I ask those present to note that this meeting will be carried live on Virgin Media channel 207, Eir Vision channel 504 and Sky channel 574. Members are asked to switch off their mobile phones or adjust them to airplane mode so that they do not interfere with the recording of this morning's meeting. Apologies have been received from Deputy Kelleher. This morning we will consider the 2017 Revised Estimates of the Department of Health. The Dáil has ordered that the revised Vote 38 - Health - be referred to this committee for our consideration. I welcome the Minister for Health, Deputy Harris, and his officials. Briefing material providing details of the Revised Estimates has been circulated to Deputies. I propose that the committee will proceed to consider the indicative appendix of Vote 38 programme by programme. If Deputies wish to ask questions or comment on any specific subheads, they can do so after we have considered the indicative appendix programmes. I ask the Minister to make his opening statement.
Vote 38 - Health (Revised)
I am conscious that many issues pertaining to today's Revised Estimates, including how various health-related matters are to be funded and addressed in 2017, were discussed when I had a lengthy engagement with the joint committee last week. The script I have circulated can be taken as read. I will make a few brief points at the outset.
I hope the 2017 Revised Estimates can be seen as a practical example of how the Government is endeavouring to put the health service on a more sustainable financial footing and to allow the HSE to set realistic and achievable targets for service areas in the year ahead. On many occasions over the years, when health Ministers have come to this committee to consider Health Estimates, they have been looking at very different vistas from the vista we are looking at now as we consider how the health service is being funded in 2017. When the new Government came into office in 2016, it was able to provide additional funding to the health service. As a result, last year marked the first time in many years that the health sector was able to come in on budget in 2016 without the need for a Supplementary Estimate. This tells us that when the health service is funded adequately and expenditure in the service is carefully and closely monitored, we can ensure the health service comes in on budget. Coming in on budget is not just about meeting an accounting target or ticking a box; it means that any additional resources the Oireachtas decides to allocate to the health service can be spent on services that benefit patients. This allows us to move towards delivering the kind of public health service we all want to deliver.
I am keenly aware that there is significant concern about the waiting times for hospital appointments and procedures that are being experienced by patients. We had a lengthy discussion about this at the joint committee last week. I said on that occasion that the HSE was about to submit waiting list plans, including a specific plan for scoliosis, to me. The Department of Health has now received those plans. It is considering them and engaging with the HSE on them. I intend to share the plans with members of this committee very shortly. The overriding aims - that by the end of October, no patient will have to wait longer than 15 months for a day case or inpatient procedure or an outpatient appointment; and that by the end of this year, no child will have to wait longer than four months for a scoliosis procedure - have not changed. Those targets have been set by the director general of the HSE. I am very grateful to him for taking this issue as seriously as it should be taken. We were all appalled to learn about the lengthy times people are having to wait. The achievement of the four-month target will bring this country into line with the NHS practice in relation to scoliosis and the NHS timelines.
As Deputies can see from the documentation that has been provided, these Revised Estimates provide for additional investment in acute and emergency services, representing an increase of €90 million on the revised allocation in 2016. The additional funding that is being provided to the National Treatment Purchase Fund will bring its budget to €20 million this year. This will increase to €55 million in 2018. A sum of €40 million is being provided on a recurring basis for the winter initiative. This is crucial because it means that as we move towards the end of this winter - one would not think it from the weather today - we will be able to plan at an earlier stage for next winter. It is my intention that this work will get under way in the Department and the HSE very shortly. Funding is also being provided for the extension of the medical card to all children in receipt of domiciliary care allowance. Deputies will have noted that a Bill facilitating this extension was published this morning. I know the co-operation of all parties will be available to ensure the Bill in question passes all Stages in both Houses by the end of the month. I think we should all be working towards that target. Deputies will be aware that reductions in prescription charges for all medical card holders over the age of 70 and their dependants came into effect yesterday. This measure, which will benefit 390,000 people in this country, is a first step in advancing the key commitment in the programme for Government to reduce the cost of medicines for all our citizens.
In the mental health area, progress is being made in developing services in line with the model set out in A Vision for Change. Additional funding has been made available for the disability services directorate, encompassing the full year cost of school leavers. This has been a very thorny issue for a number of years because adequate additional funding has not been provided to deal with the number of new school leavers coming on board every year. Those full-year costs are being met this year.
There were additional therapy support costs as well as costs incurred from complying with HIQA standards. There is a significant commitment to the fair deal nursing home support scheme and I hope there will be progress this year in trying to develop a policy platform to have a similar scheme in place in terms of a statutory home care scheme. Given the Houses of the Oireachtas provide such significant levels of funding to the HSE to deliver a health service that we all want to see and work towards, it is important that we have a performance and accountability framework in place that can monitor it. My statement, which I have circulated, outlines how the framework works. We have secured a significant increase in funding for the health services in recent years, but that does not mean that I, or anyone else, should underestimate the significant challenges involved in the delivery of a safe and efficient health service for the Irish people. Finally, while many of our discussions tend to be on current expenditure, on Monday I will be ten months in this job and I have seen, as I have travelled around our houses, a real deficit in capital spending. The Government has a capital review coming up this summer which will see €2.36 billion in additional capital allocated across Government. Additional capital spending in health will see additional benefits and efficiencies in the interests of our patients.
I thank the Minister for his opening statement. I will now refer to the individual programmes in the indicative appendix of the Vote, which are linked to performance targets. Members are advised that I will refer to a document entitled Analysis of Revised Estimate for 2017 as we progress through the programme. This document was prepared by the financial scrutiny section of the committee secretariat. I will refer to pages in this document as we go through each individual programme. Under the heading "Introduction" on page 5 of the document, Deputies may wish to take a moment to note the large regional nature of the Vote allocation and the difference between the allocation under the Vote structure and the indicative appendix structures. Has any of the Deputies any questions or opening remarks relating to that section on page 5?
I note the section where it states a number of key high level metrics are not linked to the subhead or subhead groups under which the Estimates are presented. I found this extremely difficult to go through and wonder if there might be an easier way for this information to be understood. We got a briefing, which was welcome, but it was still a little like swimming through treacle. One really feels like one is not making much progress. I understand that the format of the presentation has changed. Perhaps the Minister will indicate why. I might have my view, which I will not express now, but the format changed from last year to this year. There seems to be a bit of a disconnect between the headings that we are looking at given the money is listed in a separate document. I found it difficult to link the two and wonder if there is an easier way to do it.
The Deputy makes a fair point. In considering the health Vote, we must accept the elephant in the room, which is that the health Vote is not configured along programme lines. The Department of Health is working towards the development of programme budgeting and changing the structure of the health Vote to reflect this. It will take some time though because the financial systems in the HSE will need to be adapted to allow for it in the context of the financial reform programme that is currently under way. In the interim though, the appendices to the Revised Estimates for the health Vote have been constructed along programme lines. I do not mean to comment in any way on the committee's briefing, but the way we have tried to present it in our departmental briefing endeavours to show the programme, the target, whether it was hit and where we are going to get to this year. In some ways, it may be a more useful document to have questions on. In terms of the changes in the presentation, I am informed that the Department has not changed the way we presented our briefing since last year.
I stand corrected. In terms of moving towards matching the programme to the money, how close are we to that?
It is still a substantial body of work and we are a number of years away in terms of it. The HSE needs to be cognisant of the fact that we are going to presumably undertake more structural reform when the Committee on the Future of Health Care reports in April, which may enable us to have more fruitful conversations on structures across the health service. I looked through the various briefings when preparing for this committee hearing. When we look at section 3 of my Department's briefing, which is the performance information section by section and directorate by directorate, we have a sense of what the HSE did in 2015, what it did in 2016 versus its targets in 2016 and what it intends to do in 2017. As Minister, from the performance and accountability framework point of view, it is against the delivery of the commitments in the national service plan that the HSE should be judged in 2017.
I would have a similar problem, but I realise what the Minister is saying. Working inside the Department, they are looking at it from a different perspective altogether. Is it all right if I use the old Vote system? That system gives me an instant bird's eye view of where we were and where we will go. I believe we should know ourselves where we fell short, if we did. We can see straight away the increases in the salaries, wages and allowances. Presumably they relate to the consultants and medical staff. I hope that the consultants, nurses, GPs and other medical staff, as opposed to administration, take a fair share of the expenditure. People will say that we must have administrators, which is true, but we also must have the practitioners. My question is on the extent to which we have made sufficient provision among those specialists, consultants, GPs and nursing and medical staff.
The Deputy makes an important point. Last week at this committee we had a detailed discussion on the increased numbers of people working for the health service. A number of Deputies and Senators raised the issue of the growth in administration and management. The national director of human resources, HR, has committed to giving a report to the committee showing a more detailed breakdown. From my initial inquiries, I would make the point that we need to be careful in presuming that everyone in the admin-management section is not carrying out an important role in terms of the delivery of clinical programme. For example, a clinical nurse manager on a ward is an important piece of our health service infrastructure that is recognised by our trade union movements and nurse representative organisations as a crucial piece relating to patient safety and the operation of wards. The role may well end up being classified as administration or admin-management, but a patient going through a hospital today will see a benefit from having that person on the ground. In addition, the delivery of a number of other clinical programmes will require other people in that category.
I could not agree more with the Deputy in terms of his question regarding our desire to increase the number of people working on the front line of the health service. I am conscious, as we speak at this committee meeting this morning, that the INMO is about to engage with my Department, the HSE and the Department of Public Expenditure and Reform at the Workplace Relations Commission. I hope it is a fruitful and constructive engagement because it is essential in the interests of all of our patients. We had detailed and productive discussions with the INMO on a range of issues over the past couple of months on recruitment and retention. It is fair to say that we made progress on quite a number of them, including having for the first time in a number of years a fully funded workforce plan for nursing at a much earlier time of the cycle. It is also fair to say, not that I speak for the INMO, that there are some areas where we did not make as much progress. This relates to how some of the retention measures interact with the process that is going on in terms of the Public Sector Pay Commission and the Lansdowne Road successor talks that will follow. I hope the Workplace Relations Commission can help make progress in that regard today and over the weekend. It is not in any of our interests to see industrial unrest in the health service from next week on. We have already made progress in alleviating two other potential industrial relations disputes in the health sector.
If we were here just over a week ago, we would have been talking about threatened industrial action from the IMO with regard to non-consultant hospital doctors. That has now been satisfactorily resolved. We would also have been talking about action from next Tuesday by SIPTU health care support staff. I am very pleased that a way forward was found with SIPTU in that regard. I thank it for its constructive engagement. We had three disputes about ten days ago. Two have been resolved or put into a process towards resolution and one remains outstanding, but work is ongoing there. As the Deputy knows, we intend to hire 1,000 additional nurses this year. I accept the INMO's point of view that we lost an awful lot of nurses. Numbers have been growing, but I say that while accepting that there is still a way for them to grow to get back to the levels they were at before the crash. I do not disagree with the Deputy's assessment.
The Minister mentioned the industrial disputes, two of which have been headed off at the pass and one which I understand is on its way to the Workplace Relations Commission, WRC. We obviously wish everybody well with that. The settlement of those disputes is not without cost, since the Estimates were produced and the disputes were settled. Where did we get the wriggle room from in terms of being able to settle? The settlement with the doctors is fairly substantial, as I understand it. It is the living out allowance, which I think is in or around €3,000 per person. The SIPTU settlement is obviously more complicated because it is a longer-term solution and involves making good commitments that should have been costed. These commitments were given, but it was regrettable that the staff had to ballot to get it. However, they got it and that is good news.
I wish to talk about flexibility. I am in the Chairman's hands if I am jumping around too much between issues. Since the salaries were mentioned, and in terms of the flexibilities that exist, where would I find that in the mass of paperwork that I was given?
It is a very fair point. I reiterate that if we have to find additional resources for pay measures above and beyond the Lansdowne Road measures that were agreed by and expected by Government in advance of the preparation of budget 2017, there is no new pot of money to use. I am conscious of that and I am sure the INMO is conscious of that as well.
The IMO - the doctors - is being dealt with in the process of the anomaly in the Lansdowne Road agreement. As the Deputy knows, the Minister for Public Expenditure and Reform has outlined that that will have to be dealt with centrally by Government. The SIPTU process, if I can call it that, is yet to conclude in that regard.
With regard to the INMO, we had already provided for the recruitment of 1,000 additional nurses in budget 2017. I do not wish to pre-empt this, but if we have a successful conclusion in the WRC and if there is a cost to that - I do not want to say too much about this or I could get into all sorts of trouble - I would be happy to come back to the committee and talk about how that cost would impact on the current Revised Estimates before the committee today. If the Deputy's assertion is that there is not funding within this Vote to meet those additional costs, that is an assertion that is correct.
I thank the Minister. If it is okay, we will now move on to the second programme, which consists of four parts. It refers to primary care services, which has a total Vote of €3.852 billion. That is on page 7 of the document. It is broken down to primary care reimbursement services, which have a Vote of €2.807 billion, social inclusion, which has a Vote of €134 million, primary care, which has a Vote of €834 million, and palliative care, which has a Vote of €77 million. The first item on page 7 is the total primary care service budget of €3.852 billion.
I might start off with the Minister with regard to palliative care. It is a topic we have discussed at a number of our committee meetings. There is not national coverage for community palliative care services. I note that the Vote has gone up by 0.3%. Perhaps the Minister will comment on that.
This is an area that is extraordinarily important and one in which significant progress has been made over the past ten years or so from a very low base in this country in terms of access to palliative care and in terms of the provision of hospice services in general. If one looks at a map of Ireland now, as I did recently with the palliative care people in the HSE, there is significant hospice coverage around the country with a number of blackspots, if I may call them that, intended to be filled in within the coming years. Some of those are Cavan and Monaghan, the midlands and my own county of Wicklow. There are a couple of obvious places on the map.
With regard to actual palliative care services, let us look at the increased provision and increased targets this year in the document I circulated from the Department. Some of them are worth putting on the record. For access to specialist palliative care services in the community provided within seven days in the normal place of residence, a target of 91.5% was set for 2016. We achieved 95%, with a view to maintaining that 95% target this year. The number of patients in receipt of specialist palliative care in the community in the reporting month was 3,341 in 2016 and will be 3,620 in 2017. Access to specialist palliative inpatient beds provided with seven days was achieved at a rate of 96.8%. Our target for this year is 98%. The number accessing specialist inpatient beds - this is a new key performance indicator that was not in last year - has a target of 3,555 for each reporting month this year.
The number of children in the care of the children's outreach nursing and specialist palliative care team is a very important and emotive area. We have set new key performance indicators for this year. There were 453 last year. The number of children in the care of the children's outreach nursing team has a new target of 269 for 2017. The target number of children in the care of the children's specialist palliative care team in Crumlin hospital or in Temple Street for each of the reporting months is 20 for 2017. That is a new target for this year as well. This is an area in which substantive progress is being made and that is reflected in the figures I have outlined. It is also reflected in the great work that the Irish Hospice Foundation has done with the Department over a sustained period and in the evaluation report on children's palliative care, which was published only a matter of months ago.
As an add-on to that, in my area in County Clare, there are excellent community palliative care services. The difficulty is that they are understaffed and stretched to the limit and beyond in providing the services. There can be an unavoidable delay in nurses coming to visit people in the community because of the lack of staffing. Perhaps the Minister will address that issue. I will then bring in Deputy O'Reilly and Deputy Kelleher.
The Vote that I am here to account for today does allow for increased investment in the provision of palliative care in 2017 to address the deficits the Chairman has highlighted. This is an area in which we are coming from a historically low base. I am not suggesting in any way that enough is done, but I do genuinely believe in the increased investment this year. When we look behind the monetary amounts, the number of extra patients expected to benefit this year in the figures I outlined is to be welcomed.
With regard to palliative care, the Minister referenced the map and the blackspots on it, for want of a better word. It is a much bleaker map if we look at the palliative care available for children. Paediatric end-of-life care and palliative care is sorely lacking. I was in Donegal the week before last and I met Ms Ashling Nibbs and Ms Gina Grant from Our Children's Voice. Ashling very recently lost her son Órán at the age of seven after a very tough time. He was brought home to die and only lived for a couple of hours. She struggled greatly to access services and, in the end, there was only goodwill. There were no services available. When the Minister talks about the map, he may want to look at two maps. We can obviously measure the progress that has been made in terms of adult services, but I do not think that we could say that what is available for children is anything approaching acceptable.
The only outreach palliative care available in Donegal is provided by charities. It is not provided by the HSE.
We need to look for future planning at two maps. We need to look at the real map for children. It is stressful enough to travel from Dublin up to Donegal with a sick child but it is different when one is bring that child home to die, knowing that there is no service there for you. There are a lot of parents in that situation and they watch these proceedings closely. I am sure they want to hear what is in store for this year. For Aisling's son, Órán, it is too late, but Aisling is committed to this cause and she wants to see, as a legacy to her son and others who have passed away since, that they might be able to make progress in that area.
I have two questions on palliative care. The first has been discussed on many occasions, in this committee and elsewhere. I refer to end-of-life care in nursing homes, the complications that arise when residents die in nursing homes and the impact that can have on public opinion of the nursing home. If there is a high number of residents dying in a nursing home, it can read badly at times. In the context of assessing and supporting residents in end of life in a nursing home, it is something we should look at. There are HIQA inspections and oversight. Some nursing homes have end-of-life support facilities. Not enough of them do. Sometimes - I have tried to get to the bottom of this - there is almost an incentive to transfer residents from nursing home to hospital in end of life for a number of reasons. It is something that has to be looked at in a clinical fashion to determine why it is happening. Can the Minister support nursing homes to allow residents die on the premises, without overly complicating it and without it reflecting badly on nursing homes, if there are a high number of residents dying in them, where they are dying in the context of palliative supports, as opposed to keeping the numbers down and transferring them to hospitals? That certainly is something that we should look at.
We talk about the pressure on acute hospitals. A busy hospital setting is no place for a family to mourn their loved one. Has any assessment been made of the number of patients who die in hospital as opposed to elsewhere and whether we have a higher propensity to die in hospital as opposed to either in the home or a nursing home with supports? It is an area that should be examined, not only in the context of the emotional side of it with hospital being a busy place but, equally, in the context of resources and the pressures on hospitals.
Paediatric palliative care and palliative care have to be looked at separately. I do not mean to dismiss anybody's mother or father, or natural death, but the trauma on a family in the context of paediatric palliative supports and bereavement is significant. We all can understand that. At times, one must look beyond the immediate short term and there has to be greater supports for families of children who die. Except for a lot of voluntary work and good work being done by communities and groups that rally round, it is an area that is greatly under resourced and understaffed. There is a lack of understanding of the importance of ensuring that there is enough support, both in the short term but also in the longer term. That also includes support for siblings who are often forgotten in the context of a child's death in a family. It can have a profound impact for a long period of time. That needs to be looked at. Before we clap each other on the back, it is an area that needs a great deal more support in communities.
Does the Minister want to respond to those?
I will start with the nursing home matter that Deputy Kelleher raises. The Deputy is correct. On the issue of the 'flu this winter, for example, once the HSE started engaging proactively with the nursing homes when we put the additional measures in place in January, we saw that there is a willingness on behalf of nursing homes and their representative bodies to work with the health service to cater and care for the needs of residents within the nursing home without the need to transfer them to the acute hospital. It became apparent that the nursing homes were willing to work with the health service and if that work can be built on further, that will have two results. First, it can result in nursing homes no longer feeling compelled to send an older person to an acute hospital when the care could be better provided in a nursing home, particularly if somebody has his or her own room, en suite facility, etc., and infection can be controlled. Second, an older person can often be provided with more dignity and comfort by being able to remain in the nursing home. I do not disagree with Deputy Kelleher in regard to that.
I am glad Deputies Louise O'Reilly and Kelleher raised the general issue of paediatric palliative care. They are correct. While I stated we are coming from a low base for palliative care, we are coming from an even lower one for palliative paediatric care. There is such a significant difference. When a child dies it is something that is unnatural and traumatic and has a major impact on the whole family, and a whole community. How we respond to that as a society is important. Progress has been made and I will outline some of it.
In 2009, long before the Government or its predecessor was in office, in fairness to previous Governments, Palliative care for Children with Life-limiting Conditions in Ireland - A National Policy, was published. Arising from that policy, the HSE established the Children's Palliative Care Programme. I must acknowledge that this was co-funded by the Irish Hospice Foundation. The programme at that time provided for the appointment of a consultant paediatrician with a special interest in children's palliative care and eight children's outreach nurses to co-ordinate care for children with life-limiting conditions and their families. Eight were welcome - it was starting from zero - but were clearly not enough to cover the country, as Deputy Louise O'Reilly references.
I launched, on 21 November, an independent evaluation of the Children's Palliative Care Programme. It was undertaken by specialists from the UK. It recommended that additional children's outreach nurses be hired and that a second consultant be appointed. A further two children's outreach nurses are now being recruited as part of budget 2017. We have also agreed to the appointment of a second children's palliative care consultant post, which will be funded by the Irish Hospice Foundation for the first year - subsequently, the funding will be taken over by the health service. I should also point out that there is now a new masters programme in palliative care training for paediatric nurses running between the National University of Ireland Galway and UCD because we need to ensure we continue to provide a skill set for our paediatric nurses.
I extend my sympathy to Aisling on the loss of her son, Órán. I met the group, Our Children's Voice, with some of the Deputy Louise O'Reilly's colleagues and colleagues from all parties when I visited Letterkenny relatively recently. One of those two children's outreach nurses is for Donegal. I do not have the note in front of me but from memory, I am almost certain that post is currently advertised. I will contact the Deputy if I am wrong on that.
They will be watching this. I thank the Minister.
Donegal can feel quite isolated geographically at times. It is such a large, sprawling county that to have an outreach nurse will make a big difference.
I also had an excellent conversation with Deputy Louise O'Reilly's colleague and my counterpart, Ms Michelle O'Neill, MLA, the Minister for Health in Northern Ireland, about what we can do on a North-South basis in terms of paediatric palliative care. LauraLynn has some ideas in that regard. Both the Minister, Ms O'Neill MLA, and myself have undertaken that our officials will engage. A bit like Altnagelvin in the case of radiotherapy, there is definitely scope to do something tangible there. I am also in conversations with LauraLynn, which I visited on 23 December, about its desire to expand services outside of Dublin. I hope we will have a busy year ahead in this regard.
In making a comparison between the four regions, the following would be my query.
To what extent have pressures showed weaknesses, based on the previous performance? I am going on the old document again. To what extent has it been possible to monitor potential hazards before serious difficulties arise with waiting lists or shortages in the delivery of services at any level, either in the primary care area or in the general hospital area? How are the four regions likely to fare in the course of this year? At year-end are they likely to compare favourably with each other, given the respective population demographic requirements and staffing levels?
I know Deputy Durkan is a traditionalist in regard to looking back at these figures. I mean that in a positive sense. While this is the way the document is laid out, as I said at the start, it is sometimes not terribly reflective of the way the programmes are delivered and that is the bridge we need to try and cross. I expect all four regions, without fear or favour, to come in on budget and to fulfil their commitments in the performance and accountability framework. That commitment is not just to come in on budget, it is the three other metrics that I spoke about last week, which do not often get talked about as much. These are access to services, quality of services and how they are harnessed.
We now have the hospital group structures and we have our community healthcare organisations, CHOs. While I defer to the Committee on the Future of Health Care as I want to see a cross-party view on this, my personal view is that the CHOs and the hospital groups should be integrated in a more seamless manner. We talk about home care packages and delayed discharges. It does not make sense if one section of the health service is responsible for hospital beds, but to free up a bed they need somebody to be provided with a home care package and that is the responsibility of a different organisation within the HSE. They need to be realigned. Hopefully some of that work can be done in 2017 once the Committee on the Future of Health Care reports in April.
The Deputy is correct to say that different regions have different pressures. If one looks at the country's demographic profile, some of our hospital groups and CHOs have a higher proportion of older people. There are areas that have a higher level of social deprivation and therefore generally a higher level of health need. The HSE's job is to try and reflect that in the submissions that it receives from the hospital groups and from the community health organisations. I expect that they will do that through their operational plans.
The most sensitive areas in the current year were in regard to waiting times, accident and emergency difficulties, overcrowding and primary care. Does the Minister feel adequate provision has now been made to ensure that the most urgent cases in terms of overcrowding are unlikely to recur to the same extent?
This year it is no longer acceptable to say that the HSE is not adequately funded. I say that because the Director General of the HSE, when he launched the service plan with me, said that the service plan was adequately funded for the delivery of the targets within it. There is recognition from the HSE that the Houses of the Oireachtas have provided adequate funding to deliver on the priorities in the service plan. In this year's service plan we have tried to prioritise some of the areas that have caused particular difficulty to our patients, our citizens and our staff in recent years. I spoke about earlier about the situation in previous years where children with disabilities were turning 18 in the summer but there was a lack of funding for an adequate transition place. This year, costs for school leavers have been factored into the service plan. There have been significant increases in home care and home care packages.
In regard to medical cards, where in the past there were significant challenges, in particular during the years of recession, today I will publish the Bill. I will try and get the legislation through the Houses of the Oireachtas as quickly as possible to ensure that every child with a disability whose parent is in receipt of domiciliary carer's allowance will have an automatic entitlement to a medical card. That is about 33,000 children in this country. Of the 33,000, almost 10,000 of them do not have a medical card today. The others are subject to reviews, which can cause a lot of distress and hassle and inconvenience for a family when the condition, in all likelihood, will not have changed, or certainly will not have improved.
We are now back to investing in waiting list initiatives. I will not suggest that in one year of doing so we will be able to deal with the totality of the waiting list problem. However, we will unapologetically target those waiting the longest. If the Deputy went to the doctor today and needed a hospital procedure or hospital appointment, he would go on a waiting list. What matters is how long one is on that waiting list. That we have people waiting 18 months and longer for procedures and that we have children waiting such a long period of time is not acceptable. That is why all of our efforts in regard to waiting lists will be targeted at the longest waiters. If waiting times can be reduced this year and that work is built on in following years, it will be possible to get back to the relatively good waiting list times which this country previously had.
Emergency department overcrowding is perhaps the biggest challenge. It is dependent on a number of factors. One is bed capacity. Another is staffing. A bit like Deputy Kelleher's question, another factor is to what extent we are currently providing services in acute hospitals which can be provided outside that, be it in primary care, through a GP contract, more primary care teams, community intervention teams or supporting our nursing homes to do more.
Usually the winter initiative comes to an end around now. I came into office in May. Discussions started during the summer about a winter initiative which was to take effect in September or October. This month I intend to begin having conversations about the winter initiative for 2017. I have asked the HSE and the Department to get together and do a look back and a look forward. They will examine what went well and what worked. For example, we had the lowest level of delayed discharges ever recorded. Some things clearly did not go well. We will then analyse that data and try to understand, for example, what were the reasons for significant increases on certain days. If we had GP out-of-hours for a greater length, would that have reduced the attendances? We must ensure the measures are targeted. I would welcome a conversation with this committee before the summer in regard to the preparedness for winter next year. If we follow those steps, we can reasonably take all steps possible.
I very much welcome that the Minister is introducing this Bill. The automatic medical card for children whose parents are in receipt of domiciliary carer's allowance is especially important for those who face a review every three years or whatever. Affected parents in my constituency have brought up the hardship of filling up the forms. They have a lot of other stress in their lives, especially dealing with a disability that obviously is not going to get better. The Minister will have my full party support in pushing this through quickly.
I am glad that the winter initiative talks are being started early. Some of it went right, some of it went very wrong. The earlier aspects regarding the winter start to be discussed, the better.
The extension of an automatic medical card to children whose parents are in receipt of domiciliary carer's allowance is very welcome. It is regrettable that it did not happen earlier. There is a considerable amount of political will. I said at the time that it was going to cost €17 million. When the budget allocated €10 million it was clear that there was no intention for this to come in quickly. Waiting until 1 June is time lost for a lot of people. That said, the measure is very welcome.
In regard to the winter initiative, he Minister has mentioned reduced attendances. That will not influence the number of people on trolleys, because a patient is not put on a trolley unless a doctor has made a decision to admit them.
On the figures before us, how are we to judge whether the winter initiative gives value for money? How will the winter initiative be analysed? I fully appreciate that the Minister is dealing with human beings not robots, so he cannot predict what will happen. One can say the flu happens every year, and we can park that, but crises will emerge. How will we judge whether the money allocated to the winter initiative has been effectively dispersed? We all see the trolley count. We see that it is unacceptably high. The current Minister is not the first to say that the trolley count is unacceptably high, one of predecessors stated it was a national emergency but the figure still did not reduce. How will we judge that we are getting a good return on the measures that have been pursued?
I thank Deputy Margaret Murphy O'Mahony for her support for the legislation to address the provision of a medical card for those in receipt of a domiciliary care allowance. This is an issue that unifies the House. The Bill is welcome and we will get it through both Houses as quickly as possible. The Deputy is correct to highlight the review. It is very important for the almost 10,000 parents who are in receipt of the domiciliary care allowance for the care of their child, who does not have a medical card. I meet in my clinics many people who must keep reapplying for the medical card, because the card is reviewed every three years. Now they will have certainly from the age, the child is granted a domiciliary care allowance until the age of 16 years. That will save parents a great deal of unnecessary stress due to uncertainty and the bureaucracy. That is important.
The HSE is working on an online registration system, similar to the free GP care, so that people will log on. The Department of Social Protection together with the HSE will be able to share information and cross check information. If one is in receipt of a domiciliary care allowance, the HSE will be able to verify that with the Department of Social Protection. This will reduce form filling, which is important.
Let me assure Deputy O'Reilly that the time it has taken to introduce this scheme is not due to monetary consideration. While I presume the Deputy could be correct about the figure of €17 million-----
That figure of €17 million is from the Department of Public Expenditure and Reform. I did not make it up.
I do not doubt the Deputy. As the Deputy also knows, the primary care reimbursement service, PCRS, of the HSE has been showing a surplus because people were granted a card during times of unemployment but as they go back to work, the card is being returned when it comes up for review. While the Deputy is correct that there was an allocation of €10 million in the budget for this measure, let me point out there is a degree of head room, if I may call it that, in the PCRS Vote. The arbitrary date of 1 June should not be seen as such. I have asked the HSE to examine how quickly we can introduce this measure. It is based on two components, the first being legislative change. We need to change the law and no matter how straightforward the change is, it still has to go though the process and come out the other side. We start that process today in terms of the Bill being published. Second, is the system for people to apply for the medical card without having to go through the rigmarole of significant amounts of paperwork. I am happy to work together to get the system up and running.
What is the headroom on the PCRS?
I do not have the up-to-date figure, but the PCRS had a surplus of about €30 million in 2016. It is a moving figure, but the most recent figures available to me are in that region.
Deputy O'Reilly is correct that the people on trolleys are people who have been admitted by a clinician. It is also correct that people turning up in hospital - this is not blaming people because they often have no where else to go - who may have been able to be treated in a primary care centre in an out of hours GP service in a nursing home or in an appropriate setting, takes staff from the emergency department to deal with them. Reducing hospital attendances through primary care is a component of assisting and alleviating the pressure on our acute hospitals. I equally accept that bed capacity and staffing are the other two big pieces. We have to address the issue using a three-pronged approach, namely, primary care, bed capacity and staffing. When I listen to people on the radio speak of the need to open a certain number of beds in the morning, even if their analysis is correct, they also need to be conscious of the fact that the beds need to be accompanied by staffing. It is not an either-or in regard to bed capacity or staffing. It has to be the bed capacity, the staffing and the primary care.
Deputy O'Reilly made a fair point on whether we are achieving value for money. I have asked myself this question. It is part of the reason the HSE and the Department are sitting down to provide me with an analysis of the winter initiative. That is one of metrics I want them to analyse this month. It is fair to say that it is easy to measure some aspects, for example, if one provides a certain amount of funding for aids and appliances to benefit over 3,000 additional patients. One can establish whether the 3,000 additional patients get the goods and whether they were procured at a reasonable price. It is a quick and easy to answer that. When one gets to the hospital and the numbers on trolleys, then there is a value for money element, because one can measure whether the funding was provided for extra beds and the beds came on stream. The other elements I have outlined are harder to measure on a value for money basis. If there was insufficient capacity in the hospital or if there was not adequate staffing in the hospital. We need to look at the value for money aspect but we also need to look at the blockages are as well. Some of them are not as easily measured from a value for money analysis point of view.
A flu outbreak happens every year in every country. The advice available to me from our chief medical officer, our deputy chief medical officer, our expert group on influenza was that the type of 'flu this year was a strain that we had not seen in this country since 2009. I believe the flu in 2015-16 largely affected younger people. The strain of 'flu this winter largely affected older people. That does result in increased hospital attendance.
I make the practical, not political point, and in recognition of the staff working in the health service, that during the month of February in spite of the fact that we continue to see too many people on hospital trolleys, we need to recognise the fact that we see more and more people attending our hospitals as the population grows and gets older. We had fewer people on trolley in the month of February this year than last year. It is not an acceptance of the figure, but it is a recognition of the fact that people working in our hospitals, be it in management roles or front-line roles, are doing their very best to reduce the number. In spite of the fact that more people turned up in the emergency departments, fewer people were on trolleys.
I thank the Minister. Before we go off that topic, perhaps I could sow an idea in his head in regard to nursing homes. I believe each nursing home should have a medical officer which would give consistent medical advice and an overview on how the nursing home deals with people who become acutely ill in their care. It would be an interesting study if the Minister could compare the number of admissions from nursing homes that have a medical officer to those who do not. Many of the public nursing homes have a medical officer employed by the HSE whereas most of the private nursing homes do not. If there were consistency of medical management in nursing homes, fewer people would be sent to acute departments when they become ill in a nursing home. When patients are admitted to a nursing home, most nursing homes will introduce an end of life discussion on how people wish to view an illness, should it occur. That is to be encouraged and advance directives in that regard are an item that should be foremost when anybody is admitted to a nursing home. Obviously one wants to do the best one can for a person in a nursing home but there are illnesses which will not benefit substantially in terms of treatment when the patient lands on a trolley. The introduction of a medical officer in each nursing home is something the Minister might consider.
We are skipping around a bit, which is fine if that is okay. The next item on the programme is the Vote of €2,807,000 million for the primary care reimbursement services, PCRS which is referred to in page 8 of the analysis of the Revised Estimates.
On that topic, I noticed that the percentage of properly completed medical card or GP visit card applications processed within 15 days is approximately 90%. Is that an improvement or a true reflection of what is happening? It does not seem to be reflected on the ground, where people have great difficulty in having their medical card application approved.
Is that because what is measured is the properly completed applications? The delay is often caused by missing paperwork. They are only measuring when all the legwork has been done. I am sure that the Minister recognises that many of the problems, particularly those referenced by Deputy Murphy O'Mahony with regard to parents filling out the paperwork, are not caused by the paperwork going in but rather because parents feel that they are being made to jump over hurdles. When it is all done it is measured, but the time taken could be significantly longer than the 15 days. It could stretch to months in some cases.
That is true. In 2016 there was a target of 95% of medical cards properly completed - I will deal with that point in a moment - and being processed and turned around within 15 days. The actual outturn was 89.6%, so it fell short of the target. We have set a target of 96% for 2017. The point that Deputy O'Reilly makes is valid. We all see it in our work as Deputies, where people feel that they have submitted all of the paperwork only to get another query back. I visited the primary care reimbursement centre, PCRS, and in fairness to it a number of improvements have been made in recent years after a very difficult birth, if I might call it that, relating to the centralisation of the service, including the application number one receives and the way in which one can track the application online. Those are improvements. I do not know whether the committee has been out to the PCRS centre for a meeting with management there, but I would very much welcome its input on how it can improve. I know that Deputy Durkan has strong views on this. The quick turnaround is in the interest of everyone. The size of the operation in terms of the scale of correspondence we are dealing with is very significant.
I have been out to the headquarters on several occasions. I am not a great supporter of the centralised system at all, and I hope that in the not-to-distant future we can see decentralisation, in the four regions perhaps, and with that simplification. I have brought this up before. The HSE told us a week ago there is no automatic right for a cancer patient to have a medical card. I find it hard to explain to the patient or constituent in a situation where everyone is stressed and wondering how quickly they can get their medical card, if at all.
Some of the questions are insensitive. If one receives a letter from a doctor to the effect that a patient is terminally ill, a card will issue. That is not a great help to the patient, I have to say. It does not reassure the patient in any sense. There is a certain inevitability about it that I regard as a bit insensitive.
I know that spot checks have to be made. It is commonly said to patients that there is an awareness of their changed circumstances even though their circumstances have not changed at all. It takes an inordinate amount of time to process some of those cards, especially if there is a question asked. I am not blaming the staff, but that system does not work.
There are a couple of points to note. Let me be clear and say that there is no financial need or incentive to be carrying out spot checks now. In terms of the surplus that PCRS actually found itself with at the end of 2016, unlike in previous years when previous Ministers for Health found themselves in very difficult situations regarding medical cards, that financial necessity is not there. What is a necessity is that we ensure that the system is administered in line with the law. If we do not like the law there is an onus on us to change it. That is why we are going to change the law, I hope, on the domiciliary care allowance, DCA. The reviews that the Deputy talks about for that cohort of people, which is 33,000 people - quite a few - will cease. It is hugely expensive and time consuming for both the resource within the HSE. One would be better employed turning around more medical card applications for patients to achieve that target.
It is also worth pointing out that the clinical advisory group that was set up by my predecessors to tackle the question that the Deputy is referring to is doing important work. Its first recommendation, which was adopted by the director general, was that any child under the age of 18 with cancer should be provided with an automatic entitlement to a medical card for five years. That was a very welcome development. The next step now, and the director general made this point when he was here last week, is to look at how we can apply that process to all cancer patients. The clinical advisory group, which includes representatives from Our Children's Health, Patients for Patient Safety Ireland and medics has been looking at this. My own policy perspective on this is that where people have a clear medical need and a condition that requires access to a medical card the more straightforward we can make that process as legislators the better, because it avoids all the hoops that people have to jump through. Today we are making good progress on a cohort of 33,000. The move that we have already made around children with cancer is another cohort of patients who should not have to go through a bureaucratic process. The next body of work I will be moving on to will concern other conditions, including cancer.
On that point, perhaps when people have a diagnosis of cancer, rather than having to get a letter to say that they are terminally ill, if they got a letter to say that they are having ongoing treatment for a certain period of time that should be sufficient to trigger a medical card and not have to be at death's door before being allocated a medical card.
I think the point that Deputy Durkan makes is very fair. It is important to those people working in PCRS that we provide, as legislators, the legal framework to do some of those things, if that is the view of the House. As I say, once we move on from the DCA legislation I would be very eager to work with colleagues on further legislative change where required.
The next section relates to social inclusion, which is referred to on page nine of the analysis of estimates. This refers mostly to substance misuse and the treatment of those with substance misuse issues. That is one of the metrics used here. I did have some input into looking at homelessness and drug addiction and the dual diagnosis of drug addiction and mental illness, and I understand that the allocation of money has gone from €2 million to €6 million in this regard. Perhaps the Minister could speak about that.
This is a very important part of Rebuilding Ireland, and I want to acknowledge the Chairman's excellent work in this regard. The premise is that people who are homeless have a need for a house and often have a need for other wrap-around services. The Chairman espoused the housing first principle in the programme for Government talks. Until relatively recently a view would have been taken in many parts of administrative Ireland that a house would be provided after all of the other social needs, whereas the evidence now suggests that providing people with a stable housing situation and wrapping around the services is often the way to break the difficult cycle of addiction, abuse or various other health needs. I gave a commitment to significantly increase the funding and that is what we are doing. I recently visited the Capuchin Day Centre and saw the work done by Brother Kevin Crowley. I was in a facility for homeless women and children in Mullingar, called Temporary Emergency Accommodation Midlands, TEAM, last Monday week. The message that we need to take from that is that the job of tackling homelessness and the issues of homeless people is not just something that rests with the Minister for Housing, Community and Local Government, Deputy Coveney. There are societal issues that interact here that we have to try to provide for.
I thank the Chairman for his work. I hope the funding we have provided will make a significant difference. Some of the metrics are outlined in the performance information note from my Department which was circulated to the committee. We want to get to 100% of substance misusers over the age of 18, for whom treatment has commenced, within one calendar month following assessment. Currently, it is 97%. We want to get to 100% of substance misusers under 18 years of age, for whom treatment has commenced, within one week. That figure is 81.4% now so it is quite a jump to get to 100% of people under the age of 18 this year. The percentage of service users admitted to homeless emergency accommodation hostels or facilities whose health needs have been assessed within two weeks of admission is currently 73.9%. We have funded that to get it to 85% this year. We can make a real and significant difference. We can also do other things that seem very logical.
When I was in TEAM in Mullingar last Monday week, I spoke to some women and their children who find themselves living there. They cannot speak highly enough of the facility they are living in but their medical card is attached to a specific GP and that GP may be many miles away. To use the example of somebody I was talking to from Portlaoise who is now living in this temporary accommodation in Mullingar, if she needs to bring her child to the doctor, she has to get the bus to Portlaoise and back. It is a huge burden. Prescription charges and how they are dealt with is another issue. Can we give a medical card to a centre and waive the prescription charges? I have given a very clear commitment to try to look at the prescription charge issue and the medical card issue. Can these temporary accommodation facilities have a medical card attached to the centre which can be used by those living in the centre? By virtue of it being a transient group of people, those people will change. I will be happy to come back and update the committee on those points. They are two small, practical things on the health side that we could do to ease the hassle and inconvenience for some of these people.
This is an area we need to look at to a greater extent in the future. There is an increasing cohort of people who suffer from social and economic deprivation and, as a result, find themselves under medical and mental pressure to a huge extent. Way back in the days of old, we tried to have a programme of identifying families who were at risk for various reasons. We tried to have a case worker who focused on two or three families in order to provide a safety net for them so they did not become a burden on themselves or become homeless or reliant on drugs or alcohol. I do not know how feasible that programme might be in the future but it could be very important. We need to keep that in mind when we consider the issue of homelessness.
There is also an increasing number of people, quite often single men and single women, who are dropping out of society, sleeping rough and coming to the attention of the authorities and all kinds of things. Have we arrived at the time where there is a need for emergency supervised accommodation in towns and villages throughout the country, which would not have been heard of years ago, with a view to alleviating their problems? They would have a place where they could go. They would have a roof over their heads and a place that is supervised. There could be a manager within their immediate environment in order to encourage and support them.
My last point is about younger women, in particular very young women, with children who find themselves under social or economic pressure and pushed down the list. They have little knowledge of motherhood or raising a family and do not know where to go. It is a problem that has come up again and again. They need support. We need to invest in the provision of support services, to give them something to lean on at crucial times, so they do not find themselves pushed to the side and ignored. It is something that does not immediately come into focus at present other than when talking about the future. In my time in public life, I have seen a huge increase in the number of young people who are sleeping rough, who are in danger of sleeping rough or who are dropping out of society and have become addicts for a variety of reasons and progressed in an area that is not helpful to them at all.
I am looking at the note we were given and trying to match it up to the figures. Under the heading of social inclusion, there is substance misuse, opioid substitution and homelessness. I might be missing it but there is no detailed breakdown of the services. It is all very well to say social exclusion is a problem. We could agree on that eight days a week. The issue is knowing exactly and specifically what services will be provided. What are the targets and how will they be measured? How will we know, if we are all sitting here this time next year looking at each other, if it worked or not? How will we measure whether it was successful?
With regard to the point made by Deputy Durkan, there was a fantastic project in Ballymun known as Young Ballymun which was doing exactly what the Minister is talking about and regrettably the funding for it was cut. Perhaps the Minister will raise that at his next parliamentary party meeting.
No better man.
I sincerely hope the Minister does. If he lets me in, I will support him. Deputy Durkan makes a very valid point about early intervention. It is regrettable that the funding for Young Ballymun was cut. That is only a statement; I would like an answer specifically to my question.
I will get Deputy O'Reilly a detailed note on the breakdown and the impact. It is an important point. I have some detail here that I am happy to share. Much of the additional funding in 2016 was provided to service providers to improve their own services and meet their own unmet need. I will get the Deputy more detail.
There are a couple of important points to make on Deputy Durkan's and Deputy O'Reilly's question, which relates to breaking the cycle and what we will do, apart from responding to the current crisis. There are a couple of pieces to this issue. The new national drugs strategy, which will be published shortly by my colleague, Minister of State, Deputy Catherine Byrne, is an important part. Supervised injecting facilities are a very important element. The Oireachtas will be showing political leadership in tackling this issue. We will be following on from something that works very well in many other cities if we establish the first pilot supervised injecting facility in our capital city in 2017. Items such as the Public Health (Alcohol) Bill are very important measures that will require political leadership in the Houses of the Oireachtas which I hope will be forthcoming from all parties, including our own, in addressing that issue.
The powerful message sent from the Oireachtas after the statements in the Dáil last night on recognising Travellers as a distinct ethnic group cannot be the end. There is now a need to follow on. The development of the national Traveller and Roma inclusion strategy is being undertaken by the Department of Justice and Equality. My Department is feeding into that from a health perspective by addressing the unmet health needs and addressing how one can interact with the Traveller community to make sure Travellers access the health services that are available. Funding was available under the dormant accounts fund for 2016 and 2017 and this is being used to support a number of marginalised service users.
Two projects being funded include a mobile health screening unit and an intercultural health project for refugees. The objective of the mobile health screening unit is to provide an accessible targeted screening and primary care service to a wide range of marginalised service users in settings such as hostels, prisons, direct provision centres, refugee reception centres and orientation centres. The intercultural health project for refugees will support the delivery of a range of health services to meet the emerging needs of new residents of the emerging reception and orientation centres established in Clonee and Monasterevin. A third EROC is due to open shortly. We have been having discussions on housing and homelessness and there is a need for an intergovernmental approach to that area.
Rebuilding Ireland, under the leadership of my colleague, the Minister for Housing, Planning, Community and Local Government, Deputy Simon Coveney, shows the pathway forward, but there is a role for my Department and me to play in that area and I am willing to do it. I hope the additional funding will help in that regard.
The mobile screening unit will have its work cut out for it with all of the groups that have been identified. How many staff will be working in the unit and what services will it be offering? Will they include physical and mental health screening or will it solely be physical screening? Will children be catered for? How many visits does the Minister anticipate will be made to the unit? How many stops will it make throughout the course of this year?
I will get the Deputy a detailed note. The note I have tells me that funding of €1.46 million has been allocated for the unit which will provide targeted screening and primary care services. It will visit hostels, prisons, direct care and refugee reception centres. I will forward the specific information requested by the Deputy.
It is important that both physical and mental health issues be addressed for children, adolescents and adults. We cannot have a one-size-fits-all approach. The unit cannot just rock up to one of the reception centres unless it is offering services to the entire community. There are sections of the community that are already being failed and we will be adding insult to injury if we pretend that we are providing medical services when we are not.
I will get the Deputy more details on the unit.
Before we move on, it is important to acknowledge that drug addiction, as well as the illnesses associated with it, is a national issue. It is not one that affects Dublin, Cork, Limerick and Galway only. It is important to acknowledge the important work voluntary organisations do in that regard, particularly Simon which does fantastic work and is always crying out for funds. I am sure its representatives knock on the Minister's door on a regular basis.
We have seven programmes to get through. The last section of the second programme deals with primary care services, the Vote for which is €834 million. The relevant information is on page 10 of the analysis document. Does anyone have comments to make on the section? I will make one comment while members are looking through it. I refer to the number of contacts with GP out-of-hours services. My colour blindness makes it difficult for me to distinguish between line and the other, but the number is rising. I ask the Minister to comment on out-of-hours GP services and how they are managing.
They are making a very important impact. Without pre-judging the outcome of the negotiations on the GP contract, an obvious point for discussion is the determination of what constitutes an out-of-hours service and a normal operating hours service. We can see clearly that there is a demand for the former. Given people's lifestyles, in terms of work and so forth, we need to determine what is best in terms of accessible hours for GP surgeries and figure out what the Department and the Government need to do to enable these hours to be operated. The output target last year was 964,770 hours, while the target this year is 1,550,388 hours. As the target in 2016 was exceeded significantly, there is clearly a massive demand for the service.
Another issue that arises in terms of the sustainability of the service in certain parts of the country is the ageing GP population, of which the Chairman is aware in the case of Shannondoc which operates in his part of the country. Interestingly, when I attended the OECD Health Ministers meeting, I discovered that while we had an ageing GP population here, we actually compared quite well to other European countries. However, that is not a reason not to prepare. We have a lot of GPs who are making retirement plans and need to replace them. I still believe, although not everyone agrees with me, that if we do not move towards the option of having salaried GPs in rural areas and areas of urban deprivation, there will continue to be an unmet need. I have an open mind on how that should be done, but it may mean the HSE directly employing GPs or grant-aiding GP surgeries, as it does already in organisations such as SafetyNet. I am absolutely adamant that this should form part of the discussions on the GP contract because the sustainability question goes to the very core of the issue.
On out-of-hours services, difficulties are due to the declining number of GPs but also to their geographical spread. Some areas are reasonably well serviced by GPs and their out-of-hours services can manage. However, there are many areas where, owing to a lack of GPs and their distribution, out-of-hours services are struggling greatly.
One interesting statistic is that 90% of the population now have access to out-of-hours services in 14 centres nationally. There are over 2,000 GPs providing services in out-of-hours co-operatives. There was an 11% increase in the total number of contacts with GP out-of-hours services in 2016 in comparison with 2015.
If we keep going the way we are, we will lose many GPs to the Dáil. I dissociate myself from the remarks made about ageing GPs. The Chairman is young at heart.
Is that a compliment?
Yes, absolutely.
I certainly did not mean to cast any aspersion on the Chairman.
I took no offence.
As I am trying to match the detailed note with the other documentation, please forgive me if I have missed something. I am interested in the community intervention teams, in particular, and can see that the funding for them has increased. Will the Minister give us a breakdown of the funding allocated across outsourced, direct public and private services?
We were looking for that information, but I am not sure that we have it available in the Department.
That is fine. Regarding primary care services in general, we can see that there has been an increase in the number of GP trainees. I concur with what was said about salaried GPs being directly employed by the HSE. How many additional staff will be provided in this area? I can see that there is an increase in the target for the number of attendances, but specifically, how many additional staff will be provided in each of the areas in which activity will increase? Clearly, we will need more personnel to provide the projected additional services. I also ask the Minister to tell us whether it is anticipated that the additional activity will be generated by directly employed staff or private sector staff or through some other outsourced or grant-aided mechanism.
On output targets, I ask the Minister to give us a detailed breakdown. There is no disputing the fact that the figures look good, but without knowing the detail behind them, it is hard to know if they will actually make any difference to people living in the community.
They are all fair questions. We fund the HSE and ask the executive to set targets and then agree to them. The HSE has to transpose them and the resources provided into its community health organisations, CHOs. I will ask the HSE to send a note to the Deputy detailing exactly what the increases mean for each CHO and answering the public versus private question.
The Deputy and I discussed the issue of staffing during the last oral parliamentary questions session. I think it is fair to say she is of the view that it makes sense for the HSE to directly employ people to deliver primary care centre services, be they nurses or other health care professionals. Instinctively, I agree with the Deputy. I have spoken to GPs, the Irish Practice Nurses Association and others about the issue. There is a view among GPs that while they have significant responsibilities as employers, one should not have to be a great SME-owner to be a great GP. That is certainly an issue. Furthermore, traditionally practice nurses have not had access to the same level of support that is available to nurses in acute hospital settings. While I do not want to get into the industrial relations issues in detail, HSE-employed nurses, for example, have access to postgraduate education and funding for same, but that option is not available to practice nurses.
I dispute that.
The Deputy might dispute it, but there is a budget line for it. There is funding available for postgraduate training. Whether it is enough is a matter for debate, but funding is available for HSE-employed nurses but not for practice nurses.
At my recent briefing on the general practitioner, GP, contract, I made it clear to the HSE and to the Department that while we are debating and negotiating a GP contract for primary care services, it is essential that other health care professionals, particularly nurses in the community, have an input into that process.
The Deputy asked about community intervention teams in the context of the winter initiative. Such teams can have a huge benefit in terms of hospital avoidance and hospital admissions, particularly for our older patients. If the latter are seen at home by community nurses, etc., they can be kept hydrated and well and prevented from getting sick and needing to be admitted to hospital. We provided for an increase, to 27,633 hours, in community intervention teams' total activity in 2016 and this is going to rise further to 32,861 hours. I accept that the Deputy asked me for the geographic breakdown in that regard. The increase to which I refer is a sign that we believe this model can work and we need to ensure that there will be further increases.
I asked for the geographic and the public-private breakdown in respect of it.
We will get both for the Deputy.
I called Deputy Eugene Murphy.
Not alone is the Minister young at heart, he is young like myself.
I thank the Deputy.
I wish to ask the Minister a question about dental treatment, which is on this list. There is a major problem regarding the provision of dental treatment for children. I have had a few conversations with the Minister regarding University Hospital Galway. Due to his intervention, we got a machine replaced there that was broken. The issue of concern to me is that a number of parents have approached me whose children have been on waiting list for a considerable period. Many of those children are in primary school but they will not get treatment until they have gone into secondary school. It is very necessary treatment. The children involved are concerned and upset that this matter will not be sorted out before they go to secondary school. Is there any light at the end of the tunnel, as there are fairly extensive problems in this area. The Minister has spoken to me about this matter on occasions when I approached him. There was a difficulty in University Hospital Galway with having an orthodontist replaced. I do not know whether that vacancy has been filled. The Minister might provide an update on that. If he cannot do so today, I would appreciate if he would contact me next week or whenever.
I thank the Deputy for raising this issue. He also raised it with me on a number of previous occasions in the context of his constituency and region. We have made some progress in respect of it in the meantime. Orthodontic waiting lists are a cause of significant concern. As the Deputy pointed out, for a child or an adolescent at a certain time in his or her life, his or her inability to access this treatment can have quite a significant impact on his or her overall sense of well-being. I have met parents who are concerned about the impact of this on their child's overall health and mental health well-being. I am informed that orthodontic waiting lists have been decreasing since quarter 3 of 2016 - that is, since the middle of last year - following a significant period of increase. The reduction has come about in the aftermath of a procurement initiative undertaken by the HSE. I will arrange for a detailed note on the HSE's plans in this regard to be forwarded to the Deputy. We also intend to publish a national oral health policy this year. It is very important we have a roadmap for the delivery of dental health policy in Ireland, which we badly need. Considerable work has been undertaken in my Department and by my colleague, the Minister for Social Protection, Deputy Varadkar, in terms of trying to restore some of the dental benefits. The health policy for oral health will be published this year. I will arrange for the Deputy to have a detailed note on this.
I thank the Minister. Referring back to having salaried or the direct employment of staff in general practice, if we are going to have salaried GPs, the support staff in those practices will have to be salaried and directly employed by the HSE. One of the strengths of general practice under the old contract - whatever the new contract will bring - has been the ability of those in general practice to be very flexible and to respond to patients' needs in an immediate way. Having GPs employing and having governance over their own staff is one of the strengths of general practice. There are pros and cons for having directly employed staff in general practice.
General practice is one area of the health service that works very well. People in this country largely have access to their GPs at relatively short notice. Such ease of access has been lost in a number of other countries. While I am conscious of the changes, improvements and modernisation that are required - as are our GP organisations - we do not want to lose all that is good about general practice.
We will move on to programme 3, services for older people, including long-term residential care. It has an allocation of €1.749 billion. It is broken down into two sections. Section A deals with long-term residential care, which has a vote of €940 million, and section B relates to services for older people, in respect of which there is an allocation of €810 million. Those sections are in the analysis document on pages 12, 13 and 14. While people are looking at that, I will ask the Minister a question. The number of funded beds in our public nursing homes is gradually declining. It has just fallen to approximately 5,000. Will the Minister comment on the fact that the HSE seems to be getting out of the business of looking after older people in its own nursing homes and that many of our elderly people are being directed towards private nursing home facilities?
On the same subject, which is also a favourite pastime of mine, I am alarmed by that development. It is the wrong process and the wrong direction at the wrong time. If anything, we need an increase in that area in the public health sector. I can think of a number of our public long-stay hospitals where, compared to ten or 15 years ago, the number of patients has halved. The latter was unnecessary, in my view, because there was no basis for it. The theory behind it, which was put to me on a number of occasions, was that it was more cost-effective to do it. I have not seen the evidence for that. What often happens is that seriously dependent patients end up in the public sector in any event, and understandably so. The quality of the services and facilities available in the public system in most of our hospitals - I acknowledge that standards have to be kept up at all times - is excellent and unequalled anywhere else. I do not see the reason for that approach. We need more of those beds for two reasons: first, to meet the demographic needs; and, second, to alleviate overcrowding in acute hospitals.
Regarding the increase in the number of home-help hours - while increasing, it will not go up by a great deal - can the Minister give a breakdown between the public-private and voluntary providers? I understand that when the tender process for the provision of those services is concluded, the individual health agencies will have their preferred providers and they will have to select from those. My sense of this is that the choice available to them is frequently between different private providers and that fewer home-help hours are being provided by the HSE. I echo what Deputy Durkan said. It seems the State is getting out of the business of caring for older people, which is to be very much regretted.
Specifically, with regard to the single assessment tool for older people, which is extremely important, the output targets for 2016 and 2017 are a little vague. At what stage of development is the phased implementation of the IT to enable the standardised assessment tool? It is to be phased in but that could be done over the next 200 years. The target for 2017 is to work with providers to establish the greater capacity of the single assessment tool assessments. They should be doing that in any event. The single assessment tool, the monitoring process and the frail elderly programmes should be integrated. Many people would consider those to be fairly basic but they are now being listed in the Department's targets and achievements.
I understand the need to provide information and that information is welcome, but the assertion was that something was to be phased in during 2016. However, no indication has been given of how far that process got, how many old people have been assessed using the single assessment tool and whether all public health nurses are using it. Good luck to those nurses who find the time to use it, given that they are overworked.
The distinct lack of ambition shown in the section on services for older people is reflective of how this and successive Governments have slowly put clear blue water between themselves and care of the elderly. It is not untrue to say there is a plan, be it one which has been fully worked out and written down or that is in the back of someone's mind, because clearly the Government is trying to get out of the business of looking after older people. That service has been outsourced to large, global corporations that are making a fortune. The Minister knows them and I will not name them. As I had a bad experience after I had named one of them, I will not do so again, but we all know what we are talking about. These companies are making a great deal of money. They are often the only providers on the preferred provider lists.
HSE home helps approach me - I am sure they also attend other Members' clinics - to say they are losing their hours and are not being replaced. They are going to private sector providers. There have been "Prime Time Investigates" programmes about the private provision of home care services and as I do not want to go back over them, will the Minister provide us with a breakdown of the single assessment tool and hours directly provided by home helps?
We have a major problem in accessing home help hours in Cork South-West. The graph shows an increase, but this is probably one of the main issues on which my office works. People are being held in hospital longer because of it. They would be fit to come out if they were to receive a little help and it would cost less. Perhaps the Minister might examine this matter. I presume it is the same in other constituencies. I find the upward graphs difficult to believe, given the experience of my constituency office and would appreciate it if the Minister looked into the matter.
I endorse the Chairman's opening remarks about public nursing homes. Recently, I placed a question with the Department and the HSE on public nursing homes vis-à-vis private nursing homes. In the past five years there has been a drop of 10% in public nursing homes in most regions. Is there a deliberate policy on the part of the HSE to get out of providing public nursing homes? There was serious overcrowding in Portiuncula Hospital in Ballinasloe, County Galway after Christmas. It was so bad that some children were moved from Ballinasloe to Mullingar, which did not make sense. There are two nursing homes within 20 minutes of Portiuncula Hospital, to which some patients could have been moved to alleviate the overcrowding. They are reasonably priced and provide good accommodation. In such instances why not avail of nursing homes at the weekend or whenever else there is overcrowding? The Minister will probably say that happens in certain circumstances, but at other times it does not.
The Department and I set policy, not the HSE. It is not my policy or that of the Government to diminish the role of public community hospitals or public nursing homes. However, it has been the policy of this and successive Governments to ensure these facilities will be brought up to appropriate HIQA standards. With Deputy Margaret Murphy O'Mahony, I visited the community hospital in Bandon in her constituency. It is an example of the capital investment work being undertaken to provide state-of-the-art facilities for older people in a public setting in a community hospital.
The reduction in bed numbers is temporary. Using the Deputy's case as an example, it is a reflection of the fact that in some wards there are beds upon beds and shared bathrooms which must be replaced with single rooms and en suite facilities in order that people will have the dignity we all expect them to have within a public setting. As the Deputies know, we are making major investments to upgrade these facilities. As we move towards capital reviews and providing for additional expenditure on building projects in the health sector, I expect us to increase capacity in public settings. Bed capacity is another factor that will have to be considered.
I have never approached this matter from an ideological view. People have a right to a choice. Some will choose private nursing home facilities, while others will prefer to be able to avail of public beds in community hospitals. It can be either-or, but there is an important role for community hospitals and public nursing homes to play. This is an issue Deputy Bernard J. Durkan raises with me regularly, which is right and proper, but we have a significant body of work to do to ensure the facilities will be of a standard that people in 21st century Ireland should expect to see. The care provided is excellent. I am referring to the infrastructural facilities and not in any way demeaning the care given or the dedication of the staff. Needing to make this investment should not be an excuse for removing ourselves from this service provision.
Deputy Margaret Murphy O'Mahony mentioned how there were still pressures in seeking access to some services, even though the graph was upwards and investment had increased, but the population of older people has also increased. A useful example for discussion is how well we have done in mapping demographic pressures in the education system. The Department of Education and Skills knows this because a certain number of children will turn four, five or six years of age and need school places in September. It also knows that a certain number of teachers, schools, school buildings, extensions, classrooms and so on will be needed. We need to undertake that demographic analysis in the health service. The bed capacity review forms a large part of it, accompanied by the model of care provided.
The figures before the committee show an increase in the numbers of home help hours and packages, including intensive home care packages, in 2017. However, I will level with the committee. My view - one that is shared across the House - is that until we do in the home care area what we did in the nursing home area, this will continue to be a challenge. We need a statutory scheme. We will probably disagree on what it should look like, given the wide variety of views held, but we cannot say we want people to be able to grow old at home or in their communities if the only statutory scheme available to them is the fair deal scheme. In fairness to the HSE and its predecessors, they have been providing home help without the service being underpinned by statutory provision or the clear rules, guidelines and budget lines of the fair deal scheme. If committee members examine the fair deal scheme, they will see the amount of money allocated and the turnaround time, etc. The metrics are clear. We need the same in the home help area.
The Government is committed to reverting to the Dáil within six months of debating Deputy Willie O'Dea's Bill. My colleague, the Minister of State, Deputy Helen McEntee, will launch in May a stakeholder consultation process on future statutory home care schemes. We cannot transpose the fair deal scheme in the home care area. Presumably, we do not want HIQA to regulate what happens in people's sitting rooms. We must be conscious that the setting is someone's home, but we need to consider how to place the schemes on a statutory basis.
The Minister of State is also reviewing the nursing homes support scheme. There are a number of concerns about how small business owners and farmers are treated in terms of how their assets are considered.
Deputy Louise O'Reilly asked a similar question about public versus private services. Although it is a valid question, it is an operational one, but I will get her a detailed note from the HSE on the public-private mix, tenders and the roll-out of the single assessment tool.
I have been in many CHOs where it has been used, but I will get the Deputy a note on it.
I apologise for interrupting, but I want to know for how many elderly people the single assessment tool was used last year, for how many people it will be used and the grades and categories of staff who will be involved in using it.
That will not be a problem. The Deputy raised the broader issue of home help provision. She is probably aware that last year my Department commissioned the Health Research Board to carry out an evidence-based review of all the various international approaches taken to the regulation and financing of home care services. The Minister of State, Deputy Helen McEntee, will publish the outcome shortly. We will then undertake a mapping exercise of current service provision nationally taking into account the scale and diversity of the services funded. This will be used to identify the policy options for the new statutory home care scheme. The areas we need to consider are regulation, financing, assessment and eligibility. The issue of public versus private provision is a legitimate one that needs to be considered. There is a lot of work to be done in this area. It took several years to set up the fair deal scheme which is generally recognised to be working well, apart from a few anomalies that need to be rectified. That is the next big thing we must crack. A total of 1,064 people under the age 65 years are in nursing homes. Without knowing each story behind these numbers, one of the reasons is we do not have a statutory home care scheme. I think there is consensus in the Dáil that we need to get this done. We should, therefore, move on it.
There will certainly be a willingness on the part of home helps to do so. I represented them for years. They were looking for regulation from the Minister's predecessors. They are more than willing to put themselves on a more secure footing because it can be a precarious form of employment when it should not be. It is an area that we can definitely say is going to grow. How many dementia-specific packages were part of the home care initiative rolled out last year? How many were targeted last year? How many were not delivered? How many have been targeted this year and does the Minister think they will be delivered? According to my information, the targets were not hit last year.
I will get the information for the Deputy.
Will the Minister look again at the issue of chronic overcrowding, including in Ballinasloe, and making better use of nursing homes, regardless of whether it is a community or a private nursing home? I understand that in respect of Portiuncula Hospital, there were vacancies in both private and community nursing homes, both of which provide very good services. I accept that a doctor must sign off on a discharge and ensure a person can be discharged, but the complaint I constantly receive from families is that a son, a daughter, a brother, a husband, a wife or a partner was fit to be discharged on a Friday but because there was no consultant available to sign off on the discharge, he or she remained in hospital unnecessarily until the Monday. That is three or four bed days in hospital at a time when beds are badly needed. Better use of the system could be made to alleviate overcrowding when it occurs. There is chronic overcrowding at times, as the Minister knows well.
That is a fair point. We can debate the pros and cons of the winter initiative. There has been significant progress on the issue of delayed discharges, the number of which has been reduced to its lowest level since they were first recorded. There is a direct correlation with the level of investment in providing additional home care packages and transitional care beds and with the utilisation of capacity in nursing homes, both public and private. The Deputy is right. We do not want - neither does a patient - a scenario where a patient finds himself or herself in hospital over a weekend where he or she is medically fit to go home where he or she would much rather be. Hospitals have a predicted date of discharge, PDD. Patients are clinically assessed and allocated a PDD. Clinicians should work towards ensuring somebody who is ready to go home on a Saturday or a Sunday will not be left in hospital until the Monday and that preparations will be made for him or her to be discharged. The Deputy's point is valid.
In response to Deputy Louise O'Reilly, the figures I have in front of me are for intensive home care packages. I will need to provide her with a breakdown of dementia-specific packages. The target in 2015 for intensive home care packages was 190 but 195 were delivered. The target in 2016 was 130 but 180 were delivered. The target in 2017 is to provide 190. I do not have a breakdown of dementia-specific packages, but I will obtain it for the Deputy.
My information was that packages were not delivered, but, again, I am happy to be corrected.
Before we move on to the next programme, the Minister knows that two weeks ago the committee met the Cabinet Secretary for Health, Wellbeing and Sport in Scotland, Ms Shona Robison, MSP. Deputy Louise O'Reilly and I met her prior to the Minister's meeting with her. Even though it was a short conversation, she had very interesting things to talk about. One of the ways discharges are dealt with in Scotland involves buying, renting or leasing a certain percentage of beds in private nursing homes for use by public patients as step-down and interim facilities. It is certainly a very innovative idea which we might sow a seed in the Minister's mind.
I had an excellent meeting with the Scottish Health Minister after the committee met her. I know that the cross-party group on dementia which I think is meeting today and which is headed by Senator Colette Kelleher visited Scotland. There could be more learning and co-operation on a number of issues, including drug policy, about which we had a good conversation.
We will move on to programme No. 4, which concerns acute services and for which the Vote is €4,831 million. The section is broken down into three subsections - acute hospitals and the national clinical strategy programme, for which the Vote is €4,553 million; the national cancer control programme, for which the Vote is €101 million; and the National Ambulance Service, for which the Vote is €176 million. These items are referenced in the analysis on pages 16 to 18, inclusive. I note that the Vote for the National Ambulance Service has increased by 6% this year. The ambulance service is under severe pressure in terms of the available numbers of ambulances and staff. A critical point is that many ambulances are tied up in transferring patients to overcrowded emergency departments. On many occasions one will see a queue of ambulances outside hospitals, taking them out of service for a prolonged period. This adds to the pressures on the ambulance service. Will the Minister comment on the issue?
The Chairman has correctly noted that we will see an increased investment in the National Ambulance Service in 2017, which is welcome. The first report I received when I became Minister for Health was produced by Lightfoot Solutions UK on the National Ambulance Service. In reading the report which was published on my Department's website I was struck by the huge need for extra ambulances and additional paramedics. However, it is also clear from the report that even when we do this, if we wish to meet HIQA's ambulance response times, there will still be a need to provide the National Ambulance Service with extra ambulances and paramedics because of the demographic layout of the country and the way the population is dispersed. The report specifically referenced the role of community first responders. I am very eager to look at how we can further integrate and develop the community first responder network with the National Ambulance Service. Community first responders are providing a very good service around the country, but there is a lot more to be done.
It is fair to say the National Ambulance Service has undertaken a significant reform programme in recent years that involves reconfiguring the delivery of pre-hospital care services. The objective is to have a nationally co-ordinated system supported by improved technology. This has seen the completion of the single national control centre project and all nine regional control centres migrate to a national emergency operations centre which I have had the opportunity to visit. Improvements in services in the west have been implemented, with the ambulance bases in Tuam and Mulranny now operating on a 24/7 basis and the establishment of a deployment point in Loughglynn, County Roscommon. We have seen an expansion of the community first responders scheme, with 147 groups now operating nationally. I genuinely thank them and their volunteers for their incredible dedication.
The development of an electronic patient care record is under way and that will be rolled out in 2017. On the point the Deputy made about inter-hospital transfers and making sure we free up our ambulances, our intermediate care service is now carrying out 90% of inter-hospital transfers. The National Ambulance Service, NAS, now supports neonatal and paediatrics retrieval services through the provision of dedicated resources and staff, and there is the development of an adult retrieval service. The emergency aeromedical support service has been established on a permanent basis.
It is important to say that in 2016 the number of ECHO calls received by the National Ambulance Service increased by 42% and DELTA calls increased by 19%. There has been a significant increase in investment in our ambulance services, but that is appropriate considering the pressure it has been under in recent years. The next steps are to continue the reform of the ambulance service through the modernisation programme, to implement a clinical hub desk in the national emergency operations centre, to further develop the intermediate care service, and to roll out the electronic patient care record system. As the Deputy said, the budget for the ambulance service has increased this year. Approximately €1 million of that increase is for new developments above and beyond dealing with capacity and demographic pressures. This will obviously include a number of targets in respect of intermediate care service or emergency response times as well.
As I understand it, a dispute threatened in the National Ambulance Service last year. It related to some reports, one of which the Minister has referenced; I understand there are two reports. As part of the settlement of that dispute, NAS indicated that it was going to go abroad to try to recruit people and that it had been given a licence to do so - I think that was the term used although I do not know that one would be needed. NAS said it was embarking on a recruitment programme abroad because there was a recognition that, due to the lead time from starting training to finishing it, domestic recruitment would not have been enough to keep pace with requirements. In terms of recruitment, will the Minister indicate how many additional NAS staff there will be? How many of those will be people recruited as part of this international licence?
The Minister will also be aware that in Dublin we are blessed to have our paramedic services provided by both NAS and the Dublin Fire Brigade, DFB. Members of DFB have balloted for industrial action and that is not something they would do lightly. I am very familiar with this group from my previous role. The group actually would be very reluctant to take any form of industrial action but its members have been left with no choice because they feel the service is under threat. I do not think we could cope in Dublin without DFB. Its members are, as the Minister will know, trained fire fighters and also paramedics. They deliver an incredibly efficient service. Nobody want to see that dispute go ahead and I understand there is a budget conflict between the Minister and local government but, notwithstanding that, Dublin Fire Brigade provides health services. In terms of the resolution of that dispute, perhaps the Minister could give us his view as to how that will be resolved because the future of DFB does seem to be in some sort of jeopardy. That would concern us.
With regard to the National Ambulance Service budget and the inter-hospital transfers, my understanding is that transfers are carried out through a range of different sources, including taxis, private ambulances and directly employed personnel. Will the Minister give the committee a breakdown on that? He is probably sensing a theme in my questions but perhaps he could give us a breakdown. The Minister and I have had this conversation many times and I do not believe we get good value for money from the private sector. I have yet to see any evidence that we do. I am also very interested to know the budget for taxis. People spoke about this a number of years ago, and I hope the reason no one is talking about it any more is because it has reduced significantly. I suspect it has not, but perhaps people have just moved on to talking about something else.
In respect of the 27 measures that are listed here, obviously there will be more than 27 measures with regard to a budget which, I believe, is 31% of the total Vote. He may not have it to hand, but perhaps the Minister could provide the committee with more detail in terms of the actions and plans for next year.
With regard to the IT budget, we all agree with the need to improve IT in the acute sector. That is almost worse because once everybody agrees, one is left wondering when it will happen. I could be open to question on this but even if we doubled our IT budget, we would still be short of what the average is in the OECD. It is a bit ridiculous, when one walks into a hospital, to see people walking around with files. I am sure they would much rather move to a paper-light or paperless system. Have key targets and areas been identified where actual progress can be made in this area? It is really not acceptable in this day and age to have people running around with big charts and files under their arms.
I concur with the Chairman's opening remarks about ambulances being stalled outside of hospitals and being held up. That is something that is really of concern. Obviously, it could be a waste of very valuable time.
We should acknowledge the wonderful work of the National Ambulance Service. From time to time, when people come to my clinics or speak to me, they refer to the wonderful work those people put in, many of them in very difficult circumstances. I want to acknowledge the great work that they do.
In respect of our own county of Roscommon and the Roscommon-Galway constituency, I acknowledge what the Minister said about Tuam and Mulranny and the base in Loughglynn. My understanding in respect of Loughglynn is that the ambulance was actually taken from the base at Roscommon University Hospital and it covers that area. I do not think it is a new ambulance. I am asking for clarification as I may be wrong about that, but that would be of concern. Again I make the point to the Minister that when a county loses its accident and emergency department, it is so critical and important that there is a top class ambulance service.
If an ambulance from the west has done a call to a Dublin hospital and is on its way back, it can then be called to an accident. That is fair enough. If it is somewhere in Kildare and there is an accident which it is called to, that is fair enough. A difficulty is created, however, back in Roscommon, Galway, Sligo and Donegal because the ambulance which should have been back after a certain period of time is not back. I would be concerned about such situations. Sometimes ambulances have to come into the county when an accident occurs because the other ambulance is on its way from Dublin and has been called to the scene of another accident. In that case, an ambulance has to come from, for example, Longford, Offaly or Cavan to the scene of an accident in Roscommon. I do not know whether the Minister has any comment to make on that but it is of concern to me.
I thank the Deputies. Many points were raised in their comments. I will get clarification from the National Ambulance Service on Loughglynn but my note just tells me that it is a deployment point. I take Deputy Murphy's point in respect of the importance of the ambulance service and the great work that it carries out.
This is an area in which we clearly have a lot more work to do. The Lightfoot report presents a roadmap forward in terms of the investment and the scale of investment needed in terms of both paramedics and vehicles. I made the point in my opening comment on this section that we will have to grapple with this collectively. The population dispersal in this country, according to the external consultancy, Lightfoot, poses significant challenges in terms of ambulance response times. The Lightfoot report is very clear that even if we increase the number of ambulances and paramedics, we will need to do something above and beyond that. We need to do something innovative here. Some of the ideas the Deputy has come up with are part of that process.
People have an absolute right to live in rural Ireland. We want rural Ireland to thrive and those living there have a right to an ambulance service, just like people in towns and cities, but we have to recognise that the population dispersal means we need to think outside the box in this regard. Lightfoot suggests community first responders as a starting point. I met a group from Connemara in Galway when I was in University Hospital Galway recently.
The group asked whether they could have greater use of the St. John Ambulance and the Order of Malta services. I believe there is a willingness from those organisations to do more. In fact, the complaint from the group was that communities had fund-raised for an ambulance, whether a St. John Ambulance or Order of Malta ambulance, only to find that the ambulance could not be fully utilised in all situations. Obviously, there is a regulator. It is not me; it is the Pre-Hospital Emergency Care Council. There is space for the regulator to work with us and engage with those organisations. That is something I intend to pursue. I believe such engagement could unleash additional capacity for rural communities and provide them with a far better ambulance service in addition to all of the improvements we intend to make.
I note the theme from Deputy O'Reilly's questions. In fairness, it is consistent.
We would like to think it is all about consistency.
It should make our engagements more predictable. I will have to ask the HSE to give the Deputy a note on it because these are operational matters. We have taken note of them. I urge Deputy O'Reilly to come back to me if she does not get satisfactory information in reply. That includes the question of recruitment from abroad.
I realise Deputy O'Reilly knows the history of the Dublin Fire Brigade question, but it is important for me to put it on the record of the committee. In December 2014, HIQA published a review of pre-hospital emergency care. A series of recommendations were made in respect of Dublin services to address patient safety issues, to reduce risk and to improve co-operation between the National Ambulance Service and Dublin Fire Brigade. I met representatives of Dublin Fire Brigade through SIPTU. I acknowledge the exceptional service that DFB provides. This is not an attempt to suggest anything to the contrary.
HIQA is engaged in a follow-up review to the 2014 report. HIQA expects to publish a report this month or in April. While it is fair to say that a good level of co-operation exists between the National Ambulance Service, NAS, and Dublin Fire Brigade, DFB, in providing the service to Dublin city and county, it is also fair to say that some difficulties exist. I believe that is generally recognised although the way to resolve the matter may not be. The difficulties might relate to the volume of calls received by the Dublin Fire Brigade. Some calls have to be stacked when no DFB ambulance resource is available to respond to a call. When these circumstances arise, Dublin Fire Brigade usually requests support from the National Ambulance Service.
HIQA wrote to Dublin City Council late last year indicating that the current arrangements represent a risk to patients. HIQA, as the regulator, believes this risk arises from the regular delay in the allocation of ambulance resources to patients, including a high number of potentially life-threatening DELTA calls, due to a combination of the ongoing inability of DFB to see all of the potential resources that it and the NAS have at initial dispatch as well as a reliance on individual contact with NAS over the telephone to enable supplementary resource allocation, where available. Moreover, HIQA believes there is insufficient collective emergency ambulance capacity, as currently resourced and deployed by DFB and NAS, in the Dublin area.
In light of the correspondence and to mitigate any risk to patients in the area under my remit, that is to say, the NAS, additional resources were deployed to Dublin. That was an important step. An issue arises relating to line of sight and how these organisations, both of which undertake incredible work, can co-operate.
I know that the people of Dublin city and county are proud of the track record of exceptional delivery of services by Dublin Fire Brigade in respect of fire and ambulance services. For want of a better phrase, we need to be careful not to throw the baby out with the bath water in rectifying the difficulties and challenges. No one can ignore these challenges in light of what HIQA has said.
As Deputy O'Reilly knows well, Dublin Fire Brigade SIPTU members have voted in favour of industrial action over concerns about ambulance services in Dublin. It is fair to say that the results of the ballot probably reflect a wider unrest in respect of DFB about future certainty and fire-based emergency medical services. This dates back as far as the 2014 HIQA report. I look forward to the next HIQA report. It will represent a follow-up exercise to point us along the roadmap to try to solve this situation.
My Department is engaging with the Department of Housing, Planning, Community and Local Government in respect of the industrial action vote by SIPTU members. The issues need to be grappled with in terms of where responsibility lies. Following my meeting with SIPTU representatives, I believe SIPTU takes the same view. It is a health service question. This is an ambulance service under the remit of the city council. In turn, the city council is under the remit of the Department of Housing, Planning, Community and Local Government for certain functions. I am awaiting the HIQA report and I expect it to be published shortly.
I sincerely hope the industrial action does not materialise before that report is received. It would be helpful to those people facing the prospect of industrial action - it is not something they would do lightly – to hear of the willingness to resolve the matter and keep DFB as an integral part of the ambulance and paramedic service provision for the people of Dublin.
The Minister is right. We are very proud of DFB. We are proud of the work of members of DFB. They deliver an incredible and efficient service. They need to hear from the Minister as well as from the Minister for Housing, Planning, Community and Local Government that their future is secure.
My understanding of where the issue lies relates to the fact that the computers do not talk to each other, but that this is a small rather than a major issue. However, it has been escalated. In part, the ballot reflects the uncertainty that the fire and emergency service people in DFB feel about their future. We should say to them that we see their future as part of the provision of the service in our capital city. That is nothing less than they deserve. I do not wish to keep going on about it.
It is an important issue. I want to recognise the extraordinary contribution that DFB provides to the delivery of medical services in our capital city and county. They will understand, as will Deputy O'Reilly, that I have to take on board the HIQA report and review. However, I want people to understand that my comment on not throwing the baby out with the bathwater gives people an indication of my thinking on the matter. We need to ensure we keep all that is good and best while addressing the difficulties.
There is a way to go in respect of the industrial action. I take the point that no one would do that lightly. I appeal to parties to engage to ensure that does not materialise. My Department will engage with the Department of Housing, Planning, Community and Local Government in that regard as well.
Thank you, Minister. I have inadvertently overlooked Deputy Durkan.
I can tell you most people find it impossible. However, we will not go there. If you want to move on to the next programme, I will make my comments at the beginning of the next part. It means overlapping for the sake of logistics.
Thank you for that. Next is programme 5. It refers to disability services. This has a Vote of €1.78 billion. It is referred to on page 19 of the analysis of the Revised Estimates. Does your question relate to that, Deputy Durkan?
No, it does not. Can we roll the two into one, Chairman? I was trying to be economical with time.
I will make a comment on that programme and then we can come back to you.
At the committee meeting last week a dispute arose between Senator Dolan and the Minister of State, Deputy McGrath, in respect of the provision of personal assistant hours for people with disabilities. Last year, the target was 1.3 million hours and 1.5 million hours were delivered. This year, the target is 1.4 million hours. Deputy Dolan questioned the reduction of 100,000 assistance hours for people with disabilities. Will the Minister comment on that? There was a mathematical dispute and I am unsure whether it was resolved.
I know the Minister of State, Deputy McGrath, is an able and passionate advocate of people with disabilities and I am delighted to work with him. He was going to come back to Senator Dolan in that regard. I am keen to reiterate the point made by the Minister of State. When we consider the provision of disability services, we must consider them in their totality. I know that Pat Healy, the national director for social care for the HSE, made this point at the time of the publication of the service plan, as did the Minister of State who issued a statement clarifying the situation. We need to consider the overall provision of services and the fact that some people who in the past may have been availing of personal assistant hours are now availing of a different service or benefiting from different additional investment that we have made in respect of disability services. That was the thrust of the argument being put forward by the Minister of State.
Let us consider the fact we are going to see home support hours increase and centre-based respite nights for people with disabilities increase on last year's target. We are seeing a significant increase in facilitating movement from congregated to community settings. We are seeing the maintenance of all-day service provision. We are obviously going to see improvements in terms of the reconfiguration of services for children with disabilities in terms of the associated targets.
Disability services rightly have received a significant increase in investment in budget 2017. That is for a very good reason. Considerable work needs to be done in this regard. My view and that of the Minister of State, Deputy Finian McGrath, is that we need to look at how we empower people with disabilities to have a greater say on this budget. I feel very strongly that the State's responsibility to people with disabilities does not end when the State writes a cheque to the service provider. The totality of the debate should not be about the size of the budget, but rather the impact of that budget on the lives of people with disabilities. I think and certainly hope there is cross-party consensus on this.
The task force on personalised budgets which the Minister of State, Deputy Finian McGrath, established last year can unlock huge potential in this sector. I meet people on an almost daily basis in my interaction with people with disabilities in my constituency office and my departmental office. I hear from people who ask for a greater say over how the State's funding is spent as it affects their lives.
Many members will know the group An Saol, which is a group of largely parents and some siblings who have relatives with an acquired brain injury. The State has provided services for these people. Their families are very much of the view that if they were allowed a greater say, they could spend the budget much more effectively to deliver a much more meaningful service. As part of the HSE service plan, we have launched a pilot project allowing An Saol to interact with the HSE. It is not asking for additional funding but for a greater input because its members know how to spend it better than a bureaucracy does. It was hard to have this discussion in the years of cuts, but now that we are back in years of increases there is not only an economic but a moral onus on all of us to ensure we can greater empower people with disabilities as regards their services.
Senator Dolan will hear from the Minister of State, Deputy Finian McGrath, on that. I suggest the disability budget and service plan should be viewed in terms of the totality of increases which is quite significant.
The issue of the delivery of services to the disability sector is getting attention now. It needs attention urgently. For example, parents of adults with disabilities worry about what will happen afterwards. On whom can they rely for a service? The issue of decongregation is increasing their concerns. They have become accustomed to living and working in a community with support services available to them - sheltered accommodation effectively. The needs may vary greatly between one individual and another. We know this has been provided for. If two parents are available in the household, it is a huge strain in any event. If there is only one parent to do the minding it is huge problem and they have great difficulties. If it is a lone parent, they have to put their lives on hold with obvious consequences later when it comes to pension age etc. It means they cannot work. They have no independence.
The degree to which respite is available is a help. It is not available to the extent that meets all eventualities and we need to look at that. Most of the parents want to have their child or young adult at home as much as possible but they need to be reassured as to the availability of appropriate residential care in the event of them becoming ill, including something sudden like the 'flu, for example, which can appear without warning.
I have come across cases, as I am sure other members have, where those delivering the service identify a person as suitable for relocation into the community given that he or she is self-sufficient to a certain extent and may be able to travel on the bus, for example. It does not always happen that way and sometimes those assessments are incorrect and err on the side, to my mind, of reducing the dependence on the service or whatever. That should not be the case. It should simply relate to the degree to which the person with disabilities requires support and not the degree to which support is available.
We have all seen cases of people who have dedicated their lives to caring for a loved one with a disability. It is a great thing to see but it is not exactly fair. It may not be fair to the person with the disability either in situations where the resources get stretched where the health of the parents or relatives gets stretched or whatever the case may be. I wish to emphasise those points.
I am not sure if the Minister has heard of CoAction in west Cork. The Minister of State, Deputy Finian McGrath, met people from there. I ask the Minister to talk to the Minister of State and check it out himself. They need a major cash injection for respite and for residential care. Many of the parents of special needs adults are getting very old and are getting concerned about if they get too sick or pass on what will happen to their adult children. It would be great to put their minds at ease. I can talk to the Minister another time about that set-up.
The Minister spoke about the personalised budgets. I agree with including the person with the disability in the decision in how their funding is spent. If they are not able, perhaps their family members could contribute to it. One size does not fit all. There is no point in giving money to a system rather than to them. I very much support that.
I assure Deputy Murphy O'Mahony I will talk to the Minister of State, Deputy Finian McGrath, about the organisation in Cork she raised. Either he or I will come back to her. On the task force, it is important that when people hear the term "task force" they do not believe it will run on forever. When will people see progress on this? The task force was established on 20 September 2016. It fulfils a commitment in the programme for Government on how we can provide services and supports to people with disabilities to empower them to live independent lives, but also provide them with greater independence in accessing the services they choose and enhance their ability to tailor the supports they receive. As the Deputy said, one size does not fit all, and we should not have service providers, good as they are, making all the decisions. No citizens should settle for that.
The task force has two components to ensure strong representation from all backgrounds. It has a strategy group and an advisory group. It also has a reference group being established to assist at key points. The remit for this task force is that it should make its recommendations on personalised budgets by December of this year so that by 2018 we will have a roadmap on giving greater control to people with disabilities and where appropriate their families and relatives in terms of how to access health-funded personal social services.
Somebody once told me that disability services are very well funded but people with disabilities are not very well funded. There is a degree of truth in that. It is a key challenge to ensure that the resources that these Houses allocate to people with disabilities are spent in a way that people with disabilities would like them to be spent.
Further to Deputy Murphy O'Mahony's comments on personalised budgets, how close are we to delivering on that?
The task force is due to report in December of this year. It has a project initiation document. Its work plan has been developed and approved by the Minister of State, Deputy Finian McGrath. He has identified seven streams of work, some of which will be progressed in parallel. They are a review of national and international evidence of best practice; eligibility and resource allocation; financial sustainability; supports to apply for and administer budgets; governance and accountability, which are very important in this area; appraisal; and implementation.
I have outlined the seven streams under which the task force is doing its work. It will report to the Minister of State by this December.
We will move on to programme 6 on the mental health services. The Vote amounts to €907 million. The analysis is available on pages 21 and 22 of the Revised Estimates.
Can we discuss the two programmes together?
Yes.
Can we discuss this programme with the health and well-being programme?
Yes, if that is appropriate.
Perfect, yes.
There is always a difficulty with the mental health programme. I seem to understand it every time it is explained to me but I never manage to explain it to somebody else. The mental health budget had an allocation of €35 million this year over last year. As much as €20 million is not maintained but kept back because it is allocated to the employment of additional staff, which cannot be sourced. Therefore, the money does not go into the budget but is brought forward into the following year. I am sure I did not give the proper explanation but I am sure the Minister can clarify it for me.
The Chairman made a good attempt. The first thing we must do, and I do not mean this in terms of the Chairman, is stop the debate on mental health funding being a debate on €35 million. The mental health budget for the delivery of mental health services in 2017 is €851.3 million. We have talked about the marginal figure for a large number of years. Last year, €826.6 million was spent on mental health services. That figure is up from €791 million in 2015, up from €766 million in 2014, up from €737 million in 2013 and up from €711 million in 2012. It is one of the few areas, and I fully support this policy, that even during very difficult years for the health budget and all budgets in this country, has consistently risen from €711 million 2012 right up to €851.3 million this year.
The Chairman is correct that there has been a policy of ring-fencing an additional €35 million to spend as part of that budget each and every year. Truthfully, if anyone looked at that figure over the past number of years, in many years it failed to be all spent in one year. That is not due to a lack of effort on anybody's part. As the Chairman has said, it was due to the time lags such as from the moment one decides to employ somebody, the recruitment campaign, the interview process and the taking up of the job so often the €35 million was not spent. In my first budget as Minister for Health, and the first budget for the Minister of State, Deputy McEntee, who is responsible for mental health services, we have tried to be much more upfront about this matter. We have increased the mental health budget significantly. We will increase the mental health budget, when one considers the capital spending, by a lot more than €35 million. There is no point pretending that a sum of money will be spent. One must tell people what one intends to do. The total mental health budget of €851.3 million will see the ring-fenced €35 million spent but some of that spending will not occur, in a budgetary sense, until 2018.
Crucially, people in these Houses have talked about implementing the Vision for Change policy. It is so important that we implement Vision for Change. Every political party agrees with that. Dealing with this not just about current spending. There are crucial capital spending parts of the Vision for Change that have been overlooked. If they are not delivered then one cannot implement the programme. In addition to the €35 million, of which €15 million will be spent in 2017, the Minister of State, Deputy McEntee, and the Government will expend at least another €50 million on the National Forensic Mental Health Service, which will deliver a new modern mental health facility in Portrane thus replacing the Central Mental Hospital in Dundrum. The project was granted permission in June 2015 and site preparation works were undertaken by the HSE during 2016. In the budget discussions we got the green light to deliver the project. Phase 1 will provide a new 120-bed hospital along with ten new child and adolescent mental health units and a new ten bed mental health intellectual disability unit. Significant additional capital was provided in budget 2017 to progress the project this year. A preferred bidder for the construction of the new hospital has been identified and the award of the contract process is expected to be completed very shortly. Construction will then commence as soon as possible this year. The new facility will open in 2019. Phase 2 of the project will see the provision for the mental health sector of a regional intensive care rehabilitation unit. It is important that we do these things regionally as well.
If the Minister of State, Deputy McEntee, was here today she would make the same point as me that the totality of the mental health budget is over €800 million for this year. There is a lot more than an extra €35 million being spent when people consider the full range of services of which a crucial part is capital. There have been international reports written on how we need to replace the Central Mental Hospital in Dundrum and we will do it this year. This is a more upfront and transparent way of telling people how the mental health budget is going to work.
Does the Vote of €907 million for mental health include the additional money?
Yes.
I want to start on this issue. I have been a member of a health board for a long time. One of the things that I learned was that every crucial decision, that was imminent as of today, usually took about ten years of preparation and another ten years of procrastination when it was approved. I congratulate the Minister and his ministerial colleagues for bringing things to a head in those areas. They were not done as quickly as we would have all liked but they needed to be brought to a head. There is no use talking about what is required unless we provide it because we will waste money if we continue to utilise outdated and unsuitable services in the mental health service or anywhere else for that matter.
There is a huge difference between the co-ordination of efforts between mental health services at community and institutional levels. I wish to also refer to the degree to which semi-residential or day services in the community must continue to receive the degree of attention that they require, in particular the supervision of patients who require medication. All of the problems that I have come across in recent times relate to, in some cases, the patient stubbornly refusing to accept the need for medication, refuses to take medication altogether or takes the medication when supervised but refuses to do so when not supervised. It is a question of trying to ensure the continuity between the level and quality of services available in the residential areas and the community based areas.
I would like time to finish my contribution because I must go elsewhere. I compliment the Minister and his five colleagues. I disagree with people who say that there are too many involved in this area. The health ministry has been identified as a poisoned chalice for some years. I regard it more as a hot potato in the sense that it tends to burn the fingers of everyone involved. The Department requires a combined effort under a number of headings with all hands on deck. With luck, their endeavour will work in the long run.
I wish to discuss the degree to which we do not rely on health and well-being. The topic gets more attention than heretofore. There are many things that the children in school and everybody can do that will contribute to better health. It is quite simple and comes in the form of dietary changes, etc. Simple changes can save a lot of money at some stage down the road. Unfortunately, we do not do enough in terms of health and well-being.
I wish to make two final points. First, I support my colleague, Deputy Louise O'Reilly, in terms of the use of IT in the general hospital services, GP services, and the co-ordination of activity between GPs, the hospitals and consultants, etc. to a far greater extent than happens at present. I do not know how true is the following anecdote but a man told me the other day that he could save the State billions of euro on IT, according to himself. He is probably watching this broadcast so I had better not say anything about him. We need to explore every opportunity as quickly as possible to provide a better service for patients, a more efficient and cost-effective service and a more responsive, quicker service that reduces the waiting lists.
We need to rely more on the ambulance service, as was referred to. The air ambulance service must be co-ordinated and integrated with the ambulance service to a greater extent than it has been. That is a goal we should deal with. The equipping of ambulances is an urgent issue also. We all come across ambulances from time to time that have seen better days. Vintage vehicles are alright at shows but they do not do the job to the same extent. The technology in the older vehicles cannot be available to the level required now.
Incidental to the debate - but with an impact - is the third level education access. I have come across cases of refugees or asylum seekers, for example, with very high IQs but because they do not have residency status in Ireland they cannot get access to third level education. This is a sad situation. It is not a matter for the Minister for Health but it is an issue. There are many possible students with excellent potential who could be well used, who could make a great contribution to the health services and who would have a natural tendency to want to enter the health services - but they cannot. I have taken this up with another Minister, as the Chairman knows.
My last point is around the palliative care residential services. I know the Minister has visited the facility in Harold's Cross, and others I am sure, and I believe these services should be complimented for the quality of the care they provide and their understanding for the patient in very challenging circumstances. All that can be done needs to be done in including them in the overall upgrading of services that is required.
I thank the Chairman and I apologies for speaking at length but I did my best to cover all the points I wished to raise.
Deputy Durkan touched on some of the points I want to speak on. If more money was spent on mental health as a preventative measure it would be very cost effective. More money might be put into the campaign, "It's okay not to feel okay". If people were to talk earlier and not bottle things up then money could be saved in the long run. Campaigns could advise people on how diet and exercise can help with mental health. Many of us think that diet is just for our figure, but it is very important for mental health also. Sometimes these things need to be spelled out and if money was put into that message an overall saving could be made in the long run.
Turning to an earlier discussion I have just had to leave to take a phone call and I had a quick squint at the newspapers. It appears that the operation for the young woman who was on "The Late Late Show", Megan Halvey-Ryan, due for 9 March, has now been cancelled as confirmed by her mother Sharon. I wonder about the extent to which we are in a room listening to figures - and with respect, some of these figures are vague - when real life is what happens outside of here while we are all busy analysing the figures. No amount of analysis will restore the confidence of that young woman in our health services. She was packing her bag to come to Dublin, her mum said. I was reading the article as I came down to the committee room in the lift. We need to address if there is a disconnect between what is said as an aspiration and what actually happens. I was very distressed to hear that her operation , which was due on 9 March, has now been cancelled. This touches on what we spoke of earlier but it is what is actually happening on the aspirations and everything else.
With regard to the child and adolescent mental health services, does the Minister have a figure for how many children are currently in adult units, which are called inappropriate settings, and does he have a plan to get them out from those units to put them where they should be? If the Minister does have a plan, perhaps he could identify where the costs and money for that have been allocated. I was in Sligo on Monday and I spoke to some parents who are having first-hand dealings with the child and adolescent mental health services. Actually, let me put that correctly - they would love to be having first-hand dealings with the child and adolescent mental health services but instead they are on lists. They tell me also that the list has closed and effectively no new people are being added. I note that in the report we can see the number of child and adolescent mental health services, CAMHS, referrals seen by the mental health services where one can see this figure is about to go up or is projected to go up. The people I spoke with last week are not even on a list. Does the Minister have figures for how many people try to access the CAMHS service but cannot make it onto a list? If we look at the figures for psychiatry for old age we can see figures for the percentage of accepted referrals, re-referrals, offers of first appointment, etc. There is a lot more detail there. I might have a view as to why there is not much detail about the CAMHS but maybe we could get that same level of detail because it would give us an accurate picture. I can see the percentages are there in the report but we do not have actual figures for how many children are waiting, how many children are referred and not seen and how many children have not yet managed to get onto a list.
I try not to be, but if I may I will be just a little parochial and ask about my area. It is my understanding from parliamentary questions I have asked that a business case for a psychologist in the north Dublin area is being put forward and that the business case has been put forward twice. We have the fastest growing population in the State and the highest number of young people per head of population in the State, yet we cannot access a child psychologist for the CAMHS service. This seems very wrong to me. It goes back to the issue of staffing and the crossover with the budget, and from the figures I can see the projected increase in the children using the services. Does the Minister have a clear sight as to how this correlates to additional staff? Perhaps he could give us a breakdown of the grades, groups and categories of staff involved, and if it is intended to purchase any services from the private sector, for how many hours and for what types of services.
I do not want to comment on an individual case at this committee. I have the little bit of information that Our Lady's Hospital for Sick Children, Crumlin was allowed to make public by Megan's parents to the media, but I would rather not get into the detail of that other than to say that I believe a second date has been offered for this month. I would be happy to discuss it off-----
It was not my intention either, it was just that it came up and it is relevant because we had been discussing scoliosis specifically.
No. I believe it is entirely relevant, but in this specific case I hope this girl gets her operation as quickly as possible. My priority has to be to put in place the plan from a policy perspective and from a HSE operational perspective that will bring waiting times for scoliosis in line with international norms. Four months is a huge improvement on where we were at, but it is right to try to make that huge improvement because where we are at currently is not acceptable. The new theatre will open in April and this will bring additional capacity. There will be further capacity this summer with the recruitment of the additional consultant. We are looking at every and any option including the option of using facilities in the UK. I take the point and will follow up directly on the other issue after this meeting.
On the issue of prevention, Deputy Murphy O'Mahony is right in that we must meet the challenge as it arises, but we must also look at how we can empower people, especially our young people to have the resilience skills that we all need to mind our own mental health. This is the point. We all have mental health that we need to protect, just like our physical health and well-being. My colleague, the Minister of State, Deputy Helen McEntee, is doing good work with the youth mental health task force.
There are some really good people involved in that group. It is due to report relatively shortly. It commenced in September. It is chaired by the Minister of State, Deputy McEntee, and it is working to develop action plans for the age groups from zero to 12 years, 13 to 18 years and 19 to 25 years, and for parents and what are referred to as "noticers". It is being supported in its work by a series of youth consultations to ensure that it is a plan, not of politicians telling young people but that is owned by the young people of Ireland. We see brilliant work being done, both in schools, above and beyond what they are required or asked to do, and by people in their communities as well. It is about trying to empower all of that. I agree with the Deputy in that regard.
In relation to the CAMHS services, on page 25 of my Department's briefing, as distinct from the committee's, there are some figures Deputy Louise O'Reilly is looking for on the number of CAMHS referrals, as opposed to the percentage.
According to this, the output target in 2016 was 12,415. In fairness, I do not have the outturn but that is because it is not available yet. I will get the Deputy the outturn figure as soon as it is available. The target for this year, in terms of actual persons as opposed to percentages, is 14,365. Seventy-two per cent will be seen within 12 weeks or three months of being referred for an appointment.
On the important issue of the psychologist post, I will ask the HSE to update the Deputy directly on the position. For the breakdown of public versus private grades, and the same breakdown the Deputy is looking for across the other areas, I will update the Deputy directly through the HSE.
Before we conclude, I want to raise two points regarding mental health. The incidence of suicide in Ireland is frightening. It is in excess of 500 a year and almost two and half times that of deaths in road traffic accidents. In relation to what Deputy Louise O'Reilly said, the lack of talk therapy treatments is a issue not only in Dublin but right throughout the country. In my area, we have not had a psychologist for two and a half years. There is a significant gap in supplying talk therapy. Mental health is not merely the prescription of drugs. It is talking and communicating with people, particularly young men, which group has the highest incidence of suicide in Ireland. It is important that issue is addressed. There are many voluntary organisations providing mental health services, particularly in respect of suicide, and they are crying out for funding or for the appointment of psychologists and therapists.
Lastly, on health and well-being, the graphic refers specifically to vaccination and I will concentrate on that. There is a vaccine which is in serious trouble, that is, the HPV vaccine for the prevention of cervical cancer. The HPV vaccine could possibly reduce the incidence of cervical cancer, which is associated with the HPV virus that is implicated in 70% of cervical cancers. The uptake of that vaccination programme has dropped to less than 50%. There is a lot of adverse publicity regarding the vaccine. The only way to address this is to address the parents and the young girls who feel they have been affected by the vaccine. Otherwise, the vaccine uptake will decline further. The Minister might comment on those two issues.
I take the point the Chairman makes in respect of suicide, the huge amount of work that we have to do and his own interest in this issue. I will continue to work with the Chairman and the committee in this regard.
I am pleased that the Chairman raised the issue of the HPV vaccine, which is something that we have discussed at the committee previously. The focus for 2017 is to counter misinformation on the safety of this vaccine and to increase the uptake rate in girls, as part of the schools immunisation programme. The immunisation programme in Ireland is based on the advice of the national immunisation advisory committee, which is a committee of the Royal College of Physicians of Ireland that comprises of experts in a number of specialties, including infectious diseases, paediatrics and public health. The committee's recommendations are informed by public health advice and by international best practice. In 2009, that committee recommended the HPV vaccination for all 12 year old girls to reduce their risk of cervical cancer and in September 2010, as the committee members will remember, the HPV vaccination programme was introduced for all girls in first year of second-level schools.
There are two licensed HPV vaccines available in Ireland. Gardasil is the vaccine used by the HSE in the school immunisation programme and it is provided free of charge for girls in first year of second-level school. In September 2011, there was a catch-up programme started for all girls in second-level school and the 2013-2014 campaign was the final year of this programme.
The Department is aware of claims of an association between this vaccine and a number of conditions experienced by groups of young women. More than 100 million people have been vaccinated with HPV vaccines worldwide. In Ireland, more than 220,000 girls have been vaccinated. The HPV vaccine safety has been monitored for more than ten years, not only here in Ireland but by many international bodies, including the European Medicines Agency and the World Health Organization.
An illness that occurs around the time the vaccine is given and is already known to be common in adolescence does not imply, according to the medical advice available to me, that the vaccine caused the problem. As there is no scientific evidence that the vaccine causes any long-term illness, the HPV vaccine cannot be held responsible for such illnesses. It appears that some girls first suffered symptoms around the time they received the HPV vaccine and, understandably, some parents have connected the vaccine to their daughter's condition but there is no medical or scientific evidence to suggest that available to me, the Department, the European Medicines Agency or the World Health Organization.
Any person suffering ill health is eligible to seek medical attention and access appropriate health services, irrespective of the cause of the person's symptoms, and the families of any girl suffering symptoms following the HPV vaccine are advised to seek medical advice from their family doctor in the normal manner and be referred to consultants familiar with these syndromes for diagnosis and management, if their GP believes that is appropriate. The individual nature of the needs of some children may require access to specialist services and the HSE is currently working to put in place a clinical care pathway appropriate to the medical needs of this group.
I cannot stress strongly enough that all medical advice available to us is that this vaccine is absolutely safe. That is international. Some 100 million people have been vaccinated. It saves lives from cervical cancers. Each year 300 women in this country alone are diagnosed with cervical cancer and 100 women die each year in this country from this disease. All cervical cancers are linked to high-risk HPV types and this is a vaccine that will save women's lives. In 2017, it is our intention, the HSE's intention and the intention of a number of strong advocacy groups to debunk the myth about this and to try to get the vaccination rate increased. As I say, families who believe their daughters are experiencing a medical condition that we believe is not in any way linked should seek medical advice from their GP in the first instance and a consultant where appropriate.
Can I raise one other matter, Chairman, if that is appropriate?
Of course.
It is not for discussion now but I want to briefly mention the issue of medicinal cannabis, if the Chairman would indulge me for 60 seconds. I am conscious that there is a lot of information, and, I worry, some misinformation, out there with regard to my function as Minister for Health. In recent days, I have read information and received messages from people asking that I merely sign an application and make medicinal cannabis available to a named patient. I am not going to discuss individual cases at this committee.
For the information of the committee, however, which will further consider the issue and has a timetable to do so, no licence has been granted by my Department for the provision of medicinal cannabis to any child without the recommendation or support of a consultant to oversee that. There is no application currently in my Department with a paediatric consultant recommending medicinal cannabis and the Chief Medical Officer, who unlike me is a doctor, has informed me that I cannot grant a licence without that. Every child with a condition such as epilepsy is under the care of a consultant and if that consultant or any consultant believes it is appropriate that a child should access any medication, including medicinal cannabis, and the licence is applied for, it will be dealt with as a priority and will be made available.
I believe we should change the law in relation to medicinal cannabis. That is why I commissioned the Health Products Regulatory Authority, HPRA, report in November. That is why it reported to us at the end of January. It is why this committee has it and will consider it. That is thanks to the work of Vera Twomey and a number of other brave courageous advocates.
However, I need to be clear in relation to the HPRA report. The HPRA report's recommendations state one could set up a compassionate access programme for three conditions but that the supply of medicinal cannabis would still need to be on the recommendation of a consultant. I want people to be clear. On the idea that I have a form that I can merely sign to end somebody's suffering, of course, if that was the case I would do it.
The committee will meet the Health Products Regulatory Authority on 13 April to discuss the report it has sent us. On 5 April the committee will conduct pre-legislative scrutiny on the Bill sponsored by Deputy Gino Kenny. Does anybody in the country avail of medicinal cannabis on a medical prescription at present?
Yes, and without getting into individual cases it is known, and I have confirmed on the record of the House, that a licence was granted just before Christmas for one child to receive it. Without breaching confidentiality, the licence was supported by a paediatric neurologist.
I fully accept everybody wants to end the suffering of the young woman and some of the pictures are so distressing. I appreciate if it was a case of signing the form it would have been signed and we would not be having this conversation. I do not ask the questions for anything other than information. Must the person who signs off on it be in Ireland in the Twenty-six Counties?
I will have to go back to the chief medical officer for clarification, but my understanding is it would have to be the consultant caring for the patient. The Chairman will know better than any of us that when any drug is provided, how it interacts with the patient's overall condition and other medication and its dosage need to be monitored by somebody caring for the patient. It is correct to state that in the past people went abroad and received treatment. The treatment abroad scheme does not cover countries outside Europe but in the past some people by their own manner or means went abroad and obtained treatment and then sought permission to bring the treatment home, but they still required a consultant in this country. There was a case where a consultant in this country stated a named patient required the medication the person wished to bring here. This is the point we need to get to.
I hope the establishment of a compassionate access programme, which is not just about changing the law but also about informing and involving clinicians, would increase the number of clinicians with an interest in this area and provide greater monitoring, clarity and data for medicinal cannabis. I spoke to Deputy O'Reilly's colleague and my ministerial counterpart, Michelle O'Neill, MLA, who is interested in looking at what we have done here with regard to the North. There is much work to do in the area but it simply is not correct to suggest any politician can sign this when no medical consultant is stating to do so.
I thank the Minister and Ms Prendergast for coming before the committee and assisting us with our consideration of the Revised Estimates and programmes.
The briefing documents prepared by the financial scrutiny team, which I have been using this morning, make extensive use of graphs and charts to present the financial and performance-related information contained in the Estimates and it is an innovation. Do members believe this innovation has been of benefit to the committee? Do they wish to continue to receive briefing Estimates in this format?
I have not seen any other format.
Does the committee wish the secretariat to identify items on the committee's work programme that might benefit from a similar approach?