Health Services: Statements

I welcome the Minister for Health, Deputy Simon Harris.

I congratulate the Leas-Chathaoirleach on his elevation to even higher office.

I am delighted to speak in the Seanad about my priorities for the health service and in advancing the commitments in A Programme for a Partnership Government in the Government's first 100 days in office. I will be present for most of the debate which will allow me to hear the priorities of Senators. My colleague, the Minister of State, Deputy Marcella Corcoran Kennedy, who leads the public health promotion section of the Department and will join the debate later will also be interested in the views expressed by Members.

Establishing the Committee on the Future of Healthcare was one of the first commitments in the programme for Government. I am grateful for the cross-party and grouping co-operation which allowed it to be established without delay. The Leader of the House has already raised with me the eagerness of Seanad Members to make a contribution to the formulation of the ten-year vision. It is a contribution I would welcome. While it is out of my hands in the sense that it is a matter for the Oireachtas, I hope and trust a mechanism can be found to facilitate the involvement and engagement of Senators in creating a ten-year vision for health care. This presents us with an historic opportunity to achieve something which has never happened before in health policy, namely, a long-term consensus on its fundamental principles. When one talks about ten-year strategies and committees, one can see people rolling their eyes, saying, “Another committee, another strategy.” However, this has never been done before. We have never before set ourselves the challenge of getting every political party and Independent grouping to sign up to a programme setting out where we want the public health service to be in the next ten years, regardless of what happens in elections and politics. If we can reach this consensus together, it will give the public, health service staff and management the certainty that the direction of travel will not change, even if the Government does. When I speak to people on the front line of the health service, they tell me they are not fed up of reform but are instead fed up of seeing a little here and there, with the process never being finished. Part of the reason for this is there has not been consensus. Health Ministers come and go; they tweak the system, but we never allow enough time for a certain direction of travel to be taken.

I recognise some concerns expressed since the committee was established. First, it has been pointed out that the six-month timeframe is ambitious, which I accept. However, it is up to committee members to make it work. Second, a key requirement to make the committee succeed is achieving political and societal consensus on the future of health care. I could not agree more with this objective and it will be a significant first if we can achieve it. When talking about committees and reports, it is important that the process does not create another report to be put on a shelf but actually leads to something tangible behind which we can all get, regardless of who will be in government in the future or what happens in future elections.

Again, I am fully in agreement with that view and the Department will provide every support for the committee in its important work. I intend to second somebody from it to provide support for the committee in carrying out its work.

The central objective of the new Government, as reflected in A Programme for a Partnership Government, is to use the now strengthening economy to make life better for people. During the general election I very clearly heard people stating it was grand the economy was back on track and that it might be improving in some ways but asking what we would do about a range of public services. One of the objectives which all of us involved in various electoral contests heard very clearly concerned the importance of reinvesting in the health service. The Government's objective and mine as Minister for Health must be to improve the public health service on which people depend. It is a service which really matters to families and communities and on which we and our families will depend at some stage in our lives. We all know that the health service faces many challenges. However, I am pleased to state, as Minister for Health, that I am in the fortunate position because of the work of the people to be able to preside over a period of reinvestment in the health service. We saw this last week with the revised Estimate of €500 million for the service. This will help to stabilise its finances in 2016 and the HSE has already stated it will put the health service on a sustainable footing.

It also gives me an opportunity to address some immediate pressures facing patients, as well as meeting programme for Government commitments in the Government's first 100 days in office. These commitments include enabling me to put in place a winter initiative to manage emergency department overcrowding. Work is under way on this initiative. I met the emergency department task force which is jointly chaired by the Irish Nurses and Midwives Organisation and the head of the HSE. At the meeting I asked for input and ideas. I also asked what worked and what did not in hospitals last year and what new measures we could try. I am very pleased that the funding I have secured for the winter initiative is more than the budget for it last year. This year we will have €40 million compared to €33 million last year. I extend the invitation to Senators for ideas, input and any suggestion they think would help to make emergency departments more manageable, particularly during the winter period when we see a spike in attendances. I would very much like to receive them.

It is very important that the initiative focus not just on acute hospitals but also on effective integration between primary care, social care and acute hospital services. We must stop talking about the issues and challenges facing hospitals as though they are just problems in hospitals. I note Senator John Dolan's commitment to disability services. Part of the problem is that people who do not necessarily need to be in hospital or would not have needed to be in hospital find themselves in an emergency department because they could not access a primary care or social care service. Had they been able to do so, they might not have needed to turn up in an emergency department at the weekend, or had the support been in place in primary care or social care services, they could have left the acute hospital when they were ready to do so, rather than finding themselves in the uncomfortable position of occupying a hospital bed when they would have much preferred to be at home in their community with their family. We cannot just talk about acute hospitals on their own. That is why we do not have a Minister of State for primary care services because the Minister for Health is not just the Minister for acute hospitals but also the Minister for all of the health service which very much involves primary care and social care services.

Another integral part of the initiative I am able to announce as a result of the extra funding provided is increasing resources for home care services. As a result of the provision of an extra €40 million for home care services above and beyond what was planned for in the budget, we are not only able to maintain home care and transitional care services at 2015 levels but also, for the first time in quite a period, to increase them. The programme for Government acknowledges the need to improve services for older citizens and the provision of additional home care and transitional care services will assist more older people to leave acute hospitals when they are clinically ready to do so. This will allow patients awaiting admission in emergency departments to be admitted in a more efficient manner. The initiative will also help older people and people with disabilities to remain independent at home and continue to lead active lives in their communities for as long as possible.

I hope the Seanad will note that, in terms of the future direction of health care in the ten-year strategy, one of the specific terms of references is ensuring the effective delivery of primary care service. Deputy Billy Kelleher in the other House likes to remind me of the very valid point that when Dr. Rory O'Hanlon was Minister for Health in 1987, when I was one year old, he used to talk about the delivery of primary care services. We are still talking about it. My colleague, Senator James Reilly, started this process. We must realise it is not just about buildings in the community; it is also about being able to avail of more services in the community. That is why it is an important body of work. To do it, we must recognise that we need to build general practitioner, GP, capacity to respond to patients' needs and the need for expansion of chronic disease management in general practice. Recently I met the NAGP and the IMO to discuss this issue. GPs deserve and need a new contract. We have not had a brand new contract in 44 years. Patients value their relationship with their GP and the State also needs to value it. As in any contract negotiations, the State needs to decide what it needs and what extra, additional or changed services it requires as part of a new contract.

I am very pleased that with part of the additional funding I have secured, I will be able to restore all of the funding to the mental health budget. As Senators know, owing to time related savings - a very bureaucratic phrase - some of the money meant to be spent in mental health services this year was not going to be spent and would have formed part of the base for next year. The additional funding I have secured for the health service means that I am in a position to restore the €12 million diverted from mental health services. We will, under the Minister of State, Deputy Helen McEntee, be in a position to spend on mental health services the full €35 million which had been ring-fenced for them. The Minister of State will develop a plan this year.

We will also be able to invest further in disability services. My colleague, the Minister of State, Deputy Finian McGrath, is working on this. There is an additional €3 million for services for school leavers. An important issue is where young people with a disability who are turning 17 or 18 years and leaving school will go next. As a country, we have not dealt with this issue well and need to do much better. The extra €3 million will help to provide assistance. As part of the additional funding for disability services, there will be more money for emergency placements and to bring disability facilities and residential services up to HIQA and national standards, which is important.

I wish to speak briefly about the need to improve waiting lists and waiting times, with a particular focus on those waiting the longest. It is fair to say that, as a direct result of the years of economic recession, we are seeing unacceptably long waiting lists. We will be reactivating or revving up the National Treatment Purchase Fund, NTPF. The programme for Government commits to providing €15 million for the NTPF for an initiative targeted at those waiting the longest. That funding will come from a continuing investment of €50 million per year to reduce waiting lists. I met representatives of the NTPF yesterday and asked them what they could do with €15 million, how many patients it would take off a list, how the organisation would decide who should be taken off lists and what it could do with a sum of more than €15 million. We are having a discussion on how best the Department of Health can spend the €50 million pledged in the programme for Government for waiting list initiatives. This year we are planning a specific dedicated waiting list initiative through the NTPF which will be focused on endoscopy services. I expect this to mean that the service will be in a position to carry out at least 1,200 endoscopy procedures and to clear the list of those waiting 12 months or longer. This is an important issue which needs to be addressed. I expect to be in a position to formally bring the details to the Seanad quite soon.

I acknowledge that the health service has been changing. It would be wrong not to acknowledge where success has been achieved, but we must challenge ourselves. At what point did we decide that it was acceptable for the political and media norm to be that we would only ever talk about the health service in the negative? This does a huge disservice not just to the Government of the day but also to the 105,000 people who work in the health service. Every day good things happen in it. It is, rightly and absolutely, our job to challenge things that do not go well and highlight problems, but I want to acknowledge the good work carried out in difficult circumstances by front-line staff in recent years. Life expectancy in Ireland has increased by two and a half years since 2004 and is now above the EU average. We have seen a decrease in the average length of stay in hospitals and significant progress in reducing the level of tobacco consumption. It is fair to say Senator James Reilly in his time as Minister for Health continued the good work of previous Governments in driving this agenda which has Ireland leading Europe in tackling tobacco consumption. Progress has been made in many health areas, including in how we deal with cancer and cardiac patients. It is important to recognise this progress, as well as those who work so hard on the front line.

Clearly, there is much more to do, but there is an opportunity to make realistic and achievable improvements in patient care and, therefore, a difference to people's lives. As well as the shorter term initiatives I have outlined, I am determined to progress major investment projects such as the national children's hospital and a new national maternity hospital. I was in the House last week speaking about this issue. We must look at how we can keep the population healthier through the national obesity strategy and the new national cancer strategy.

I want to be very clear. I know that I alone, as Minister for Health, will not fix the health service. While the Oireachtas is very diverse, it need not be divided on every issue.

If we are honest with each other, there is a great deal on which we agree across the Oireachtas in terms of the direction of travel of the public health service, although I acknowledge that sometimes we like to extenuate our differences for political reasons. However, there will always be issues on which we will not agree. If ever there was a unique opportunity to put in place a ten-year vision, it is now because there is a minority Government and we have no monopoly of wisdom or mandate. I am very much in the hands of the Seanad and the Dáil in how we can work collectively together. I look forward to working with Senators on all sides of the House.

I welcome the Minister to discuss important issues regarding the health system. As a GP based in rural Ireland, I would like to outline some of the issues in primary care, which is a crucial aspect of the health sector. I commend the Minister for his support of the ten-year consensus on health care provision. It is a hugely promising step for the Government which will refocus the discussions on health reform in this and the Lower House on patient care rather than political gains. I also commend the Minister for his recognition of the role of general practice. International studies demonstrate that the strength of a country's primary care system is associated with improved population health outcomes, regardless of the per capita health spend and percentage of elderly patients. Furthermore, the World Health Organization, WHO, has reported that increased availability of primary health care is associated with higher patient satisfaction and reduced aggregate health care spending and that orientation towards a specialist-based system enforces inequality in access.

The time has come for all stakeholders to work together in a pragmatic and solution-driven approach to develop a ten-year plan to reform health care. I welcome Senator Colm Burke's comment on Senators being members of the relevant committee. There is a need for better integration of primary and secondary care services. This approach is supported by international evidence that it would deliver efficiency and better patient outcomes. For every €1 spent on primary care €5 is saved elsewhere. This model works in Kilkenny, with the success of the local area integrated care committee and acute medical assessment unit. Kilkenny provides an example of what is possible in the integration of primary and secondary care services, resulting in shorter patient waiting times and GPs being given greater access to diagnostics. That would prevent the patient ending up in the wrong place at the wrong time. Patients often self-refer to emergency departments, for example.

There is a manpower crisis in general practice. A total of 157 GPs are trained each year, but we are exporting half of these highly trained professionals. An Irish College of General Practitioners survey in 2014 of trainees and newly qualified GPs found that only 37.5% of GP trainees were definitely planning on staying and working in Ireland and that only 43% saw themselves as a principal in a GP practice or partner in a group practice. An option for the remainder was working as employees in salaried posts. In the current climate, however, few existing practices have the finances to do this. While training more GPs is necessary, until an environment that encourages those who are trained to stay is created, we cannot begin to resolve the looming manpower crisis.

A further concern is the ageing demographic of the GP workforce. A report commissioned in 2015 by the National Association of General Practitioners, NAGP, by LHM Casey McGrath found that more than 900 GPs - close to one third of the workforce - had expressed an intention to retire or emigrate in the following three to five years.

In general practice 22 million consultations are carried out per year, with a greater than 95% satisfaction rating. This figure is expected to increase to 35 million annually in the next three to five years. The projected number of GPs needed to meet this demand is approximately 4,000. Approximately 2,400 GPs have GMS contracts, but given projected retirements in the next few years, we stand to have only half the required number. However, we regularly hear from GPs who have emigrated to Australia, New Zealand and Canada. They highlight consistently that the major difference between the Irish health care system and the systems in the countries mentioned is timely access to diagnostics such as X-rays, scans, physiotherapy and counselling services and expert opinion and the difference it makes to their working day and the benefit to their patients, which cannot be overestimated. In recent years the State has rightly built primary care centres. However, it is not all about bricks and mortar. It is important that activity take place within the centres to keep patients out of the secondary care system.

Ultimately, many of the challenges faced by GPs boil down to the terms and conditions of our working lives which are dictated, as the Minister said, by an ancient contract between the State and the HSE. I hope he will confirm in due course that the NAGP will be invited to negotiate a new contract on behalf of its members. I believe he had a constructive meeting with the association's representatives last week and welcome his commitment to engage further with them in the coming weeks. The organisation has made significant gains in progressing key issues for GPs since its relaunch in 2013.

On the Supplementary Estimate for health, Fianna Fáil welcomes the allocation of an additional €500 million, with €40 million for home care services, €31 million for disability services, €20 million being ring-fenced for mental health services and €40 million for the new winter initiative. Should the Oireachtas joint health committee hold extensive hearings with the Department and the HSE on what is required to meet both the demographic demand and unmet need in order that all proposed expenditure can be fully examined and scrutinised? In particular, the HSE should be invited to make a submission to the committee similar to that sent to the Department last August in order that health expenditure requirements can be debated extensively and analysed in advance of the budget in October.

I congratulate the Leas-Chathaoirleach on his recent election to the post. I also congratulate the Cathaoirleach who is not present on his appointment because this is my first opportunity to do so publicly. I also congratulate the new Leader of the House, Senator Jerry Buttimer, and all new Senators on their election.

There is much I would like to say, but I agree with everything Senator Keith Swanick said, much of which I said in the past. I am also delighted to have heard the Minister speak in the manner he did. It is important, as we celebrate the centenary of the 1916 Rising which started a process that led to our independence, that we remember what the Proclamation states about equality and treating all citizens equally. One of the most pressing needs when it comes to equality concerns the right to access health care when one needs it, not when one can afford it. That has been at the core of what we have been seeking to do. The ten-year plan and the cross-party committee will decide what it is we want. Many agree on the what but it is the how and the when that cause divisions. We want a fair health service that treats everybody equally and that will be available for them when they need it.

The points I wish to make I have made in the past. I always had the mantra that the patient should be seen at the lowest level of complexity that was safe, timely, efficient and as near to home as possible. The nearest place to home is usually the GP's surgery. We need primary care centres to deliver the excellent care GPs can provide in excellent surroundings. That sends a message. I agree that greater access is needed to diagnostics, but it also needs to be ensured people are working to the level of their competence and that GPs are not seeing patients who could be seen by nurses, that nurses are not seeing patients that should be seen by other paramedics and that consultants are not examining patients who could be dealt with within the primary care system. There is a huge opportunity with a new cadre of nurses coming through who are interested and energised, want to provide different services and are well capable of learning these skill sets.

No part of the health service is isolated.

Senator Keith Swanick addressed this issue. One cannot fix what is happening in emergency departments unless one fixes what is happening in primary care services which equally are dependent on what is available in the community. The full circle is completed by rehabilitation services.

Senator Keith Swanick talked about elderly patients. I am very concerned about the fact that there has been a movement towards the use of a medical model in nursing homes which was arrived at by the need to address the burdens on families and society and concerns surrounding the safety of elderly people living on their own, as opposed to providing a service and a place where we address their needs and help them to get the best out of life as they inevitably become more frail. That is something we must readdress continually.

I was also struck by the Minister's comments on disability services. Senator John Dolan would be the first to say people with a disability often ask, "Why am I here? I am not sick; I have a disability." It is an entirely different problem. We must address this big issue which has always caused huge tension between the excitement of investing more in cardiac bypass procedures and stents and longer term investment in education on exercise, obesity, alcohol and tobacco. That dynamic is always present and one that is very difficult for politicians to address. I have been critical of politicians on this island, elsewhere in Europe and at the United Nations for being more likely to go for the big bang of the new cardiac unit rather than the slightly softer option of providing more PE classes in schools, promoting exercise and education in order that people will realise one can prevent many illnesses. Dying from infections is no longer a threat in the western world; the big threat is posed by chronic illness and non-communicable diseases. The broader issues surrounding this are influenced by child care services, for which we must have a vision. The Government has started on that route in making child care more affordable, giving every child an equal chance in life. Again, that is the big problem for us. We all know the things we want; we all speak to them, but we must acknowledge that funding is finite and that if we invest here, we cannot invest as much over there. I, therefore, return to the argument about the provision of a new CAT scanner versus the introduction of a new public health initiative.

I congratulate the Minister on his appointment and wish him well. I will be as supportive as I can possibly be. I encourage him to pursue the issue of the establishment of a patient safety authority urgently. It was to be advertised before I left office, but then it suddenly changed into something else. We still have no patient advocacy agency in the country, although we need one. I often said when I was Minister for Health that I often felt that I was actually the Minister for ill-health because it was all about disease, illness and sickness. There was no emphasis on the need to keep people well and encourage men and others to go to see their doctor early when there was something wrong.

I wish the Minister and the committee well, but I echo strongly the request made by my colleague, Senator Colm Burke, that there be Seanad involvement. We will miss out hugely if we do not have it.

I will be very brief. I congratulate the Minister on his appointment and thank him yet again for coming to the Seanad.

There is not much of a mention of the National Treatment Purchase Fund in the programme for Government. In the past it was demonstrated to be a very able, efficient and focused group. Under the new Government arrangement, it was somewhat tapered and called the special delivery unit within the Department of Health. It was a stand-alone operation in Tara House on Tara Street. I do not know whether it has been subsumed into the Department, but there is room to explore and consider its capacity to access really good competitive deals in both the private and the public sectors. Let us not fear the private sector and the synergies between the private and the public sectors. What people want is fast treatment. The person who has been waiting the longest needs to come first. That is the issue. I would, therefore, like the Minister at some stage or other, not necessarily today, during one of his trips to this Chamber to elaborate on the role and the potential for expansion of the National Treatment Purchase Fund.

I welcome the Minister. I am delighted that he is here with us dealing with the health programme, in particular the need for a ten-year development plan, which is extremely important.

One of the things that concerns me about the health care sector is that on every issue that comes up in the media the content seems to be very negative, whereas there are many positive things to be said, to which the Minister referred. It is interesting how the report of the HSE was made available and laid before this House in the past two weeks, yet it received very little coverage. I remember being at a meeting not so long ago at which people were saying the health system was crumbling. I asked them what particular aspect was crumbling, but the debate went on.

I started to look at the figures to see what exactly the health service was doing. Last week I raised the issue of attendance at outpatient clinics in hospitals. There were 3.3 million attendances which, over a five-day week - most outpatient clinics operate five days a week - worked out at 63,000 patients per week, or 12,500 per day, which is a huge number. If one considers emergency departments, it works out at approximately 23,000 patients per week. The question is how we can work towards making the services provided more efficient but also, particularly in emergency departments, how we can work towards reducing the numbers in order that services would be available outside the hospital system.

My colleague, Senator Keith Swanick, made very important points about GPs and the support provided for them. It is also important to realise that in recent years GPs have suffered unfairly in the making of cuts. I remember meeting a number of GPs in the past 12 months who identified the fact that they had suffered cuts of up to 40%. I am not exaggerating the figure. As a result, they find that they cannot provide the level of service they want to provide for their patients. I was given one very simple example. If someone comes into a surgery and needs three stitches in his or her arm, the pack costs €30, but the GP is only entitled to claim €26 outside of the time he or she gives in providing care. The easiest option, therefore, is to refer the person concerned to an emergency department. That is just one example of what I am talking about, namely, the inadequate support given to general practitioners.

I agree with Senator Keith Swanick in what he said about the National Association of General Practitioners. All of the medical unions should be involved in negotiations on the contract for GPs because it is not a contract for 12 months or two years but one which I hope will be in place for a long time, possibly five, ten or 15 years. Therefore, it is important that all those involved in providing medical care be involved in considering what the contract should contain.

We face a number of major challenges, of which I think the Minister is aware, as he has highlighted them. A simple example given at a presentation by GPs that I attended was that there were approximately 600,000 people over 65 years of age in Ireland. Within 14 years that figure will increase to 1 million. A very interesting figure is that 51% of all hospital beds are occupied by patients over the age of 65 years. If one works out the ratio, the number of additional beds that will technically be required in the next 14 years is quite substantial, unless we can make improvements in a number of other areas to make sure we will have fewer people going into hospital and that the care they will require can be provided outside the hospital setting. The budget for the HSE last year was €13.895 billion, of which €3.621 billion went to non-statutory agencies.

In addition, a huge amount is spent on private health care such that in the OECD Ireland is now the second highest spender on health care per head of population, but are we getting value in real terms? Could we deliver a better service with the money being spent? I believe we could.

Another issue we need to consider and which should be part of the health plan, although many may say it should not, is medical education, on which we are spending about €90 million per year. Within 12 months those who benefit from 60% of that investment will have left the country. We need to look at how we can keep our own within the health service and if they do want to go abroad for a period, we should at least be able to bring them back. This is affecting smaller hospitals, in particular. In hospitals outside the major centres of population, Dublin, Cork, Limerick and Galway, up to 70% of medical practitioners are non-Irish. They are providing a good service, but we should have a system in place that encourages Irish people to stay in Irish hospitals.

I thank the Minister for attending and I will be really positive. I thank the Government for its investment in Áras Deirbhle in Belmullet because for many years there was no investment in the nursing home. This is hugely important in the context of what I am going to say.

In the light of the negative impact on rural areas of centralising and privatising health care services in Ireland, Britain and many other countries, will the Minister consider a proposal to provide as many such services as possible in rural and urban settings? Sinn Féin and I have long believed a new approach is necessary to overcome the challenges met by those living away from large hospitals and acute specialist hospitals in accessing health care services. This growing problem is not confined to those living in remote rural areas, although the lack of transport and a good road network and the cost involved in accessing the most basic services is greater in these areas, including where I live - Erris, County Mayo.

There is a really good strategy, Developing Community Hospitals, in use in Scotland; there is, therefore, no need for us to reinvent the wheel. The Minister may be familiar with Belmullet hospital where, under the then Fianna Fáil Government, half of the beds were closed in 2010. We led a very active campaign - Senator Michelle Mulherin will testify to this - to try to keep them open. However, the then Government insisted on closing them. We are left with the infrastructure of a large hospital that could be used as a centre in the delivery of the services we need. Will the Minister consider initiating a pilot project to develop a multidisciplinary health service facility at the hospital and having a cost-benefit analysis carried out to deliver it? We could lead the way in examining whether it might be a method of tackling the shortfall in the provision of services between centres of excellence and acute centres. We could look at the possibility of providing a community casualty unit to prevent people from having to travel elsewhere to have minor injuries treated. We could examine the development of an electronic health records system in order that patient information would be available, provided proper broadband services were available. We could also revisit the development of technology which never happened but which was promised under the primary care strategy. The Minister will recall the pilot projects established in that context. The major problem with them was that proper resources were never provided for them. Putting a sign with the words "Primary Care" above a door does not make a facility a primary care centre. Investment is needed. The potential identified within the centres could be used not only to provide primary care services but also in the development of multidisciplinary health service facilities. We could test this model in Belmullet to discover if it would work. Using this model many safe and effective services could be delivered at local level. We could have an integrated patient transport policy included. My direct question to the Minister is whether he would be willing to look at this issue and work with us in the community of Erris in Belmullet to test this model to establish whether it would work in other areas of the country also.

Mr. Simon Stevens, head of the NHS in England, realises there are many shortcomings in the centralisation and privatisation of health services. The way in which the health system has developed has left us in a situation with which none of us agrees where the treatment provided is based on where one lives. Whether a person lives or dies can come down to where he or she lives. People living in areas such as the one in which I live are at a major disadvantage in trying to access services. I remind the Minister that patients from Belmullet who are seeking to access the most basic services being delivered in Galway are obliged to make a six-hour round trip. Some may have to attend two, three or four appointments in one week. That is not the way to treat some of the most vulnerable patients, namely, those who are ill and require to access health services.

I ask the Minister to examine the Cuban model of delivery. It is very interesting. It delivers an excellent health care service to a population of 11 million for less than what it costs to deliver services at Beaumont Hospital.

Will the Minister comment on the ESRI report on the possibility of universal health care delivery, particularly as it has long been our policy? It has often been ridiculed on the basis of the argument that we cannot afford it. We have always said we could afford it and it is interesting to have the evidence to back this up.

I look forward to working with the Minister and hope he will have an open-door policy in addressing all of the issues to which I have referred. I ask him to consider the impact on the health service of the policies of previous Governments and how they have militated against those living in rural Ireland, in particular.

I welcome the Minister and wish him well. I also welcome his statement on the future of health care. While ten years seems to be a long time, what is significant is that he referred to bringing all sides on board and obtaining different views on how we might achieve a more desirable health care system for everybody. This will require dialogue which will take place in the context of increasing demands on health services. People are living longer and coping with chronic health conditions. With advances in medicines, there are available new drugs and new treatments for cancer and other life-threatening illnesses and diseases. Periodically, the debate to the effect that the State is required to fund new drugs is played out in public. The pharmaceutical companies are trying to obtain top dollar, while the State has to watch its budget. These are the realities, but all the time we are talking about human beings.

It is worth remembering, even as we try to deliver them, that health care services must be provided for everybody, regardless of a person's finances or what he or she can afford. If someone is sick or dying, he or she does not have any option. It is at this time that he or she is really vulnerable. If the State is worth anything, it must continue to strive to find ways to make the provision of health care services a reality for all citizens. I know that the Minister is committed to doing this.

I welcome the convening of the new committee on the future of health care. I support Senator Colm Burke's suggestion that Senators be included among its membership in order that the Upper and Lower Houses will be represented on it.

I welcome the opportunity to tease out the issues and get down to the nuts and bolts of the debate.

I ask the Minister to intervene in a pressing issue that has arisen in Ballina District Hospital, County Mayo, namely, the escalation of an ongoing dispute between WestDoc which provides the hospital with an out-of-hours general practitioner service and general practitioners who provide the service during normal hours. These services provide 24-hour cover and allow the hospital to function. I have been informed by staff of a threat to withdraw general practitioner services from the hospital in the coming days. This would result in the closure of the hospital, which is difficult to believe. The staff who contacted me are very concerned about patient care. Ballina District Hospital is a step-down facility with a large number of elderly, frail patients. It provides a top-class service, as everyone who uses its services will attest. People are delighted with the care and attention they receive. The hospital's closure would lead to 59 patients being transported by ambulance to Castlebar General Hospital. Staff are also fearful for their jobs. While discussions are ongoing, the dispute appears to be escalating and a threat of withdrawal of service has issued to the Health Service Executive. I ask the Minister to ensure all obstacles are overcome and that the parties will move towards finding an immediate solution to the dispute.

I commend the general practitioners who provide a very good service for the hospital. I also commend hospital management with which I worked closely to have all beds in the facility reopened. In 2011, when the previous Government was elected, the number of beds in the hospital had declined to 40 and it was feared that there would be further bed closures. Working with the Minister and the Health Service Executive, managers at the hospital and I fought long and hard to secure the reopening of beds and the expansion and renovation of the hospital. In conjunction with the Mayo Roscommon Hospice Foundation, for the first time Ballina District Hospital provides hospice suites. A great deal of good work has been done at the hospital and it is a matter of grave concern that it may close. Such a scenario would be unacceptable and have knock-on effects. Mayo General Hospital, like all hospitals with an emergency department, suffers from the problem of requiring patients to wait on trolleys. Ballina District Hospital and hospitals in Swinford and Belmullet which also provide step-down beds provide a lifeline for Castlebar General Hospital by relieving pressure on its emergency department. I would appreciate it if the Minister reverted to me on this extremely urgent matter. The parties involved must sit around a table to knock out a solution in the interests of health care provision in the region.

The Government must adhere to the timeline for ratifying the United Nations Convention on the Rights of Persons with Disabilities by the end of the year. Work is being done on the legal and legislative changes required for ratification. In parallel, implementation planning is needed for the urgent restoration of practical measures such as home supports, personal assistance, neurorehabilitation services and therapies and so forth. Previous speakers referred to other measures and many more come to mind. The mobility allowance is dangling by a thread and the motorised transport grant was abolished. Budget 2017 which will be introduced in four months will indicate whether there is a willingness and an ambition to move beyond words in terms of the importance of the inclusion of people with disabilities.

Not to put a tooth in it, the question being asked is whether the long-running crisis in disability and mental health services will continue to be viewed as acceptable. These areas of health care have not been adequately addressed for decades. Austerity measures have brought a vicious and continuing harvest of poverty, exclusion and loss of hope to people with disabilities and their families. The restoration of services lost is the immediate priority. We must proceed on a programmatic basis thereafter.

The ten-year plan announced by the Minister is very welcome. I will make a couple of points about some of the relevant issues and tensions.

Every year we have what are described as the "new disabled". At least 50,000 people will become disabled or require disability or mental health services this year. Disability is, therefore, a societal issue. We do not have disabled people and the rest of us because disability can and will come to everyone's door. Reference was made to an increase of 2.5 years in longevity in the past 12 years, which is a significant improvement. While mortality rates have declined significantly in the past 20 years, morbidity rates have increased. The ten-year plan is extremely important because we should have been planning decades ago. Let us start to address demographic changes such as longer lifespans and an increase in the number of people living with disabilities and other conditions that reduce their capacity. People with disabilities and their families have been paying the price for the failure to plan.

As people move out of institutions, others, often young men and women, are moving into nursing homes and other institutions. Some health programmes receive statutory support, while others are provided on an administrative basis, for example, personal assistants, home help services and so forth. This has allowed these services to be filed away for the past decade.

The Department of Health has always been the default service provider for people with disabilities. When people require education, employment activation, accessible transport, housing and so on, it is regarded as a health issue because a disability is involved. However, they are issues for the relevant Department, whether it be education, housing or transport. I ask all Senators to think about this matter because the Department of Health has always been at the short end of the problem. Other Departments have primary responsibility within their remit for the lives of people with disabilities and their families. It is long past time that they faced up to this. The nature of disability is changing. At one time the narrative was that there were people with disabilities and able-bodied people. That is no longer the case. We are all on the slippery slope. As a result of improvements in health care and social service provision, many people have what I describe as disabling conditions such as those of an episodic nature. We must reconsider our approach to these issues, which will mean ensuring Departments other than the Department of Health share the burden. Enabling measures are required to keep people at work and ensure young people will move from education into training and employment. Budget 2017 will be the first critical step to be worked on.

How did the 50,000 people who will become disabled this year view budget 2016? Most will have asked whether their income had improved or they or their families were better off as a result. This year, however, the same people will view the budget from the perspective of having a disability and will ask whether they will be able to remain in employment, secure a job or continue to function as a parent, look after elderly parents or engage in the community.

I have three requests. First, the ten-year plan must strongly factor in disability and mental health services and find ways to draw in community organisations and groups working in these areas. Second, budget 2017 must provide for the restoration of services.

Third, we must focus on community living and participation. Other Departments and public bodies must get their act together and not leave everything to do with disabled people to the Department of Health.

I thank the Minister, Deputy Simon Harris, for addressing us. I welcome the Minister of State, Deputy Marcella Corcoran Kennedy, to the debate.

Like my colleagues, I support the setting up of a cross-party committee on the future of health care which will have a longer term focus on health policy in the next ten years, which is welcome. During the recession health budgets were hit but now that we are in a better economic position it is important that we direct resources appropriately towards the fairer delivery of services.

I would like to refer to many issues within the health service, but I will focus on stroke care. The suddenness of a stroke can be very difficult for patients, families and carers. The effects range from very mild difficulties such as hand weakness to more complex challenges such as speech difficulties, sight loss and paralysis on one side of the body. As an occupational therapist who has worked specifically with stroke patients for the past eight years, I become deeply frustrated when, following a stroke, many patients are unable to gain access to specialist rehabilitation services in a timely manner. There is the potential for these patients to improve, given access to the right services. An audit report on stroke services carried out by the Health Service Executive, HSE, and the Irish Heart Foundation published in January this year found that the death rate had dropped from 19% to 14% since the last audit had been carried out in 2008. Some 8% of stroke patients were being discharged to nursing homes compared with a figure of 15% in 2008. That is a substantial reduction, which is most welcome.

The Minister has rightly said there are good developments every day within the health service and these changes are very much driven by the HSE national stroke programme which is currently led by Professor Joe Harbison who has shown great leadership in the reorganisation of acute stroke services. The position has been improved from having one stroke unit to 21. There are approximately 250 medical doctors trained in thrombolysis or clot-busting treatment. That means that real improvements are being made in the initial stages following a stroke. However, stroke remains Ireland's biggest killer after cancer and heart disease. Stroke patients must be treated with the same level of urgency as cancer and heart disease patients. The key finding of the audit was that a very high proportion of survivors suffered needless disability. I listened attentively to Senator John Dolan's contribution because there is a lack of rehabilitation services once they have been treated in hospital for a stroke. With medical advances, we must have better and more timely access to rehabilitation services. It is important to consider such services within the context of community and hospital services for those under and over 65 years of age.

The audit shows that only about half of patients are admitted to a stroke unit at any one time during their hospital stay. In 2016 treatment in a stroke unit is the most basic requirement. All of the clinical evidence supports the benefit for stroke patients. Treatment in such a unit improves their outcomes and recovery. For patients under the age of 65 years, the position is of even more concern. These patients find it extremely difficult to gain access to inpatient rehabilitation services because the only service is provided by the national rehabilitation service in Dún Laoghaire. Many patients wait for months. We need to make sure multidisciplinary teams are properly resourced.

One of our major challenges in providing rehabilitation services is the delivery of more units. I ask the Minister of State to ensure the specialist rehabilitation unit planned for Roscommon County Hospital will be progressed as quickly as possible. It is essential that the project team which comprises hospital, clinical and estates personnel be assembled as quickly as possible. I ask the Minister of State to ensure that that will happen without delay. We must ensure we provide proper services for the people of the west who find themselves in a very difficult position when they require rehabilitation.

On early supported discharge services, I ask that there be a greater focus put on community care and properly resourcing early supported discharge teams.

I welcome the Minister of State, Deputy Marcella Corcoran Kennedy.

I am pleased to contribute to this important debate. First, I wish my colleague, the Minister of State, Deputy Marcella Corcoran Kennedy, every success in her portfolio. In the previous Oireachtas we both had different roles, but I very much enjoyed our engagement in my role as Minister of State with responsibility for business and employment and hers as the very successful Chairman of the Joint Committee on Jobs, Enterprise and Innovation. I also extend my congratulations to the Minister, Deputy Simon Harris, on his appointment. It is not overstating the case to say that as a society we very much depend on their success as Ministers. There is, therefore, no extra pressure.

For some time I have been stating privately and publicly that the future direction of the national health service requires a long-term, consensus-driven strategy and approach, with a genuine role in the process for all stakeholders. That means that everybody across society, not just those of us who are privileged to sit in this and the Lower House. The success of this proposition and the proposed ten-year programme for health services requires all of us to be honest with one another. It requires an honest Government but also requires an honest Opposition. We need to start with a vision for the kind of health service we want to see provided. It follows from this that we must be absolutely clear on how we plan for and resource that service. We, therefore, need to have an honest discussion.

The provision of first-class health care comes at a cost. It is very costly, but it is something that is worth paying for. Treatment in acute medical settings is particularly expensive and the operation of emergency departments is, by definition, very costly. Those of us who have and will have a need to use acute hospital services deserve to be treated in a timely and effective manner and provided with the best possible treatment by staff who are supported and valued in hospitals that are accountable and managed by people with the right skill sets and who understand it is the patient, the citizen, who should be at the heart of health care service provision. They should also accept that their jobs and the way in which they manage them in hospitals should be open to the closest of scrutiny.

We are also familiar with the problems experienced in overcrowded emergency departments across the country. I am acutely aware of the long-standing problems experienced in Our Lady of Lourdes Hospital in Drogheda, my home town.

I have been party to many efforts, particularly in recent years, to address the hospital's multifaceted overcrowding problems. We need to step back and take a clear-headed look at this issue. Many of the problems experienced in emergency departments and the reason for the bottlenecks in the making of appointments, outpatient services, surgery and so on in acute hospitals can be traced back to the lack of prioritisation of the provision of integrated primary care services and the notion of prevention being at the heart of the life of a healthy society. Remarkably, Ireland has the only health service in the European Union that does not offer universal coverage for primary care services. We have a public hospital system that is largely fed by a private primary care system. This is the perverse way in which the health system has evolved organically since the foundation of the State. Many sneered at the idea that we would provide free GP care for young children and those aged over 70 years. It was dismissed by some as a political stunt, but it was the start of an ambition to provide such a service for all citizens in a move towards a new national community health service. My party's vision for a new integrated primary care service involves the proper integration of GP services, advanced nursing practitioners and allied health professionals and staff being active in community settings treating and managing patients away from expensive hospitals.

If we believe the pressure on hospitals is enormous now, what will it be like in the years to 2020 and 2030 when it is anticipated that there will be a 40% increase in the incidence of chronic disease in Ireland? To avoid this apocalyptic scenario, we must develop dozens of new community-based clinical programmes that will target the most prevalent and complex chronic diseases in order that people will have consistent access to treatment and prevention strategies without needing to visit hospitals. This approach would have an empowering effect on patients, liberating them from excessive reliance on the acute hospital setting.

We cannot afford not to make these step changes in the delivery of services. It is important that we put the primary care vision and the integration of services at the heart of everything we do in our vision for the health service in the coming years. We can build consensus on this approach.

Cuirim fáilte roimh an Aire Stáit go dtí an Teach. I apologise for not being present for the earlier part of the debate. Unfortunately, I had to honour a prior commitment.

I welcome the Minister of State, Deputy Marcella Corcoran Kennedy. I have known her for a long time and know of her passion and commitment to public service. She has hit the ground running in what is an interesting, challenging, fruitful and rewarding portfolio. There will be tangible successes as a result of the personal commitment she brings to everything she does. In the previous Oireachtas she worked on the justice committee. It is an exciting prospect.

It is appropriate that we debate the health service in the first weeks of this Seanad. It is welcome that a new conversation is developing. I have always adopted a positive approach to politics, even in the most difficult of circumstances. If we engage, are positive and seek consensus, we can achieve much. If we divide, we will be conquered by outside forces. If we unite, we can conquer.

I was heartened by the commitment in the programme for Government to agree a ten-year plan for the health service. The Minister for Health, Deputy Simon Harris's first public comments after his appointment were in that vein. He wanted to reach agreement and set up an all-party Oireachtas committee to devise a strategy for the next decade. That is appropriate, as health care is not a political football but a political issue. For too long, it has been a political football and all sides in the Oireachtas are to blame. We have seen the vulnerability of the health service and used it as a political football to gain traction in opinion polls, notoriety and votes, but that is not an appropriate approach to the health service and for the millions of people who depend on it.

We spend much less on health services per capita than many other countries, including, for example, the Netherlands and Germany. It is claimed that it is not a question of finances but of how resources are spent within the health service. I contend that it will remain a financial matter until such time as we realise we cannot have first-class health services if we continue providing for tax cuts in budgets, but that is a difficult political decision to make. It is easy to knock 0.5% or 1% off various tax rates and in so doing put more money in people's pockets which everyone likes and to which everyone aspires, but it means that there must be give elsewhere. I would prefer to see no tax cuts being made and instead the money being put into the health service to restore much of what has been removed in recent years.

We in this House have a role to play in the formulation of the ten-year strategy. I am unsure whether a select committee is being set up by the Minister to formulate the strategy; I hope not, rather I hope it will be an Oireachtas joint committee. Some Senators have vast experience in this sector. Senators Keith Swanick and James Reilly are GPs, while Senators Joan Freeman and John Dolan have experience of implementing health services and dealing with related issues, for example, mental health services and in dealing with persons with disabilities, etc. They want to serve, make a contribution, engage and be involved in the formulation of the ten-year strategy. No one expects everything to happen instantly - it will happen incrementally - but the best way to ensure we will have a health service over which we will be able to stand and of which we will able to be proud some day is by agreement, consensus and pulling all of the expertise and various strands together.

The position on emergency services in the mid-west from where I come can only be described as diabolical. Reconfiguration happened, even though facilities were not in place to handle it. The 24-hour emergency departments in Nenagh and Ennis hospitals were closed and services consolidated in Limerick where there were no facilities available. The service is collapsing. Consolidation and reconfiguration should not have happened until such time as the new emergency department had been built and opened. I am glad that we will have a state-of-the-art emergency department in University Hospital Limerick in 2017, but reconfiguration put the cart before the horse. It was bizarre.

The medical profession-----

I am sorry, but the Senator is over time.

This is an important point. The medical profession and all stakeholders have responsibilities. There is anecdotal evidence of GPs referring patients unnecessarily to emergency departments. The committee that is being formed to develop the ten-year strategy needs to engage with all stakeholders. Where possible, the strategy should have their unanimous agreement.

I have to call the Minister of State at 6.40 p.m. I will try to get in as many Members as possible, but I ask them to be brief.

I congratulate the Minister of State on her appointment to the important health promotion brief, in which she can play a part in reducing the spend on health services, depending on what policy is articulated. We have had a good discussion. The spend on health services from the public purse is approaching €14 billion, with an additional €5 billion provided by VHI and from other private sources, giving a total of almost €20 billion. The health sector has been debated in both Houses and by commentators in the past ten years, in particular, as people are living longer and as demographics change. There is a higher incidence of disease and a need for prevention, treatment and cure. As a result, there is a cost to the Exchequer and private health insurance companies which must be met. The health sector faces major challenges and having a ten-year vision is the correct way to approach them. I believe we need a 20-year vision both in this country and across Europe. We should not stop at a period of ten years but look much further ahead, taking on board new treatments and so on.

A number of issues need to be targeted, one of which is the cost of drugs and patenting arrangements and how that cost can be reduced. Care of the elderly and home help hours provision, in particular, must also be addressed. Demand exceeded supply by 10% at the end of 2015 and the position will not improve this year, given that the number of home help hours has been cut again. The average cost of a home help is €75 per week. The alternative is for the elderly to participate in the fair deal scheme and seek long-term private or public residential care. The average cost of public care is €1,390 per week, while in the private sector the average cost is €893 per week. When these figures are compared with the cost of a home help, it does not make sense. The Department's strategy seems to support increased spending on the fair deal scheme, for which more money has been allocated this year, as well as for the home help service. That is only one example of how resources are not being targeted efficiently and effectively.

The Department and the HSE have spoken a great deal about seeking efficiencies across the sector, but that is not happening. There are no financial oversight or performance-related auditing and accounting practices to achieve value for money and more effective outcomes for the patient. The approach is, therefore, not patient-centred, rather it is about going into hospital and cutting costs. Until the system is changed from providing a block grant for hospitals to one in which the money follows the patient, patient care will not be at the centre. For example, Letterkenny General Hospital should receive a block grant based on performance last year, not this year. It does not make economic sense. I am examining this issue from a financial point of view in allocating resources more efficiently and effectively. Reference was made to the OECD report on spending on the health sector. It found that the spend in Ireland was higher than average but that outcomes here were lower than average. Our ten-year vision must be considered in that context.

There are many other issues to be raised but other Members are offering. I would very much like to have an opportunity to engage in an open-ended debate on health services, with contributors having extended time because every Member has something to offer. Our spokesperson, Senator Keith Swanick, has made the case on primary care services and I agree wholeheartedly with him.

I wish to share time with Senator Niall Ó Donnghaile.

We could form a multidisciplinary team in this House. We have among us Members who are GPs, mental health advocates, registered nurses, addiction and disability advocates. I ask the Minster to please include us in the membership of the Committee on the Future of Healthcare.

I welcome the Minister of State. Some would commiserate with her on being given what is perceived to be a poisoned chalice, but, unfortunately, the health system has been fatal for patients with whom I have been involved, given the savage cuts made during the years of austerity. I hope we will turn things around and make a great plan for the next generation and the generation after it which will need it most.

I would like to address the issue of inequality. Inequality in health care provision is its most shocking form. The Committee on the Future of Healthcare will convene and draw up a blueprint for the sector. I hope there will be a frank and open discussion in order that we will try to come to a consensus on what is best for this and the next generations. We must realise we will have to pay and that it will cost more. The population is increasing and people are living longer; therefore, our needs will increase. Good health is the basis of every single facet of our lives.

I will push for the introduction of universal health care. We need to look into it, but many countries have it as a right, with health care being free at the point of delivery and based on need alone. I work in the health service which is hanging by a thread which is in danger of wearing away. We are overburdened and the position is chaotic. I will, I hope, bring forward Sinn Féin's vision taken from its health policy document which has been costed and analysed. It will take an additional €3.6 billion to get to where we need to go in order to have universal health care for all.

Is the Minister of State aware of the second annual report from the national health care quality reporting system which was published recently and reported on in The Sunday Business Post? There are significant variations across the State in the survival of patients following a heart attack or a stroke, while the mortality rate in small hospitals is almost 17%, well above the average of 6%. It is across all seven hospitals mentioned in the report. Perhaps the Minister of State might comment on this.

I am grateful to have the opportunity to address to some of the issues mentioned in the plan. I was wondering, with all of the health care professionals in the Chamber, if one of them could prescribe some antihistamines for me because it is hay fever season and I am struggling. I hope I will get through this debate.

One of my main issues with the Minister's plan is the lack of a reference to cross-Border health care and implementation plans. Border communities suffer disproportionately and as a result of partition face unique and demanding issues, but it is not all doom and gloom, which is why I am surprised there is no reference to the issue in the plan. There have been outstanding cross-Border initiatives, for example, the provision of a cancer treatment ward in Altnagelvin Area Hospital in Derry. Gone are the days when people from County Donegal had to travel to Dublin to receive treatment. They now only have to travel a short distance to Derry. There is the all-Ireland network of heart services which deal with cardiac problems, particularly for children, which has been a positive development. Perhaps, as part of the broader discussion on health services, we might examine the needs of Border communities and how we work with colleagues in the North. I am sure we will have a willing partner in the Northern Ireland Minister, Michelle O'Neill, MLA, in working with us to address some of the critical issues. Based on scientific evidence, she moved recently to lift the MSM ban on the making of blood donations by gay men. The Irish Blood Transfusion Service is currently appealing for donations which tend to drop in the summer months.

Obviously, one of the core issues at the heart of the health service and looking after people in need is the making of critical blood donations. Will the Minister of State, or her colleagues, address the House on what moves could be made to lift the ban in place here?

Unfortunately, in accordance with the order of the House, there is no time left for the other Members who indicated to contribute.

I thank those Senators who generously congratulated me on my appointment to my new role as Minister of State with responsibility for public health promotion. As this is my first time in the Twenty-fifth Seanad, I extend my sincere congratulations to every Member. I am looking forward to working positively and constructively with him or her in the years to come. Members will note the optimism in the use of the term, “years to come”. In politics, one needs to be positive and optimistic.

I am pleased to have heard most of the excellent contributions made across the Seanad and the Dáil on the Committee on the Future of Healthcare and the health service. The committee will look carefully at the future of the health care service. I welcome its establishment which was a key commitment in A Programme for a Partnership Government. Universal health care is not just a policy to be implemented or for change for the sake of it, rather it is a direction on a journey towards a better and fairer health service for all citizens. Given the year that is in it, it behoves us to follow through on the ideal of cherishing all of the children of the nation equally and to create a vision for a universal single-tier service in which patients will be treated on the basis of health need rather than ability to pay. While this task is challenging, the committee provides a great opportunity to bring us further along the road towards universal health care.

I have taken note of the questions asked by the last two speakers and will refer them to the Minister for Health, Deputy Simon Harris, for a direct response. I have also noted the comments on the committee being a joint committee in which Senators should have an opportunity to participate. I will ensure the Minister is directly advised of this. The Department will be happy to assist and advise the Houses of the Oireachtas, as appropriate. I look forward to the outcome of the committee’s work and wish it well in its deliberations.

When is it proposed to sit again?

At 10.30 a.m. tomorrow.

The Seanad adjourned at 6.45 p.m. until 10.30 a.m. on Wednesday, 22 June 2016.