebar; two at Ard Evan, Carndonagh, eight at Killybegs; five at Merlin Park Hospital, Galway; five at Áras Mhic Dara; 12 at the Hospital of the Assumption; five at St. Ita's, Newcastle west; and 20 at the Royal Hospital, Donnybrook. I should emphasise that these beds are provided as responsive measures and are not permanent openings.

On the issue of senior decision-makers, there is no real relationship between senior decision-makers and delayed discharges. At the point at which a person is classified as having a delayed discharged, he or she has already completed an acute phase of care and a decision-maker has signed off that he or she is fit to be discharged. The issue of senior decision-makers is more a front of house one. In certain locations where it has proven more difficult to recruit senior consultants and there is an excessive reliance either on temporary consultants or on more junior staff because of the absence of senior decision-makers, this tends to result in a higher than typical admissions profile from emergency department presentations. This means that patients who might otherwise have been discharged by a senior decision-maker are listed for admission, which adds to the number of people awaiting admission and, therefore, increases the number of people on trolleys. The senior decision-maker issue is key in terms of trolley counts but only in a small number of locations where there are typical or patterns of difficulty in recruiting staff. This is often the case in some of the smaller hospitals on the western seaboard.

On Senator Burke's questions regarding vacancies, the vacancy profile is likely to have been changed significantly by the announcement by the Minister for Public Expenditure and Reform of a further extension to next year of the grace period for retirements. There are likely to be consultants and senior nurses who but for that announcement, because it is persons above a certain income threshold who stand to benefit, will not now, we hope, be retiring but will continue their working careers. The Senator is correct that we need to ensure that we accelerate the pace at which we recruit known future vacancies. However, in that regard we must take into account the fact that an individual is not obliged to give us significant notice of their intention to retire. In other words, until an employee has actually formally indicated his or her retirement, we would not be at liberty to proceed to recruit to replace him or her. I am certain there are ways we can improve the position.

On the issue of appointments without interview, it is important to stress that these are not persons coming in off the street into jobs. Rather, they are people who had previously been through a recruitment process and were already employees of the relevant health entity, be that the HSE or one of the agencies. The process of moving people from one role to another was a by-product of the employment moratorium at a time when certain grades of staff could not be recruited while at the same time more senior personnel were being encouraged-persuaded to leave the system via incentivised exit processes. This is one of the reasons there are so many people accounted for in this way, in addition to the regularisation process, which was broadly speaking provided for under the terms of the Haddington Road agreement. During the same period, one of the hardest cuts to the training budget in the health service was imposed. It is something that during my time in the HSE we have sought to reverse significantly. It is undoubtedly a by-product of that period that some people were promoted more rapidly than might otherwise have been the case because more senior staff were exited from the system and that they could not be supported in the way that one would wish when people are promoted. There are now significant programmes of development in place through HSE learning and development, funded external training programmes, funded third level training, action research and so on.

An internal audit is under way. We have been in correspondence with the Committee of Public Accounts in relation to that audit and in relation to the consistency of the application of the regularisation protocol to ensure it was done strictly in accordance with the terms of the relevant circular. This process is, as I said, currently under way by the HSE internal audit function.

In regard to Our Lady of Lourdes Hospital, I will pass over to Mr. Woods to comment on that. Mr. Hennessy will then comment on the drugs issue and I would like to come back in again after that.

Mr. Liam Woods

We would be strongly supportive of, and have already been seeking to include in our public notices, the wider use of the minor injuries unit in Dundalk. In regard to Our Lady of Lourdes Hospital, we are looking at a set of arrangements to support the hospital, including the provision of 24 private nursing homes in the short term. In terms of the recommendation from the LRC, that is resource-dependent and so we will have to consider it in terms of the full context of the recommendation which only arose yesterday.

Mr. John Hennessy

I am happy to follow up with Deputy Regina Doherty in relation to palliative care.

To be fair, it is not only an issue for the Department of Health.

Mr. John Hennessy

I take the point that there is a broad strategic issue across multiple Departments in relation to palliative care. In the context of the Department of Health, it is a critical service that has a huge bearing on the operation of the overall health service. It is acknowledged that the palliative service countrywide is uneven. However, as evident from the responses we are attempting to address that in a systematic and strategic way and to bring consistency and standards into place. This takes the form of addressing gaps where inpatient specialist units are concerned. There are some examples about which I can speak in detail to the Deputy, including in relation to additional consultant posts and clinical nursing posts. There is a very strong focus in our service plan 2015 on addressing this issue and on working closely with voluntary providers and the hospice foundation. I accept the point that there is a wider dimension to this that involves multiple interests, including other Departments.

On Deputy Dowds' question regarding the cost of drugs, I will forward a precise response to that question to the Deputy. In approximate terms, current reimbursement costs are €1.8 billion per annum. That encompasses drugs provided under the medical card scheme, drugs payment scheme, long-term illness scheme and hi-tech medicines. On reductions, the approximate reductions over 2013, 2014 and 2015 will be €400 million. This is part of a concentrated and ongoing programme of cost reduction on drugs and medicines designed to bring us more into line with our European neighbours. Drug components, in terms of reference pricing, and preferred prescribing initiatives, are significant issues. The process of seeking to achieve the outcome required while ensuring continuity of supply continues.

I should point out that in the coming weeks the committee will undertake work on the cost of drugs and hi-tech medicines.

While I do not wish to be rude, I think Mr. Hennessy's response to the issues I raised in relation to the 37 recommendations and six days of oral hearings is dismissive.

To be fair, it is not only Mr. Hennessy who needs to give a response. Mr. Breslin also needs to respond.

I am not blaming him. Can I get a response to my request that officials meet with members of this committee who are interested in going through the 37 recommendations?

That is a reasonable request, to which I had intended to respond earlier. I believe that a small group of people should meet with the Department and the HSE in relation to the framing of the type of strategy that we need in relation to end-of-life issues because this is not only about hospice care.

We all know that from the hearings. It would be a very worthwhile exercise to sit down and decide not just why this or that was not recommended but on a framework for delivery. The Department and the HSE would be quite willing to engage in that process.

Mr. Tony O'Brien

In regard to Soliris, or eculizumab, it was the HSE’s objective from the outset to secure a basis upon which the additional patients who needed that drug could have access to it. The purpose of the process was to try to reduce the cost of the drug. The statement I issued could not reasonably be interpreted in any sense as being critical of the patients. How it is reported may affect how it is interpreted. How it is written does not lend itself to that interpretation. All the adjectives were directed at the drug company, not the patients. The reason given for the decision was to ensure that patients were not caught in the crossfire of the disagreement between Alexion and the health service.

Is it not fundamentally wrong that a group of people, no matter what the issue, have to take to the airwaves to highlight the fact that they are deprived of something after a clinical decision has been taken to prescribe or recommend a particular product?

Mr. Tony O'Brien

It is logical that while the process is ongoing and patients are unclear as to the outcome they will raise their concerns and reflect them here, and the committee will raise those concerns on their behalf. It does to some extent affect the negotiating position that the company takes. Anyone involved in a negotiation will take a view as to where the strength of the argument lies and who will have to blink first. Ultimately we blinked, because it got to the point at which we were satisfied that the company would not change its position and that to carry on would render no benefit.

I do not resile in any sense from the comments I made. While it is reasonable for drug companies to seek to recover the money they invest in development and some element of profit, I believe in this case we are seeing excess profitability. It is not only reasonable but essential that we draw attention to that and seek to secure a reasonable cost for drugs, given that ultimately the overall budget is limited.

Mr. Jim Breslin

An interesting point, which links back to a question Deputy Dowds asked, is that a very difficult decision is made all the more difficult when there are known individuals whose quality of life is at stake. In this situation there was a very small group of people whose families and communities were, quite rightly, extremely anxious that they get this drug. That is a particularly invidious situation for everybody. I include Mr. O’Brien and the team in the HSE in that. I know how difficult it is for the family, but for any of us to make a decision where known individuals are at stake is really hard. That has resource implications, just as the question about a vaccine for meningitis B has resource implications. The only difference in the case of meningitis B is that we do not know who will be affected by not having that vaccine. It is yet to emerge, if we do not implement that, who will get meningitis B who might not have caught it if we had used the vaccine. It is a more anonymous process, but we have to weigh up its costs and benefits. We make decisions all the time on investment, whether in accident and emergency departments or on home help services, where we do not know the individuals involved. The particular flavour of the recent matter which the committee might consider in its deliberations is how much more difficult it is when it involves a very small, defined group of people. We are trying to avoid playing God in those circumstances. It is a very difficult place for everybody to be.

Why do we in Ireland find it harder to beat the drugs companies down to a reasonable price?

It is because we are smaller.

Is that the only reason?

I will take the answer to that in the next batch of replies, because some people have been waiting all morning to speak.

I welcome the Minister of State and the officials from the HSE. This time last year the waiting time for the fair deal scheme was approximately six weeks. In the meantime it went up to 16 weeks, but now, because of the resources put in, it is down to 11 weeks. It is quite alarming to hear that by the end of this year it is projected that the waiting time will be between 18 and 20 weeks.

Several families are borrowing money to get a loved one into a nursing home. The application takes approximately four weeks and they then apply to various nursing homes. If a place comes up they are afraid to lose it, so they borrow the money. After they have done that and settled their loved one, they panic in case the money will run out before the fair deal place is secured. Has the HSE received applications from several families wanting to waive the fee for one or two weeks because they cannot borrow any more money and are afraid their loved ones will lose the place and they will go back to square one? How will the HSE deal with this in the future? As soon as a place comes up families will borrow money, but it is not a bottomless pit. A family who came to me recently said the most they could borrow was €6,000. If the waiting time goes up to 18 or 20 weeks they might have to borrow €20,000, and even with that they would not secure their loved one’s place.

Are we any closer to making Daxas and fampridine available on the medical card scheme?

Mr. O’Brien said 97% of patients access specialist inpatient beds for palliative care within seven days. That is good, but is it in their area of choice? Is it suitable for families? Is it in the patients' home towns or is it miles away?

Mr. O’Brien said the number of discretionary medical cards had gone from 50,000 to 70,000 in the past year, but I presume most of that is the returning of cards that had been taken away. There are some very sick children with life-limiting conditions who are financially outside the medical card bracket. I know of a case which is so rare that there are only four people in the world on the special trials. The family has been refused a medical card. The child will undergo numerous operations. The mother has had to give up work to care for the child. Where does discretion fit into this? I am sure there is no one in the primary care reimbursement service, PCRS, who can assess how much that rare disease will cost the family.

I will resubmit my questions, Nos. 21 and 22, and break them down better, because the replies were of no help. Would Mr. O’Brien guide me with regard to whom I should send them to?

It is a pleasure to have the witnesses here, particularly the Minister of State, Deputy Kathleen Lynch.

I thank the Minister of State for her honesty. She is always up front and does not beat around the bush. I left the room - I had to go upstairs for a while - but I have listened to what the Minister of State said about the fair deal scheme, which is in crisis. The unfortunate part about it is that it is the people who are in crisis as well, the families who are dealing with it on a daily basis with loved ones they cannot manage. I was interested to hear the Minister of State say that a new community was opening somewhere - I think it was Waterford. I hope it does not end up like Hollybrook in Inchicore. Two years down the road, it is still a step-down facility for St. James's Hospital, although it was supposed to be a new 50-bed unit for people who needed nursing home care. We are now left without extra beds. It is an awful shame, because there are many people living in the Dublin 8, 10 and 12 districts who were promised that a percentage of the beds would facilitate them, and this is still not the case. I hope that the unit the Minister of State is opening, wherever it is, does not end up the same way. I have one question, which the Minister of State might not be able to answer now. When will the Hollybrook care centre open up to the community again? When will it actually take people who are living in the community, rather than being a step-down facility for St. James's Hospital two years on?

I thank Mr. O'Brien for his report, which is always informative. It probably covers too much to get in at any particular time. Could Mr. O'Brien send us some information about the palliative care response for people who are dealing with very ill people at home? What exactly is the role of the palliative care staff who come in and visit them at home? What service do they actually provide? Is it just changing a drip? More information would be very helpful.

I welcome the Minister for Health, Deputy Varadkar, and thank him for making a super effort to be here. We appreciate that.

I welcome the Minister, the Minister of State and their staff, who are always welcome to the health committee meeting. The national rare disease plan launched last summer - July, I think - was universally welcomed. It is an interesting initiative in that such work has not previously been done. It is one of the reasons there was such a positive attitude among politicians, medics and so on. Apart from saying it seems to be a good plan, which seems to be the accepted view on it, since it was launched last July there is the issue of funding, which is always difficult given our financial position. Is there any expectation that some funding will be initiated to at least make a start in implementing a very good plan? Is there an expectation that we could begin to move it along?

Could we get an update on the children's hospital on the St. James's campus and the satellite centres at Blanchardstown and Tallaght? When will construction works begin and, more importantly, when might they finish?

I have heard people talk about crowding in accident and emergency departments. I heard the Minister speaking in the Seanad last month and he talked about a minor injuries unit in Smithfield, Dublin. We have one in Loughlinstown hospital, which is also very under-used. How can you get that message out to people - to go to the minor injuries units rather than ending up in some other very crowded accident and emergency department?

Could the Minister of State, Deputy Lynch, talk to her colleague, the Minister for Education and Skills, about the difficulty regarding speech therapy for young children, especially those with Down's syndrome and, within that cohort, those who are diagnosed as mild? This is also the case for children with autism. If children go to an ordinary primary school they do not get speech therapy, whereas those who go to special schools do. It is very unfair. Perhaps the Minister of State could talk to the Minister for Education and Skills about whether speech therapy could be delivered in a primary school setting rather than in health centres, because at least the teachers know who the children are and they are in school every day. Many of them miss appointments in the health service, and months go by without the children receiving that therapy.

Finally, I congratulate the Minister on the public health (alcohol) Bill. We have been talking so much here about overcrowding in hospitals. We know that 2,000 beds are taken up every night in our hospitals by people who are addicted to alcohol.

I remind Deputies that on 10 March we are holding pre-legislative scrutiny hearings on that Bill.

I welcome the Minister and Minister of State and their officials. I have a few quick questions. I am sorry I did not have an opportunity to submit questions. Would the Ministers and the head of the HSE acknowledge, in light of the recent coverage of concerns about obstetric services, that we had a big warning several years ago with the Galway tragedy ? If we just adopted a policy of aiming for an entirely consultant-provided obstetric service, with trainees there to be trained and not to provide services, many of the problems we encounter on an ongoing basis would no longer occur. This would save money. At the moment we are spending quite a bit of money on obstetric indemnification. The simplest way to reduce the indemnification cost associated with obstetrics is to reduce the risk, and the simplest way to reduce the risk is to increase to 100% the proportion of patient decisions made by fully trained obstetricians and not trainees. This is the standard that many of us who have dealt with the private sector are used to, and I believe it is the one that should be applied. Not only is it humane medicine and logical public policy, but it will also save money.

With respect to the ongoing crisis, I am very sympathetic to the fact that emergency departments sometimes get crowded in an unexpected way in response to flu, severe winters and different things that can happen, but we do not have all our ducks in a row on this yet. I have had occasion several times in the last few weeks to see patients of mine in the emergency department of St. Vincent's hospital, and it is as overcrowded as I have ever seen it. One patient of mine is an elderly gentleman who was admitted to St. Vincent's private hospital with a chest infection, who needed to be admitted not for cancer treatment but for antibiotic treatment. His very supportive family wishes to take him home, will pay most of the costs of his support at home and will pay for their own carers, but they are aware that they are entitled to a certain level of HSE support. During the last week, for some reason I could not quite understand, the planned discharge with HSE coverage suddenly evaporated. We were told that the HSE had decided, because he was so dependent, that he needed more care than it had originally budgeted for, which is reasonable. It then stated that it was not prepared to give that care, which we can discuss, but inexplicably it said that if he was transferred back to the public hospital he would be entitled to a higher level of HSE support than he would get coming from the private hospital. At a time when our emergency department should consider issuing stilts to people coming in so they can pick their way through the trolleys that are blocking most of the floor space because we cannot get people out of beds on the other side, it is illogical that this would occur. Clearly, this is no one's fault; this person is dealing with their budget and their rules. However, there is a complete lack of joined-up thinking on this. I thank Mr. O'Brien for taking my inquiry personally. I will make the details available to him on a personal basis afterwards.

With respect to the consultant hiring crisis, those of us who tried not to wallow in schadenfreude have to say, "I told you so." Over the years, multiple attempts were made to change the conditions of employment of consultants, and we saw what this resulted in - a decline in appointments. There is one quick, simple fix, which would go a long way towards reducing the burden. Why do we force healthy, fit, intellectually capable, highly skilled people who do not want to retire to retire at 65?

Can anyone explain that to me? We do not make our politicians retire. A few of us are in the process of trying to get a test case together for the courts on this, which will be heard by judges who do not have to retire at 65. The decision is being made by Ministers who do not have to retire at 65. When Bismarck, the Iron Chancellor, first introduced the concept of retirement at 65 as an optional life choice-----

The Senator is over time.

I am not quite finished. Hear me out for a moment.

The Senator must stick to the schedule.

The Chairman let everybody else go. It is me every time. This is the third time in a row and I had to leave the last meeting.

The Chairman is fair to everybody. I will let the Senator finish on this point because he feels victimised, but the Chair is fair to everybody, in fairness.

At the time Bismarck introduced this policy, the average age at death of a German was 41. The average age at death of a German who was still alive at 65 was 67. On average, people lived two to three years after retirement. A woman who is alive at the retirement age of 65 now will live well into her 80s, as will a man. The average age at death is approximately 80 for a man and mid-80s for a woman. At a time when we cannot sustain the burden of pension debt, why are we forcing people who do not want to retire to do so? I do not get it at all and it makes no sense. I have seen very healthy and fit people. A particular surgical colleague of mine who was running a clinic, operating, teaching students and running a research lab one day was told the next by the State that he had to become its dependant. By the way, the same State subsequently hired him to a very full administrative role in which he is doing a very good job.

For the record, non-spokespeople had an average of three minutes to speak while Senator Crown got six. He can pick his stilts through the timekeeping on that one. I welcome Senator Thomas Byrne who is joining us in place of Senator Marc MacSharry. While he has not formally joined us, he is very welcome to the committee. We look forward to working with him.

I want to follow up on Deputy Pearse Doherty's important question on Soliris. Mr. Tony O'Brien's comments to the committee this morning have already caused a stir locally. They were broadcast on the news and I have received many phonecalls on them. They appear to be directed at the patients. This type of comment does not appear to be placed before other resource issues. The Supplementary Estimate-----

To be fair to Mr. O'Brien, he said in his presentation that he was not aiming his remarks there. He said that the adjectives he used were aimed at the drugs companies.

For clarity, he should simply withdraw that paragraph. One could easily apply the same logic to the Department of Justice and Equality, which the Minister for Health, Deputy Varadkar, said in his Supplementary Estimates speech was responsible for €52 million of extra cost last year on foot of delays in periodic payment legislation for catastrophic medical accidents. Why is the Department of Justice and Equality not being targeted in the same way? We are talking here about three or four patients, one of whom had to answer questions on this very point last week on radio. While I have not discussed the matter with him since, it appeared to be very difficult for him from what I heard on the radio. Mr. O'Brien should withdraw the statement and get back on board with whatever negotiations he is having with the drug companies. It was an extremely unfortunate thing to say. When I received the e-mail from the HSE last week announcing the provision of Soliris, which is already being provided to ten people and was just being extended to three or four others, I refused to send it on to the individuals who had been in touch with me as they would have been very hurt had they seen it. Of course, they saw it eventually. It was very unfortunate and seemed to be a spanner in the works of a good news announcement extending a drug that was already available to other patients. Mr. O'Brien needs to withdraw those comments.

My question is on the HSE appointment of locums. It goes to the issue of a number of investigations which are under way. If someone is working in a hospital as a locum and an error is made, nothing prevents that person from being re-employed in another hospital. There is no mechanism to record issues. There is an issue arising where a hospital is short a doctor on a Friday, for example, and rings up to find that the only person available is someone who may have had difficulties in other hospitals but is put in to a job for the weekend. There is no record within the HSE on this issue. I ask for something on that. Is there a mechanism for dealing with this issue?

I apologise for being late. I was in Strasbourg at the European Parliament and my flight connection was late. I hasten to add that while the flight was late; I was not. I was perfectly on time, but these things happen sometimes and ministerial air transport is not as available as it was in the past. I had to get a later flight. Thanks to modern technology, I have been able to tune in on my iPhone for most of the morning and have followed the proceedings. I will touch on some of the questions and Mr. O'Brien and Deputy Lynch will want to come back on others. There is probably no point in making my opening statement at this stage.

On the national rare diseases plan, I am very keen to see a national rare diseases office opened this year, if at all possible. It will not require a huge spend this year. People can often be very frustrated when a great deal of work is done and programmes, statements and strategies are produced and agreed which are not followed up on. It is important that we at least make a start on that one in 2015.

Deputy Mary Mitchell O'Connor asked about the children's hospital and satellite centres. The planning application for the children's hospital on the St. James's campus will be lodged in June. The design is being finalised and is hugely exciting. It will be an iconic building. It is really impressive and even has its own football pitch. At the same time, the planning applications for the satellite centres at Blanchardstown and Tallaght will also be lodged. While it will then depend on An Bord Pleanála providing planning permission, there have been extensive pre-planning negotiations. Assuming it gives permission within 18 or 36 weeks, as the case may be, we can certainly commence site works by the end of the year with tendering and construction commencing in 2016. There has been a great deal of talk about what we are going to do in 2016 and how we are going to commemorate the centenary. I am very enthused by all the different plans for 2016, but there will be no better testament than to begin the construction of our national children's hospital on the site of the South Dublin Union, which, of course, was one of the sites of the Rising 100 years ago. It will be to recall the commitment in the Proclamation to cherish all the children equally. Construction is to start on the satellite centres next year and they can be open to see patients at Blanchardstown and Tallaght in 2017. It will be 2019 before the main hospital at St. James's will be fully constructed and it will start to see the first children then and be fully commissioned over a period of months after than.

The Deputy is completely right about the minor injury units. There are units at Loughlinstown, Smithfield, Cork, Dundalk, Roscommon and Monaghan. They are not open 24-7 but they are open a great deal of the time. Mr. Tony O'Brien and I have discussed ways in which we can advertise that a bit better in order that people know these services are available, use them a bit more and are not waiting in emergency department waiting rooms when they could be seen elsewhere. The downside is that the HSE will no doubt be criticised for spending money on PR again, but this is an occasion when spending money on a bit of advertising and public relations makes sense.

I thank Deputy Mitchell O'Connor for her comments on the public health (alcohol) Bill. We have a lot of problems in our health service, not least issues such as overcrowding in emergency departments and long waits for treatment. We can address that in the short term by-----

There is significant interference with the Minister's microphone.

Does the Minister have a pacemaker?

Not that I am aware of, Jerry. I do lose time from time to time, so maybe I have had a pacemaker put in. It is Jerry and the pacemakers.

Alcohol, obesity, smoking and inactivity contribute to a significant number of problems in our emergency departments and I am very keen to start doing things in that space. I know members are engaged in pre-legislative scrutiny of the public health (alcohol) Bill and I welcome their input. Nothing is set in stone and I am very keen to hear members' views as to how the Bill might be improved.

Senator Crown had a query regarding maternity services. We have been paying a great deal of attention to maternity services in the past year or two. It is important to reiterate that maternity services in Ireland are safe. In Ireland some 60,000 women are pregnant at present, and for many this is their first pregnancy. These women do not need to be worried unnecessarily about concerns about our maternity services. That is evidenced by the fact that our maternal and perinatal mortality rates are on a par with anywhere in the western world. We have more consultant obstetricians and midwives than ever before. Although we do not have enough of either, we have more than ever before at a time when our birth rate is falling, not increasing. That is not to say that mistakes are not made. Medicine and midwifery are judgment calls. One will visit a patient, examine and conduct investigations, talk to her, put all the information together and make a decision. Sometimes the decisions that are made are wrong, but that does not mean that the standard of care is poor or that doctors or midwives are not competent. Sometimes there is malpractice, and when it occurs, it is important that there is open disclosure. It is important that hospital management, doctors, nurses and midwives are honest with patients and their families about what happened and engage in full and open disclosure. It really bothers me that this is not always the case, even though that is the policy. It will become the law in the future if I have anything to do with it.

Senator Crown has suggested that midwifery services be entirely consultant provided. I do not agree with that. The Senator and members will agree that we always need doctors in training but perhaps the ratio of doctors in training to the number of consultants is wrong. Perhaps we need more consultants and fewer doctors in training, but one always needs a stream of doctors in training coming through in order that we have consultants. We have a very good community midwifery service and some very good midwife-led units in the country. There are many models in other parts of the world, from Finland to Holland, where many of the maternity services are midwife-led and not consultant-led. We are working on a maternity strategy this year and I want to have it completed this year. Some aspects of it may turn out to be politically controversial, but I am not bothered about that as I am more concerned about high quality maternity services than votes. Part of what will have to be considered in the formulation of the strategy is the appropriate ratio of consultants to doctors in training and whether there is scope for expanding our midwifery-led services as well. Perhaps the consultant-led medical model is not the correct model for all maternity services in Ireland. I cannot answer the question regarding patients and perhaps a member from the HSE can do that.

I agree with Senator Crown's comments on the retirement age of 65 years. The new contracts do not require that doctors retire at 65. However, some existing contracts do and a contract is a contract. I have no personal objection with doctors staying beyond the age of 65 years. Quite frankly we need them, so if they are willing to stay on, we should be very open to it.

I read the statement and I heard Mr. O'Brien's comments on my way in on the issue of Soliris and it is very clear that any criticism was directed at the company and absolutely nobody on this side of the table or anyone under any circumstances wants to be or intends to be critical of patients. We will be critical of vested interests on occasions where it is necessary.

Mr. Tony O'Brien

I will respond to some of the questions asked by Deputy McLellan. The Deputy raised a real issue in respect of the fair deal scheme and the times when we have extended the waiting period beyond financial approval for access to the scheme itself. We know it results in some families going to extraordinary lengths to care for their loved ones, as is perfectly understandable. Unfortunately, access to funding is governed by the legislation which requires that it is done in chronological order, which means places are allocated in the order in which people applied and were approved. We are not in a position to provide financial assistance outside of that. I will ask my colleague, Mr. Pat Healy to comment on people asking for exemptions.

Mr. Pat Healy

We are very sensitive to the fact that families and individuals are under pressure. The guidance we give to our local offices is to be sensitive to the needs of people and help them to understand very clearly where they are on the waiting list. We try to give them the likely waiting time of, say, ten or 11 weeks, depending on where they are, and by and large it arrives around that time. One cannot be absolutely exact as it is fluid, but we try to provide as much information and guide people as to when they are likely to get the formal place and to expedite it as quickly as possible.

The review of the fair deal scheme is almost complete. The one thing it will tell us is that the fair deal scheme is unsustainable in its present form. The idea that a person with means would pay in the range of €250 to €290 per week for a service that is costing anything up to €1,200 to provide is unsustainable. I take on board the point made by Deputy Catherine Byrne. In my view people who never owned their own home, always rented a house from the local authority, and have no other income other than the State pension should be protected in terms of access to the fair deal scheme, but there will have to be changes. It is an incredible scheme. It is called a fair deal for a very good reason, because everyone has access to it. We have to take a serious look at the additional funding that will be needed. Some of the funding will have to come from the public purse but equally we have to look at other sources of income. I am not going to pre-empt what is in the review but if it does not deal with the funding element of it, it will have done a very poor job. There are other elements and I hope it will allow people in the community access to fair deal while still being able to remain in their own home. We have to step back and take a serious look at the scheme. I hope that people who have an interest in it would come together with us and take a look at how it can be achieved.

Mr. Tony O'Brien

We publish detailed data in each of our performance assurance reports on palliative care. I think the sort of referral may go some way to answering the question. For those gaining access to palliative care as an inpatient, 49% are referred from their home, 47% from an acute hospital, from which we infer that it is geographically proximate, 2% from a care home and 2% from a non-acute intermediate care or private bed. The primary diagnosis breaks down at 88% cancer and 12% non-cancer. In the age breakdown, less than 1% are aged up to 17 years; 30% are aged 18 to 64 years; and 69% are 65 years or over. Access is reasonably timely.

Deputy Catherine Byrne asked a related question about palliative care in the home. That is comprehensive care and I can provide the Deputy with the detailed answer but it would include infusions, pumps and dressings.

Pain management.

Mr. Tony O'Brien

Those things after pain management. We will provide her with the detailed answer. I will ask my colleague, Mr. John Hennessy, to come back to Deputy McLellan on her question on discretionary medical cards and on Daxas and Fampridine

I am sorry if we have not correctly identified the information that Deputy McLellan wanted. Sometimes we do not always fully get it. I will ask Mr. Ray Mitchell, who is here, to engage with the Deputy to ensure we have a proper understanding of what she requires and that she gets it.

We have discussed the issue of Hollybrook before. It is currently in use for a specific purpose. I understand, although I do not have the data, that many of the patients who are in it for its current purpose would be from the geographical area but it is not being used for its intended purpose. This is a transitional use linked to development of the national children's hospital.

In respect of the matter raised by Senator Crown, of which he was kind enough to give me advance notice, we will look into it.

It is clearly not intended for it to work in that way.

On the broader issue of obstetric services and emerging issues, we are in the process of putting in place a specific office in the National Hospitals Office to deal with this. It will be somewhat along the lines of the national organ donation and transplantation office and the national cancer control programme to bring a specific focus to how we manage the improvement in obstetric services. More will follow on that in the coming weeks.

I do not have access to the statement I made in writing on Soliris but it was made carefully. I will listen back to the comments I made this morning but I do not believe any reasonable person could construe it as a criticism of the patients in question. I have to be in a position to express a view about any drug company that seeks to charge more than what I consider reasonable for a particular drug. The reason we were commenting on it was because in this instance we were required to make a decision on it. In the other instances to which the Senator referred, we were not required to make a decision.

On Deputy Mitchell O'Connor's question on speech and language therapy for children in mainstream education, it is the progressing disabilities policy, a policy with which we are full steam ahead. There has been some opposition from some quarters but most are now on board.

Mr. Pat Healy

As part of rolling out that new programme which joins up the services provided by voluntary providers, the HSE locally, the Department of Education and Skills and schools, 80 posts were made available last year, 33 of which were speech and language posts. This year, 120 posts have been made available with 50 of these being speech and language. We certainly recognise the importance of meeting the challenge of dealing with waiting lists for speech and language therapy services for children.

The difficulty mentioned by the Deputy was that up to this point, the community waiting times were significant but a child in a specialist school got it as part of the school’s service. As we are mainstreaming people with disabilities, we are hoping the service will be delivered in the community for everyone.

Mr. John Hennessy

I will write to Deputy Sandra McLellan on the reimbursement of the named products as I do not have the information to hand. We could spend the day discussing how the discretionary medical card system works. Due to confidentiality reasons, I will not be able to speak about specific cases. These applications are treated extremely carefully as it is a statutory scheme. The decision-makers and medical assessors involved in the assessment take account of the impact of medical conditions. That is done by medical staff and includes ensuring children have access to the health services they need without undue hardship. The figures the Minister referred to earlier speak to that too, namely, that the number of discretionary medical cards has increased by 25,000 over the past six months.

Discretion is stretched to the limits available under the scheme. As the Deputy knows, a series of reforms are under way with the General Medical Services scheme. The first meeting of the clinical advisory group was held this week which will continue refining the discretionary medical card system further.

It must be borne in mind that the expert panel, when it considered this issue last year, could not distinguish between one medical condition and another where access to medical cards is concerned. In the end, it reverted to means as the only appropriate way to deal with it. As the Minister outlined, it must be remembered that people have access to health services regardless of whether they have medical cards. That includes hospital care, definitely cancer care, as well as the long-term illness scheme, the drugs payment scheme, grant support for the supply of equipment based on clinical need and therapy supports. Community intervention teams, which have been very active over recent weeks, are available to the entire population regardless of medical card status.

Medical officers have regard to the reality of medical conditions when doing their assessments and the impact of those conditions. The issue of hardship will always be a difficult one.

The point I was making was that if the HSE does not understand the medical condition, how does it define the hardship associated with it?

I raised a question about the case of a non-consultant hospital doctor moving from hospital to hospital. For example, one week one could be working in Dublin and then working as a locum in Cork the following week. Errors could be made but no records might be kept to ensure the same person is not put into a locum position at the last minute in another hospital. What is done in this regard?

I want to return to the issue of Hollybrook community nursing unit in Inchicore. When local people telephone me asking why people living in the area cannot access the unit, I have to tell them it is a step-down unit for St. James’s Hospital to facilitate the national children’s hospital. When this unit was first opened, I stood on a platform as a local public representative telling people the facility would be used for people living locally. I welcome the fact the children’s hospital will be located at the St. James’s Hospital site. However, the Hollybrook facility was to provide new beds for the local area. This did not happen. It has left me in a very vulnerable position as a public representative locally. I attended all of the meetings for the planning application for the Hollybrook facility.

I have been promised numerous times at this committee that Hollybrook will return to being a nursing home care unit for respite but it has not. I want an answer on this because I cannot tell people lies. I am obliged as a public representative to tell them the truth when they come into my office and ask me why they cannot get an elderly person living in Inchicore into Hollybrook for respite care, even for a week, when it is on their doorstep. It is not acceptable they are told to go somewhere else. I will keep on bringing up this issue until Hollybrook returns to its original designation as a nursing home, not a unit to facilitate St. James’s Hospital.

Before the election, will a detailed policy document be published on universal health insurance to allow for a proper adjudication on what it will entail?

The Minister stated his aim was to provide a realistic budget for the health services for 2015. Is it realistic considering what was stated this morning? As Mr. O’Brien stated this morning, if we are to continue with the existing profiling, the fair deal scheme will be under serious pressure by the end of the year, hospital waiting times could be up to 20 weeks with 2,000 people or more waiting for the cancellation of elective surgeries.

Will there be a requirement for a further injection of money into the health service to alleviate the pressures forecast by the HSE? It is clear that a review of the fair deal scheme is necessary because it is unsustainable at present. If it is demand-led, it needs to be underpinned by funding on a continuous basis. I recall when the scheme was first published that the fear of God was put in people that their homes might be taken. I assure the committee I was not spreading those rumours. It is important that the terms of the review be published in order to allow a debate on how we fund the scheme. This is about the future as well as the here and now.

I have a question on organ donation. Like Senator Burke, I know a number of people in Cork who are concerned about the issue of organ donation. I would also like a reply to the question on the recruitment of consultants at Beaumont Hospital.

I ask the Minister of State, Deputy Kathleen Lynch, to respond to the question on the fair deal scheme, and the HSE will deal with the question about recruitment in Beaumont.

I listened to Mr. Breslin's answer to the question about universal health insurance on my trusty iPhone. That is the position. We are pressing ahead with the first concrete step, which is to provide free GP care for those aged under six years and over 70 years, and we continue to widen discretion for medical cards. I do not like the term "private health insurance" because it is just health insurance. We do not have public health insurance in Ireland. I want to make health insurance more affordable, and this initiative is already showing good results, with an increase in the number of people with health insurance in the last two quarters. I expect to see a significant increase this quarter and next year with the introduction of lifetime community rating. When we receive the findings of the work from the ESRI and the Health Insurance Authority in the next couple of months, I will bring a roadmap to the Cabinet on further implementation of UHI. It will then be a matter for the Government to decide whether to proceed on the basis of that roadmap, but I think it is the way to go. However, the issue is much more complicated than anyone appreciated at the outset, not least because we do not even have a basic patient identifier for every patient in the country or a single financial system across the hospitals. A considerable number of building blocks need to be put in place before we proceed further. If we have learned anything from Irish Water, it is that we should not set up new entities in a hurry.

There are various ways of measuring the health budget, including outturns, Estimates and income from different sources, such as insurers, car parks and payments received from patients. This is the first time in seven years that we have increased the budget, which is a considerable achievement. The increase is approximately €150 million, or 1.5%, which allows us to end the cycle of cuts and make targeted improvements in a number of areas, including mental health, primary care, hepatitis C drugs and the extension of BreastCheck. Money is still tight, however, and the 1.5% increase in our budget is reflected in the 1.5% increase in the budget for the fair deal scheme. If there is a backlog or an increase in demand, the money is not available to deal with that. The Minister of State, Deputy Kathleen Lynch, the witnesses from the HSE and I are in a similar position to everyone else working in the health service, whether they are managers or working on the front line. We are trying to deal with a wide range of problems and a huge level of demand on the basis of constrained resources. We are spending €1.5 billion less than we did seven years ago and we have 15,000 fewer staff. Not many other countries are in that boat. I assure the committee that we are doing our best within these limitations, and we will continue to do so.

On the issue of discretionary medical cards, members will appreciate that I cannot comment on individual cases. I do not have access to patients' information or financial details and I do not make decisions based on individual cases. I have some responsibility for the rules, however, and we have made a number of reforms. Terminal illness cases have medical cards for as long as they are needed. Random reviews of discretionary medical cards are no longer carried out. Discretionary card appeals go to medical officers for adjudication. This is important because it means it is not just a financial decision made by a computer or an official. Local health officers can make a visit if an issue arises, and can offer other supports including aids and appliances or a doctor visit card. Supports are now available which were not available in the past. For example, the cost of wigs for children undergoing cancer treatment is reimbursed regardless of income. A number of changes have been made in that regard. The number of discretionary medical cards is now 75,000. Approximately half of these are restored medical cards and the other half are new cases. Including doctor visit cards, the number of medical cards is 108,000. I expect the number will continue to increase, because it is my view that we need to widen discretion further. This will be done with the assistance of the clinical advisory group that was recently appointed. The Minister of State, Deputy Kathleen Lynch, and I will be meeting the group in the next couple of weeks to see how we can widen discretion to take in more of the hard cases we hear about from time to time. However, as I said last November when we announced the ten-point plan to reform the medical card system, as long as there is a threshold, whether that is a means test or a sickness test, there will always be people who are just above the threshold. All of us know cases of elderly people who are €5 or €10 above the threshold. If we raised the threshold by €10, there would still be people who were just above it; they would just be different people. The same issue would arise for any kind of sickness test or medical needs test. The only solution to this is universality, which would mean individuals and families were not required to submit reams of information about their finances and health. This is why it makes sense to provide medical cards to those aged under or over 70. It is the first step towards no longer making a distinction between people based on means or sickness tests. I hope I can make the argument more strongly in the next several months that the solution to unfairness and anomalies in the system is to get rid of means tests and sickness tests and replace them with a universal system, beginning with the youngest and oldest in society.

In regard to the review of the fair deal scheme, I agree with Deputy Kelleher. The two most successful programmes for delivery of health in this country were in primary care and mental heath, because everyone bought into what was planned for the future. That is the way we should proceed. When the review is published I hope everyone with an interest in the issue will get together to discuss it. The review might tell us that people in the community should be able access the fair deal scheme or to get home help and enhanced home care packages to allow them to stay in their own communities. The scheme is based on the individuals concerned contributing 80% of their income, but that clearly would not work in a community setting because the individuals would still have to buy their own food and pay their bills. These details need to be hammered out, but we have to consider the issue carefully. The scheme is fair in that it allows people to access care on an equal basis. However, times and needs have changed. We need to consider the issues arising in a broad context, as well as ensuring those who cannot pay are protected.

I hope when the review is published that we will be able to get together, sit down and take a serious look at how to deliver this care into the future.

Mr. Tony O'Brien

We will take Senator Colm Burke's question on non-consultant hospital doctors away and see how we can improve that. I ask Ms Angela Fitzgerald to answer on the issue of recruitment for the transplant service.

Ms Angela Fitzgerald

It is important to say that there was a great deal of negative media coverage. It is not correct to say that there is a risk associated with our being a net exporter; nor is there any threat to the programme. That is important to say for people who are waiting for transplants as well as for the committee today. Two issues were raised. The first was the issue of transplant surgeons, and we have some vacancies in that regard. One vacancy has arisen through retirement, and we might take on board some of the comments that were made here today on retirement age. One vacancy arose on foot of a personal decision by a person to go back overseas.

We should compliment Professor David Hickey, who has been a pioneer. We thank him and wish him well.

Ms Angela Fitzgerald

It is also a testament to the surgeons in Beaumont who have agreed to continue to work on the rota, which continues as normal. Last year, there was an increase on the previous year in terms of the number of donors under the living donor programme. What we are looking at is both short-term and medium-term solutions. Positively, there has been very good collaboration between Beaumont and St. Vincent's at two levels, one of which is retrieval. One of the reasons transplant is not an attractive discipline is that people are up at night. A surgeon gets called in to retrieve organs and then has to transplant them. We are looking at what happens in other countries where there is a shared rota around retrieval. It will help immediately. The other issue is the pancreatic programme which Professor Hickey was involved in. We are looking at ways for St. Vincent's and Beaumont to collaborate. The important message is that the programme is stable right now. Some immediate actions are being taken to deliver on the transplant complement. The other thing we are looking at is that transplant surgeons also do urology work. We are looking at developing urologist posts, which has happened. The post holders have been appointed and will take up their duties. That will ease the burden of the workload.

The other question raised was on donation. It is fair to say that last year donation levels dropped. It is not always understood why that happens. What we have looked at is what works well in other countries. The Spanish model is one under which consultants are appointed who promote the concept of donation actively within their hospitals. I think that is what was referred to in Cork. Six posts have been approved, one for each hospital group. The role of the post holders will be to advocate actively with families to donate organs. The posts have been approved and the recruitment process is under way. We are also changing the model of co-ordination for procurement, which will also enhance donation rates. The last thing is that we have put nursing staff in who will promote organ donation on the ground. A number of immediate actions are happening in respect of both the short term and the medium term.

The committee has published a number of reports on organ donation, concussion in sport, deep-brain stimulation and palliative or end-of-life care. We might consider meeting in private session to discuss how we can advance all of those reports. We seem to have got little or no feedback on some of them. In the case of end-of-life care, it has been disappointing to the members. We might liaise with Mr. Jim Breslin and the HSE on that issue. I think we are finished.

I have a question. I was at the Order of Business.

We have been in session since 9.30 a.m. I will give the Deputy two minutes.

Mr. Tony O'Brien recently expressed some surprise at and challenged the perception that there was manipulation of outpatient appointment waiting lists. He challenged the notion that people suffering chronic pain were being written to on the closure of outpatient appointment waiting lists. In fact, the Minister himself challenged The Sunday Business Post on the affirmation that sick people were being written to across the State positively confirming that there were no referrals being accepted across many of the pain clinics and other specialties in our hospitals. I have collated hundreds of letters from sick people who have received correspondence to say that as a consequence of resources, no new referrals onto waiting lists for outpatient appointments are being accepted. One of those letters concerns a referral to a pain clinic in Dublin. The letter states that as a consequence of the lack of resources, the clinic will not accept any new referrals onto outpatient appointment waiting lists. I have a catalogue of correspondence to people, families and GPs expressing concern with respect to the stockpiling of sick people who cannot get onto a waiting list. I would like Mr. O'Brien to comment on the status of people who are not on a waiting list for urgent attention for pain relief or in respect of other disciplines. They are not showing up in the statistics.

To be fair, the practice in the committee has been that Deputy Keaveney's party colleagues on the committee have the facility of putting in questions in advance to the HSE and the Minister. They are Deputy Billy Kelleher, Deputy Robert Troy and Senator Marc MacSharry, who has been replaced by Senator Thomas Byrne. To be fair to Mr. O'Brien, he may not have answers now to the questions Deputy Keaveney is asking. To help the Deputy, I suggest that he forward to Mr. O'Brien for reply his catalogue of information. Perhaps Mr. O'Brien or his officials might meet with the Deputy separately. I am trying to be fair to everybody and have given the Deputy time. We have been here since 9.30 a.m. with Mr. O'Brien and the Department.

I would like a reply on the public record. I appreciate that the Chairman is trying to be fair to me, but I am trying to be fair in the context of transparency by having a public comment from Mr. O'Brien, who recently denied that this situation existed.

Mr. Tony O'Brien

I am not sure if the position the Deputy is putting to me is the same situation I may have spoken about in relation to issues raised by The Sunday Business Post.

I am not sure either.

Mr. Tony O'Brien

I am not sure comments I might have made about an assertion in a particular newspaper that there was a national policy of doing A, B or C relate to what Deputy Keaveney suggests about specific instances. My suggestion is that Deputy Keaveney provide us with that file and we will engage with him on it.

At Mr. O'Brien's earliest convenience.

Before we finish, I thank the Minister, Deputy Varadkar, the Minister of State, Deputy Kathleen Lynch, Mr. Jim Breslin and his team from the Department of Health and Mr. Tony O'Brien and his team from the HSE. I thank Mr. Ray Mitchell for co-ordinating the meeting today. I thank everyone warmly for participating. The Select Sub-Committee on Health will meet on Tuesday, 17 February 2015 to deal with the issue of plain cigarette packaging, and the joint committee will meet this day week.

The joint committee adjourned at 1 p.m. until 9.30 a.m. on Thursday, 19 February 2015.
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