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Seanad Éireann debate -
Wednesday, 15 Jul 2015

Vol. 241 No. 8

Transplant Patient Services: Motion

I welcome the Minister for Health, Deputy Leo Varadkar.

I move:

That Seanad Éireann calls on the Government to ensure:

- the vacant posts in Beaumont Hospital in urology, with an interest in transplantation, be categorised as very urgent and receive an exemption to the current pay scales on offer;

- the recent practice of instructing transplant patients to attend hospital emergency departments be complemented by providing access to senior specialist nurses or attending renal registrars first; and

- the commencement of the treatment abroad fund to provide dual kidney and pancreas and pancreas only transplants for people on the waiting list in order that the available donated Irish organs can be utilised.

The issue with respect to Beaumont Hospital and the situation regarding the retirement of Mr. David Hickey is causing great anxiety among the 526 people who are awaiting kidney transplants and the eight people who are awaiting pancreatic transplants. As we can imagine, the uncertainty surrounding organ donations services in such a life and death situation is a concern for a patient who is waiting for a telephone call regarding their situation.

We included the first point in the motion following consultation with those who are experts in the organ donation area. The current pay scale being offered to recruit a new surgeon is €110,000. That can be compared to a pay scale of €700,000 on offer in the United States for the same level of expertise. It is little wonder that the four attempts to fill the post have not succeeded. The description for the post needs to be changed to some extent and the pay scale on offer must be breached. Otherwise, it does to matter how many times the HSE advertises the post, when we are competing with Canada, the United States, England and Australia for the same very small pool of experts we will not win that battle. The Minister must overcome the issue of breaching the pay scale for this post.

I note from a reply the Minister gave Senator Colm Burke in response to a Commencement matter he had raised on this issue - I look forward to hearing the Minister's reply to this motion - that the Minister did not address the issue that these patients are being instructed to attend emergency departments. As the Minister will be well aware, the last thing a transplant patient, who is ill, should do, or should be told to do, is to go to an emergency department, but that is what these patients have been told to do. A clear message needs to be sent from the Department that such advice is being reversed and that access to specialist nurses will be made available for these patients, as it was available in the past. The advice that has been given beggars belief and obviously that came from someone who does not understand the risks of sending a transplant patient into an emergency department where he or she will pick up an additional infection, if he or she does not have one already. It can life threatening for a person to go there. Those patients need to access to specialist nurses and to the treatment abroad fund. I look forward to the Minister's reply on that point. I note that he stated in that reply that every effort was being made. Four attempts have been made to fill this post without success. A fifth attempt will hardly be successful if the same pay scale and conditions are offered. Unless additional funding is put in place, we will get the same result.

I ask the Senator to conclude.

The most important point is that the hundreds of people who are awaiting organ transplants are suffering anxiety and in a state of distress as a result of this uncertainty.

I second the motion and thank the Minister for coming to the House to take it. I have written to him about this issue and have had a response from the Department. Other colleagues in this and the other House have also written to him about this issue.

The bottom line is that I have met pre-transplant and post-transplant patients and what is being asked of them is extremely unfair. I know that there are problems with filling this vacancy. I am referring specifically to the pancreas side of services. Of course, the Minister cannot magic up a surgeon who will take the job. Some points set out in the reply he gave to Senator Colm Burke's Commencement matter last week are completely incorrect. It is stated in the reply Beaumont Hospital wrote to all the patients in May, but it did not. It did not write to the pancreas transplant patients. It is stated a joint assessment clinic for the eight patients who are waiting for a transplant will be held on 24 July, but those patients know nothing about it. It is also stated they will not have to go to the emergency department - they know nothing about this - and that they will go to the co-ordinators. That is not happening. I hope the Minister has come to the House in order that these points can be clarified.

With others, I have met these patients and know that the Minster wants to resolve this issue. I am raising this issue on a humanitarian basis, not on a political basis. The fact of the matter is that these people should not be going to an emergency department. The Minister will probably give a response to the motion about kidney and pancreas transplants, but I would like him to focus specifically on the pancreas side and the replacement of Mr. David Hickey. I am interested, first and foremost, to the hear the Minister's response. What we are looking for is very clear. If we cannot provide the service here, let us pay for it to be provided abroad for these patients. The National Treatment Purchase Fund was in place to provide for this. Let us make sure these patients have access to the co-ordinators.

As I am very tight on time and I am more interested to hear what the Minister has to say, I will leave it at that. He knows what the situation is. This is a life and death situation which has to be sorted.

I welcome the Minister. He gave a comprehensive reply when I raised this issue as a Commencement matter. I want to refer again today to the issue of long-term planning and the need to ensure vacancies are flagged at an early stage. I know it is not within the Minister's powers to resolve that immediately. The last time I debated this matter with him, I made the point that the HSE was unable to tell me how many consultants intend to retire during 2015. This is fundamental to this whole issue. If we are trying to plan for the filling of vacancies, information needs to be available at central level. The HSE needs to know what positions are likely to become vacant in the next 12 months. That would enable the advertising process to start before the vacancy arises. If I offer a job to someone who is working in Canada, it is likely that it will take him or her at least nine to 12 months to come to Ireland to take up the job. It is extremely important for us to take that into account, especially in the very specialised area of transplantation. A degree of urgency is required in forward planning. We are experiencing problems as we try to fill vacancies. Reference has been made to the €110,000 pay level. In fairness, people can come in on different increments. They do not have to start at €110,000. There is discretion in how that is managed. I would make a complaint in this regard, however. If a person who has worked as a consultant for three years also has an MBA degree, that is not taken into account when the pay scale at which he or she should start is being calculated. I think there is some intransigence among HSE management regarding this matter. It is an issue that needs to be resolved. The manner in which we deal with this entire issue needs to be prioritised.

I welcome the opportunity to speak to the motion. I thank the Minister for making himself available at short notice to debate it with us this evening. It is literally a matter of life and death. I thank Senator Mark Daly for proposing the motion. I acknowledge the particular interest he has shown in the issue of organ transplantation in recent years. I am aware that it is a personal priority of his. I first raised this issue in April after I was contacted by someone who pointed out the delays occurring at that stage - four months into the year - in replacing Dr. Hickey and the other surgeon who left the team at Beaumont Hospital. I thought the delay was unacceptable at that stage; therefore, it is nothing short of frightening at this stage that we have not been able to organise pancreas transplant operations in all that time. I understand 15 donations have gone to waste because no surgical team was available to carry out the transplantation. That is deeply worrying and is putting lives at risk. Ms Ciara Kelly said in The Irish Times that she has been waiting three years for her second pancreas transplant and is getting weaker by the day. She is afraid that by the time the service is in place, she will be too weak to have the operation. That is genuinely frightening. Patients are really scared that they are not going to get this service.

I have a number of questions for the Minister, the first of which relates to appointments. I know he has said that a transplant service will be in place at St. Vincent's University Hospital from September this year. I would share the same concern as Senator Mark Daly. If it has not yet been possible to appoint somebody, how can the Minister be confident that the service will be available in September? Can he give us more detail of what is involved in the clinic that is supposed to take place on 24 July next? Is it just an assessment clinic? If so, in some respects it might just involve telling people what they already know, which is that they need to have a transplant as soon as possible. I would like to repeat a question that has already been asked. Why have we not been able to pay for treatment abroad? In the article I mentioned earlier, Ciara Kelly says she made such a request to the HSE but it refused to entertain it. I do not understand this because there is a procedure in place that enables us to send people to the United Kingdom and elsewhere to have urgent operations such as this. As I have suggested, it could be too late by the time this facility is available to people like Ciara Kelly here. I ask the Minister to respond to these questions.

I welcome the Minister to the Chamber to deal with this comprehensive and decent motion, which highlights an issue of extreme importance. I suppose the construction of the motion means we cannot support it in its current form. Surely there is no intention to ask the Minister to become involved in the recruitment of clinicians at any level. If we go down that route, we will open very dangerous territory. For that reason alone, the motion as it stands must fail. I suggest the idea that we should pay certain clinicians more or less than their colleagues is also something we would not like to explore. I think everyone understands the recruitment of clinicians depends on many variables other than pay alone. Perhaps other problems in the career pathway are preventing the recruitment of clinicians. I do not know whether that is the case. Senator Averil Power put a decent question to the Minister when she asked how it could be said that we would provide this service in September, given that we had failed to recruit these clinicians to date.

I thank the Minister for coming in at short notice. I know it is difficult. I should mention that I have a dog in this fight, as they say in the vernacular, because I am a member of staff at St. Vincent's University Hospital. In that capacity, I would like to welcome the new unit at the hospital and the new service that will be offered in our institution. I am trying to see beyond that today. As someone who has tried to become an expert on these arcane dealings in the past eight hours, I wish to know whether my understanding is correct. It seems that St. Vincent's University Hospital intends to interview folks who are interested in becoming its new hospital-domiciled or hospital-resident transplant surgeon with an interest in pancreas transplant. I understand it is hoped these interviews will take place fairly soon. The aspiration is that one of the suitable candidates, all of whom are qualified to do pancreas transplants, will pass the interview, accept the job offer and turn up for the job. As the Minister knows - I do not mean this as a personal comment on him or his administration - many factors have conspired in recent times for a variety of reasons and, as a result, the movement from somebody sitting down in an interview to actually taking up a post is fraught with pitfalls. There has been many a slip 'twixt cup and lip.

At this time, we have a promise that a resident transplant surgeon based at St. Vincent's University Hospital will be performing this procedure. In that context, I will conclude by asking a bigger question that has to be asked about the health service. What kind of forward planning is involved in this? I would like to hear the Minister's honest opinion on the matter. Was the move from Beaumont Hospital to St. Vincent's University Hospital planned for a long time? Was it precipitated by the retirement of a distinguished person who has given heroic service, and whom I wish extraordinarily well for a long, happy and productive retirement? The doctor in question has really blazed a trail. How long has this move been known about? Is there something wrong with a system that does not have sufficient redundancy in it to cope with one retirement, one parental leave or one person gong out sick? I know the Minister will turn his considerable talents and his attention to the issue of rationalising and developing a really good nationally-based transplant service, with national strategic goals. I wish him well with it.

I welcome this opportunity to update the House on the current position on pancreas transplants. Two consultant transplant surgeons left the renal and pancreas transplant programme at Beaumont Hospital at the end of last year, one on early retirement and the other on leave of absence for professional development purposes. Four consultant transplant surgeons remain and the renal transplant programme in Beaumont Hospital is continuing. Every effort will be made to fill the posts. Given the limited number of surgeons who specialise in transplantation, the filling of such vacancies poses a real challenge. Mr. David Hickey, who retired at the end of last year, performed pancreas transplants in Beaumont Hospital, as well as his kidney transplant work. I acknowledge the work he did and the outstanding care he provided to his patients over the years.

Beaumont Hospital is now collaborating with St. Vincent's University Hospital on a combined approach to kidney and pancreas transplants. It is proposed that pancreas transplants, of which six were performed in 2014, will move to St. Vincent's University Hospital. Most pancreas transplants are combined with a kidney transplant. The arrangements being put in place for such cases will involve transplant surgeons from St. Vincent's University Hospital and Beaumont Hospital working together on the St. Vincent's University Hospital campus. I am informed that the pancreas transplants will be carried out by an existing surgeon who is already a member of staff at St. Vincent's University Hospital. As Senator John Crown mentioned, other interviews are now planned by the hospital to fill other posts.

A joint assessment clinic for patients who are waiting for a kidney and pancreas transplant, involving consultants and nurses from both Beaumont Hospital and St. Vincent's University Hospital, will be held on 24 July. Arrangements will be made shortly for the assessment of the three patients who are awaiting a pancreas transplant only.

Management and clinical staff at both hospitals are committed to ensuring an optimal service will be put in place for the long-term benefit of those in need of pancreas transplants. As St. Vincent's University Hospital is already established as the national liver transplant centre, and is a designated centre for pancreatic cancer services, it is well placed to undertake these transplants.

On exempting transplant surgeons from current pay scales, as has been suggested by Senators, revised scales were agreed for new entrant consultants in January and were endorsed by the IMO in a ballot. Under the agreed pay structures, it is possible for consultants with experience to commence at the sixth point of the incremental scale, that is €155,000, rising to €175,000. It is also possible to appoint a consultant to a type C contract, which could mean somewhat lower remuneration but the ability to make substantial private practice income as well. Furthermore, it is open to health service employers to seek approval from the Department of Public Expenditure and Reform for entry of new consultants at a higher point on the scale in exceptional circumstances. If it is considered appropriate, this mechanism will be available in the case of a very experienced applicant for a transplant consultant appointment in Beaumont Hospital or St. Vincent's University Hospital, should one apply.

If a patient who is under the care of Beaumont Hospital after receiving a transplant encounters problems, he or she is asked to contact the renal registrar via Beaumont Hospital's switchboard. If this occurs during daytime, he or she may be asked to present to the renal day ward for assessment. If the renal registrar is contacted by a patient out of hours, she or he will be advised to present to the emergency department first, where the patient will be assessed by the emergency department staff and also reviewed by the renal registrar, and-or the consultant nephrologist, if required. In addition, the patient can contact the transplant co-ordinators at Beaumont Hospital for guidance.

The treatment abroad scheme allows for public patients to be referred to another EU or EEA country or Switzerland for specific treatments not available in Ireland. It can also allow for the referral of patients where an undue delay is being experienced in access to a necessary treatment in Ireland. Given the logistical and time constraints involved, it is not practical to utilise the treatment abroad scheme to provide pancreas transplants in another country to patients who are living in Ireland, using an organ procured somewhere in Ireland. Furthermore, it would be necessary to develop protocols and service level agreements with the other country, something that would be unlikely to be achieved within the timescale of the proposed transfer of pancreas transplantation to St Vincent's University Hospital, which is a matter of weeks away, all going to plan.

I share the commitment of Members of Seanad Éireann to organ transplantation. I know it has been raised on many occasions in this Chamber. I want to see a further improvement in organ donation and transplantation rates in the coming years. I realise that the potential for transplantation depends on suitable donors becoming available, but there are a number of areas on which we could concentrate to maximise the potential supply of organs, to match them up effectively with potential recipients - most organs are not matches, unfortunately - and to carry out successful transplantations.

I believe we need to ensure the most appropriate infrastructure is in place to support organ donation and transplantation; to ensure appropriate capacity and resources in transplant hospitals to facilitate increased transplantation; to ensure all those who die in circumstances where organ donation is a possibility are recognised and that their families are made aware of the possibilities of helping others; to build on the progress being made on the living kidney donor programme; and to strive to reach the point where organ donation will become the norm when opportunities arise.

This year, additional funding of almost €3 million has been provided to Organ Donation and Transplant Ireland, ODTI, which is part of the HSE, to facilitate the development of the most appropriate infrastructure to support organ donation and transplantation. The extra investment includes provision for the appointment of 19 whole-time-equivalent staff dedicated to organ donation and transplantation across the country.

Organ transplant can make an enormous difference to a patient and the lives of those around him or her. As Minister for Health, I am keen to ensure we do all that we can to ensure as many people as possible benefit from this gift of life. I can assure the House that every effort is being made to have all the necessary arrangements and protocols in place to facilitate St. Vincent's University Hospital being in a position to undertake pancreas transplants from mid-September, should a suitable donor-recipient match occur.

Cuirim céad fáilte roimh an Aire. My colleagues and I in Sinn Féin are acutely aware of the totally unacceptable position for transplant patients in general and, in particular, the challenges facing those awaiting a pancreas transplant. My Dáil colleague, Deputy Caoimhghín Ó Caoláin, has been in touch with the Minister, experts in the field and those who have received transplants. While he has received a response from the Minister that suggests everything is being looked after, we fear the reality is quite different.

While we agree with the urgency with which the post must be filled, we cannot agree to making an exception as regards pay for this post. Certainly, this post must be filled, but, as suggested by recent OECD figures that Ireland has among the best paid consultants in the world, pay is not the only consideration. Pressure on staff and poor systems are listed highly among the reasons staff leave these shores. We note that 200 to 300 new medical consultants are required to fill existing vacancies and those that will arise in the next 12 months. We currently have 2,713 consultants. The Hanly report of 2003 recommended that by 2012 there be 3,600 consultants. It is only by ensuring we have adequate numbers of staff and suitable systems in place that staff will want to apply for posts.

I am concerned that nursing staff in St. Vincent's University Hospital in Dublin 4, as good as they might be, might not have the expertise or the capacity to deal with such cases. The issue of seriously immuno-suppressed patients being advised to attend emergency departments is also concerning. Eight patients are currently on the active waiting list. Five are awaiting a simultaneous pancreas and kidney transplant and three are awaiting a pancreas-only transplant. Therefore, we cannot support the motion as it is, but we ask the Minister to address the staffing in general, to ensure a safe environment is guaranteed for those who have had transplant and to guarantee that those awaiting surgery will have it performed in as short a timeframe as possible.

It is a disappointing reply even on the practical matter of continuing to ask transplant candidates to attend emergency departments, given that we know their very attendance could affect their health and lead to a catastrophic result for them. I understand the issue of staff not being available, but to continue to ask people to put themselves in harm's way in a health service is deeply concerning.

I know this is the reply written up by the Minister, but it is the same reply that was written up for Senator Colm Burke last week. It states that "[g]iven the logistical and time constraints involved, it is not practical to utilise the treatment abroad scheme". Can the Minister imagine if he was on the organ donor list? He would have all the time in the world. He would go through hell and high water, all the logistical challenges and use all the time he had left to get treatment, whether at home or abroad. We do not have a surgeon for pancreatic transplants, we apparently do not know how many consultants are going to retire in other organ donation areas and we will not even give patients the benefit of finding treatment abroad.

The Minister was not here when we recalled the Seanad to debate this issue, but having met people who are meeting for a life or death telephone call, the simple act of telling them they must continue to go to emergency departments is a travesty. I know that is the reply we are given, but it is not even best practice. It is actually harmful. The least they could expect is that they would not be asked to do something that would harm them by their health service of all things.

Question put:
The Seanad divided: Tá, 14; Níl, 23.

  • Byrne, Thomas.
  • Craughwell, Gerard P.
  • Crown, John.
  • Daly, Mark.
  • Healy Eames, Fidelma.
  • Heffernan, James.
  • Leyden, Terry.
  • Mooney, Paschal.
  • Ó Domhnaill, Brian.
  • O'Brien, Darragh.
  • Power, Averil.
  • Reilly, Kathryn.
  • Walsh, Jim.
  • Zappone, Katherine.


  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Kelly, John.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Noone, Catherine.
  • O'Brien, Mary Ann.
  • O'Donnell, Marie-Louise.
  • Sheahan, Tom.
Tellers: Tá, Senators Paschal Mooney and Darragh O'Brien; Níl, Senators Paul Coghlan and Aideen Hayden.
Question declared lost.
The Seanad adjourned at 9.45 p.m. until 10.30 a.m. on Thursday, 16 July 2015.