As we now have a quorum, we will commence. Apologies have been received from Deputy Louise O'Reilly. I remind everyone to switch off their mobile phones. This meeting has been convened to consider the Supplementary Estimate for Vote 38 - Health. I welcome the Minister for Health, Deputy Simon Harris. He is accompanied by departmental officials Mr. Colm Desmond, Ms Fiona Prendergast and Ms Pamela Carter. I invite the Minister to make his opening statement.
Vote 38 - Health (Supplementary)
I thank the Chairman. I will take some of my statement as read but I will highlight a few points.
I thank the committee for the opportunity to bring forward this Supplementary Estimate for Vote 38 this morning. The total additional funding I am seeking for 2017 is €195 million. Of this, €40 million is for a winter programme and €155 million is towards overspends in non-performance related areas of the HSE. While the amount sought is significant in monetary terms, it is important to point out that it represents less than 1.4% of overall health expenditure this year and is indicative of the particular challenges to be balanced in health and the priority the Government attaches to addressing areas of particular concern.
It is fair to say that the improving economy has made extra spending on health and other priority areas of public expenditure possible. We need to keep our economy strong so that we can continue to develop our health infrastructure and the provision of our health services into the future. The mid-year expenditure report highlighted the issue of health funding as a major policy challenge, not just in this country but internationally. Despite welcome increases in recent years, a financial challenge remains as we deal with a larger and older population, more acute health and social care requirements, increased demand for new and existing drugs and the rising costs of health technology. The costs of payments under the State Claims Agency are also rising, increasing the cost of health above that necessary to meet the health demands of our changing population.
This year, the anticipated level of overspend by the HSE is linked to the impact of the 2017 pay agreements for which the health service was not funded, State Claims Agency settlements being above budget, a shortfall in income in the acute hospital sector and expenditure in a number of service areas. The HSE, through its performance and evaluation framework, has undertaken to reduce the level of the final potential overrun in the performance areas. I am aware of both the limited Exchequer funds available and the need to ensure that poor financial performance is not rewarded. In this Supplementary Estimate, we are addressing the funding requirement arising from decisions made subsequent to the national service plan, particularly central wage agreements and shortfalls arising from items outside of the management's control of the health service, such as income shortfalls and the overrun in settlements by the State Claims Agency. It is important to say that these items are outside the immediate and direct control of my Department and the HSE and are as a result of central decisions made by Government since last year's budget or by the actions of third parties.
I welcome the fact that this year's economic performance has provided us with the scope to increase budgets again, providing €40 million for the early commencement of a range of measures to address winter pressures. This will provide additional acute hospital capacity, long-stay and home support for older people and measures in primary care. The 2018 budget will allow for further developments in these areas, as well as in areas like new drugs, the national cancer strategy, the national maternity strategy and the continued development of the National Ambulance Service. I also welcome the fact that, in general, where service improvements were approved and implemented in 2017, the funding is in place for 2018 for their continuation. This is important. We cannot have stop-start measures in the health service. When we fund something in one year, we want to be able to continue that and, indeed, grow it where possible in the next.
I will now set out briefly the items that make up this year's Supplementary Estimate. The sum of €50 million relates to the State Claims Agency. I have already outlined the rationale behind that sum. A total of €75 million of the Supplementary Estimate relates to central pay decisions taken after the 2017 budget was finalised. This funding primarily relates to the acceleration of the Lansdowne Road agreement and the reinstatement of the non-consultant hospital doctor living out allowance. Members will be well aware of the decision to bring forward earlier payments under the Lansdowne Road agreement. Obviously, that has had a knock-on effect in the context of a health service that employs over 100,000 people. A total of €30 million of the Supplementary Estimate relates to a shortfall in income generated in acute hospitals. The core purpose of the public health system is to provide services for public patients. Nonetheless, as we have discussed on many occasions, historically and currently a proportion of activity in public hospitals involves the provision of care to private patients. It is only right and proper that insurance companies make a contribution to the cost of using our public facilities. In his 2010 report, the Comptroller and Auditor General identified that for 50% of private patients, no private inpatient charge applied as patients were either accommodated in a designated public bed or a non-designated bed. The Health (Amendment) Act 2013 was implemented to address this issue. It is Government policy that the users of private services in public hospitals should pay for the cost of providing them. It is also important to say that a working group comprising representatives of my Department and the HSE is looking at all of these issues in terms of the public and private sectors and how they interact. Committee members will also be aware that in the context of the Sláintecare report, I have set up the de Butléir group to look at the question of decoupling private from public in the health service. I have made my own position on that issue very clear. I would like to see them decoupled but it is important that we consider any unintended consequences through the aforementioned group.
Finally, €40 million of the Supplementary Estimate of €195 million relates to measures to improve scheduled and unscheduled care. Members will be aware that this money will allow for the early commencement of a range of measures aimed at alleviating pressure in our acute hospital system. It is made up of €30 million for winter and unscheduled care measures and €10 million for further work through the National Treatment Purchase Fund, NTPF, and the HSE's waiting list initiatives. There are lots of figures out there relating to waiting lists. Sometimes it is quite hard to digest the very significant range of figures out there and to what each list refers. In that context, Trinity College in Dublin is doing work on how best to record and report waiting list figures so that we can have accurate data comparable with that of other countries. It is important to say that the numbers on inpatient and day case waiting lists, that is, the number of patients waiting for a hospital procedure have fallen for three months in a row and I expect that trend to continue into 2018.
In view of the fact that the items giving rise to these increased costs are, in the main, outside the immediate and direct control of the HSE or are in an area in which we would like to make further improvements in terms of scheduled and unscheduled care, this request for a Supplementary Estimate is fair and reasonable. This additional funding combined with the 2018 budget provision is a practical example of how we are now reinvesting in our health service. I seek the committee's approval for this Supplementary Estimate.
I thank the Minister. Before I invite members to contribute, I remind them that the subject matter of this meeting is the Supplementary Estimate. That is our focus today.
I welcome the Minister and his officials. The Minister went through the various reasons for needing a Supplementary Estimate. He referenced issues that are outside the control of the HSE, that is, costs that arise from third-party decisions, including pay awards. He also referred to decisions that were made subsequent to the national service plan, particularly central wage agreements and shortfalls arising from items outside the control of management such as income shortfalls and overruns. I can understand how overruns cause difficulties and there is legislation coming down the track to address the issue of periodic payments. That should address some of these matters.
I wish to focus on the shortfall arising from wage agreements.
Will this assist in funding section 38 bodies which are in as much difficulty as the HSE is because of central wage agreements? Are they expected to fund that out of cuts in services or will this Supplementary Estimate be available to those entities and organisations that find compliance with the wage agreement impossible and have to cut back services?
The provision for capital expenditure this year was €454 million. How much of that is for the children's hospital? I do not need a detailed breakdown but how much has been incurred to date or will be by the end of the year for the children's hospital?
I will get the data on that for Deputy Kelleher. While I am digging that out, I will address sections 38 and 39 bodies. Section 38 bodies are covered. If one works for a section 38 body, one's status is similar to that of a public servant. Section 39 bodies, as the Deputy and I know, are in quite a different situation. We have a number of section 39 organisations which provide services that our citizens benefit from. The people working in them do not have the same status of being a public servant. Their employment situation is legally different and I think that is fair. I am conscious that a number of these organisations have outlined to me, and I am sure to Deputy Kelleher and many Members of the Oireachtas, their concerns that they had pay cuts during the difficult years and that they may not be in a position to be competitive in recruiting staff to provide services. No service should be cut because we provide grants and service level agreements for specific services to be provided. The Taoiseach outlined in exchange with Deputy Kelleher's leader in the Dáil a few weeks ago that he asked the Minister for Public Expenditure and Reform and I to engage on this and see if a way forward can be found.
The Supplementary Estimate that I am bringing today does not relate to section 39 bodies but we are examining the issue. It is important to say that section 39 bodies are different. They are grant aided. The HSE has service level agreements in place with voluntary providers in exchange for a level of service but employees of section 39 organisations are not public servants and therefore are not encompassed by public service stability agreements. This means that they were not subjected in a legal sense to the financial emergency measures in the public interest, FEMPI, legislation which imposed pay reductions. I understand, and have heard from many of them, that for a variety of reasons, pay was cut in those organisations. I am committed to working with Government colleagues to try to find a process or way forward for what is a complex issue but it is not part of this Supplementary Estimate.
I will send the Deputy a note on specific expenditure for the children's hospital project.
I do not need it analysed down to the last shovel.
The total cost for the delivery of the project at St. James's Hospital for both the outpatient and urgent care centres is €1.07 billion, of which €1.004 billion is Exchequer-related. Car park and retail facilities are not intended to be Government-funded on the basis that they are commercially viable businesses which can be commercially funded. The project is managed and delivered within these parameters. We will have the specific level of spend envisaged for 2018 at the publication of the service plan and I will find out for the Deputy the amount expended this year.
There is a shortfall in income generated by acute hospitals of €30 million. In light of Sláintecare and the decoupling of private and public health care, we will see this happening continuously. It did not come in as a Supplementary Estimate but will be in the original figures next year. It is interesting that it is €30 million. I understand where all the money is going and commend the Minister on the 1.4% increase, which is not a huge amount of the budget but is still a vast amount of money. There is a €30 million shortfall in income from acute hospitals and €50 million for the State Claims Agency. We think of the money that we need. I understand there is a certain amount of money there for starting the implementation of the Sláintecare report but this is something that we know will reorientate the health service. A concern many people involved in the public sector and the provision of health care have is that the budget always seems to increase. If there is an increase in demand, one can understand how a budget would have to increase but we should really look at efficiencies that can offer more for less.
I commend the Minister on the money that he and his Department have diverted to try to address the fall-off in the HPV vaccine. We often see the Minister at this committee and I feel like he is almost a member of it at this stage. He took this on fearlessly and took the advice of experts since he is not coming from a medical background. It is a lesson to all Ministers that if experts come to one with expert advice, it should be taken on board. We have seen a reversal in the downward trajectory of the HPV vaccine uptake. It has gone from 50% to 61% which, as far as I know, is a first globally. The Minister, his Department, the Irish Cancer Society and the rest of us who put our heads up when it was an unpopular thing to do stood up for the health of the people of Ireland. Hopefully it will go down as one of the Minister's greatest achievements. I am sure he has plenty to come. While we have this momentum, we should look at funding to address male vaccination. I know we had projected it to happen in the future but now that we are on a roll, it would be my view that we should take advantage of it and that people should realise that in 30 years' time, the Minister and I will be walking down the street among women who would have been dead but for the Minister's intervention and bravery.
I have previously raised the Trinity College Dublin work that the Minister mentioned with regard to the waiting lists. The number of people waiting on lists is a concern but a certain amount of rationalisation has to be done. I have had many instances with my own children where the consultant does not want to see them for two years because he or she is waiting to see how whatever is wrong with them develops. I was not aware that they then entered the waiting lists. They are waiting but it does not relate to a supply of care, rather a period that has to pass before they can be assessed correctly. I look forward to Trinity College Dublin's work on this. When we talk about the alignment of the community health organisations and other groups, we need to know what we are counting to have an impact.
Will the Minister update us on what has happened with scoliosis patients in Ireland to date and what we are hoping to achieve next year? I am sure everybody is concerned. We are all conscious of media reports and the suffering of children waiting for scoliosis treatment.
I thank Deputy O'Connell for her comments. I fully agree with her on the value for money issue. When I became Minister for Health, I found it somewhat astonishing that we do not have a structured programme to ensure that every euro counts in the health service. Just like the Deputy in her own business and anybody in family life seeks to make sure that they get good value for money, there are a number of initiatives throughout the HSE but we need a more concerted and structured approach. I hope we can act on that with regard to future service plans. We cannot just increase the budget for health every year. We have to see what we are getting in return for that budget. I acknowledge that some progress has been made in recent years. We saw, for example, the activity-based funding for our health service based on how many procedures were conducted by a facility. There has been a commencement of linking provider payment with clinical objectives. The Ministers, Deputies Regina Doherty and Richard Bruton, and I have addressed Healthy Ireland and paying money for school meals. We make sure that we only fund school meals that tie in with our Healthy Ireland agenda. We have much more to do and I would like to see a structured value for money drive in place. Often, these things are needed in times of recession but the time to do it is actually now when the economy is growing and we are reinvesting. We should not be complacent. I do not think there is a citizen who does not believe that we can get better value for money for the health service and I hope to be able to move on that shortly.
I thank Deputy O'Connell for her kind comments on the HPV vaccine.
I thank her and other members of the committee for their leadership. Her professional background as a pharmacist meant she was not afraid to call out the nonsense, myths and scaremongering that was going on. I have been attacked and vilified by many a keyboard warrior for my position on the HPV vaccine, as have many other people in this room and in the Houses of the Oireachtas generally, but the HPV vaccine campaign has been a very good example of collective clinical and political leadership. The HPV Vaccination Alliance, all of its constituent NGOs, many of which Deputy O'Connell listed, have been incredible in coming together, calling out the myths, demanding that people put the facts out there and not just accepting myths as fact, which is often a risk in political debate these days. It was never about lecturing or preaching to parents; it was about asking parents seeking to make the decision - and any decision for one's child is a very important decision one must make as a parent - to get the facts and telling them where they can get the facts. I refer to the new website, hpv.ie, which provides all the information for parents along with the basic advice that if one wants medical advice, one should go to a medical professional, be it a pharmacist, doctor or other appropriate individual. This concerted and co-ordinated effort has seen Ireland reverse what has been a global trend that when uptake of a vaccine decreases, it continues to do so. This year, thankfully, the number of girls who have been vaccinated on foot of decisions they and their parents made will be up by well over 10%. I instinctively agree with Deputy O'Connell's desire to see the vaccine extended to boys but, as always, I must continue to follow the medical evidence in this regard. HIQA is carrying out a health technology assessment at present, the results of which are due next year. If there is a positive recommendation there, we will absolutely act on it. We should not be in any way complacent about this because while we have seen an increase in uptake of the vaccine, we cannot let our foot off the pedal on this one. We must continue to be very vigilant and to provide factual medical information to our citizens and not to pat ourselves on the back for too long on this one because there is still a long way to go. Nonetheless, Deputy O'Connell is right: there are women, young girls, who got the vaccine this year who will be alive in the future as a result of the increased uptake. We need to see this trend continue, and I thank Deputy O'Connell for her work in this regard.
I appreciate the opportunity to provide some clarity on the issue of scoliosis because we have discussed it in this committee on many occasions. When the "RTÉ Investigates" programme was broadcast earlier this year, 312 children were waiting for spinal fusion or spinal procedures. As we all know, people are placed on waiting lists all the time. Waiting lists are not static; they grow as more children need procedures. As of 1 December, that number has decreased to 156 patients, so we have halved the number of people on the list overall. This is due to an incredible effort on the part of the most dedicated clinicians. I know there was a legitimate debate about consultants and public and private care previously in this committee, but this group of clinicians has gone above and beyond the call of duty with might and main and worked additional hours with nursing colleagues, management of the children's hospital and the CEO of the Children's Hospital Group, Eilish Hardiman. Huge work has been done.
Regarding the four-month target specifically, just over 60 children will be waiting over four months by the end of the year. Obviously, we must work into our calculations the fact that time moves on. It is still intended to meet the four-month target, but it is fair to say that some parents will have been offered treatment that for very good reasons they will not have been able to accept. Taking one's child abroad, for example, is not an easy decision; it does not always work for families. The assurance I am giving people today is that, whatever the number, children left waiting over the four-month period by the end of this year will have a date for early 2018 by the end of the year. I also wish to debunk a myth I have heard and read today about the "abandonment" of the four-month target. I will be very clear about this. The HSE and I have brought together a scoliosis co-design group. We have asked patient advocate groups and clinicians, the people actually carrying out the surgeries, to come into a room with a group chaired independently by Brian O'Mahony in order to come up with a sustainable plan for scoliosis. They are due to make recommendations which, I think, will be published in January. I will follow them to the letter. We will do absolutely everything that that group commits us to doing. The point about the four-month target is important because I have sat in rooms with clinicians, the people carrying out the scoliosis procedures, as recently as two weeks ago and they have told me that for some children the four-month target will not be appropriate, that some children will need the surgery much sooner and that other children, for a variety of other reasons, including growth spurts, may need in their medical interest to have the surgery done at another time. We must be clinician-led in this. I wish to be very clear: the scoliosis co-design group is a group of patient advocates and doctors who carry out scoliosis procedures. They will come up with recommendations. We will hire additional consultants, we will have the theatre in Crumlin open full-time and we will in 2018 have what we have never had before in this country, a sustainable scoliosis service. We will be able to end the process of having to outsource procedures abroad during the course of 2018 as well, and we are making huge progress on this. I am very eager that we do not have a little progress made in 2017 only for the problem to recur because this problem has been ongoing for years. We will put in place a sustainable service. I thank the clinicians for their leadership in working with the patient advocate groups. The idea of an abandonment of the four-month target is not accurate at all. Whatever target is set will be set on the basis of the clinical advice of the scoliosis co-design group, and this is an appropriate way to act.
Deputy O'Connell is entirely correct to raise the important matter of waiting lists. We need to be very careful when we set policy in the interest of our citizens that we know the scale of the challenge, and there is absolutely a major waiting list challenge in this country. However, people on the M50 in the morning are not concerned about how many cars are on the M50 but about how long they will have to remain on the M50. Therefore, we must ask what are we measuring and what is a sign of success? That more and more people are using the health service and undergoing procedures in the health service, including procedures which were not available in some cases a number of years ago, particularly in the area of ophthalmology, is in and of itself not a problem; the problem is when people wait too long. When the RTÉ programme, which highlighted a number of very important issues, was broadcast, I said I would be fully transparent and that we would publish every list, including lists that have never before been published under any previous Minister for Health and put them all out there. The problem now is that some people are misrepresenting the reality. There are many different lists. There is the active list. This details the number of people who are actually waiting on a given day for a hospital operation or procedure. The numbers on this list have fallen for three months in a row. How many people are waiting for an outpatient appointment, an appointment with one's consultant? These are very important metrics. These are the people who are actually waiting today. How many people are waiting for a scope today? That is very important. However, there are three other lists. There is a list called to come in, TCI. In this case one has received one's appointment date and the appointment will take place within the next six weeks. In other cases, people's appointments have been suspended and they are on a suspended list. Perhaps they have seen a doctor, who told them they are not medically fit for a certain procedure on a given day. No Minister for Health can tell that doctor to go ahead and carry out that procedure. Is that patient waiting, or is he or she not medically available for a procedure he or she has been offered? Then there are planned procedures, which are the cases Deputy O'Connell raised, and which are perhaps the most important when it comes to people misrepresenting the lists. People use the service regularly. They need regular check-ups, perhaps regular procedures, and they might see a doctor today and the doctor might tell them to come back to him or her in three months time. They get an appointment date for three or six months time and they have that appointment in three or six months time. Are they waiting? According to some of the figures one sees in the media, they are, but according to that patient, I reckon, if one spoke to them or their family, they are not waiting in that sense. Rather, they will be seen at the time at which the clinician wants to see them.
Trinity College, independent of me - the NTPF had asked it to do this - is looking at how other countries report and record waiting lists in order that we can have accuracy in this regard. Please do not get me wrong - we have huge challenges in this area. However, we need to know exactly where the challenge is and not try to fix a different challenge that may not actually exist in such an acute fashion. I hope Trinity College will examine other countries and see how best we should record accurate waiting lists. This is the other thing. We hear people say there are X hundred thousand people on waiting lists but they are not all individual people. Anyone might be on a list two or three times for two or three different procedures. We therefore need to be very clear about what we are measuring because I can receive from the taxpayer a significant fund of money and I need to be able to direct that into the appropriate place. Getting the list accurate, recording the figures appropriately and showing our citizens what is going well and what is not going well and how we will fix it is very important. I hope the Trinity College group will be in a position to provide us at least with some interim guidance very early in 2018 in order that we can have an informed debate about where the challenges are and what we will do to fix them.
I welcome the Minister and I welcome the introduction of the Supplementary Estimate. It encompasses many of the sensitive areas to which we have brought attention in the course of this year and for a number of years. It is to be hoped that the detail provided and the specific target areas will result in a clearly identifiable result at the end of the spring. We can talk about these matters ad infinitum, but putting in place the measures to deal with the issues as they present themselves is very important. It is also a litmus test of the health services. This challenge of waiting lists and access to accident and emergency services and elective procedures and so on has become an annual challenge.
If we do not get to a position where we can identify precisely a smooth flowing and seamless delivery of services, questions will always be asked. What the Minister has pointed out is very important. Who is on the waiting list? Have they been approved for a procedure or are they awaiting diagnosis? Is a delay required? Unless and until these people are diagnosed and have a specific requirement, there is no use counting them anywhere. I remember dealing with a patient years ago who was allegedly on a waiting list but he would never be put on a waiting list because he was not medically fit to go through with the procedure. That was not said.
There are a number of matters about which I have become a little worried over the years. It is well known that there are professionals in the system who can identify at an early date areas likely to cause problems. In other words, they will be overly stressed or overloaded etc. The people in those areas must be more active and let the Minister know about it at an earlier date. It should not fall to any investigative body, including RTÉ or the Committee of Public Accounts, which deals with issues retrospectively. It should be known and identified within the system and measures should be put in place to deal with the matter. This is instead of it dragging the system down, along with the reputation of many people within the system who work extremely hard in a very demanding and challenging area.
The number of claims has caught my eye in recent times. Reference has been made to the claims agency and provision is being made in the area. It is €50 million. How many of those claims would be preventable? I know accidents happen but if accidents repeatedly happen in the same institutions, I would ask questions. Why would they happen repeatedly in the same institutions? For example, is there evidence indicating that in particular hospitals there seems to be continued risk of claims arising? Quite a number of claims in the media in the past few years have been in respect of maternity hospitals. I know accidents will happen but if due process was followed and all precautions were taken, there should not be a liability on the system. With the best will in the world, one cannot eliminate accidents and they will happen. There is a necessity to look again at the degree to which we see the same institutions named or involved with claims.
There is also the cost of claims. We hear about the award, with the included legal fees. Are we spending money wisely and could preventative measures be taken? In order to provide a good service, we need to address such matters at an early date. To what extent are measures or steps being taken within the health services to address those areas, with particular reference to the unfortunate hospitals that seem to be named repeatedly in respect of claims? I am not in any way attributing blame but if they appear again and again, there are issues. Is there a problem in the system or is the fact that it is a high-risk area the explanation? We need to know.
There is a figure of €30 million for acute general hospitals and it is good to have identified that specific area. I repeatedly made the point over the past year that in order to solve something, one must identify the precise area that requires attention, which is causing a problem or slowing the system. It is not rocket science and it is very simple but one needs to have the inside track and be able to identify precisely where the slow-down or shortfall is taking place. It is a question of identifying where the system is being snagged so the issues can be addressed. If issues must be addressed, that must be done. There is no point in saying we cannot do X, Y or Z because it would cause upset. Upset is caused to people who are victims of snags in the system as well. In the past couple of days I received a reply to a parliamentary question to the effect that a patient will be waiting another 12 to 15 months for an orthopaedic procedure. Having identified the issue and with diagnostics undergone, why is it taking 12 to 15 months for this to happen? There must be some movement along the lines. What if every procedure took 12 to 15 months? Perhaps a patient has a more acute need than another at a particular time, which is correct.
The patient suffers the pain. I am sure everybody here has come across cases where people have suffered intense pain for two or three years, and that is unacceptable. We must put ourselves in the shoes of patients. Having been worried and concerned about a condition and having received a diagnosis, he or she is then told to wait. It can seem like an awfully long time for somebody in severe pain. I will not repeat what I said at a previous meeting, which identified the extent to which patients are being recirculated through the system. That should not happen. Patients are not getting treatment but are going to the accident and emergency departments. When they are discharged, they come back through the system, perhaps twice, or three, four, five or six times. There needs to be an examination to identify the areas with respect to which that is most prevalent. We are moving in the right direction but we spoke of the shortfall of income in acute general hospitals.
It is important to note that when patients are admitted to hospital, they have the option to be treated as private or public patients. This is moot. What are the implications in the event of a patient being admitted to a public hospital and having an option of going private or public? I would claim to know the answer but I would like to hear it more graphically described. It is very important. I am slowing as I come to the end.
I have referred to scheduled and unscheduled processes already and I will not go through it again only to say the unscheduled ultimately become scheduled. What was not urgent yesterday could well be urgent tomorrow. We need to be sure about such matters. The National Treatment Purchase Fund is the only way to my mind that lists can be cleared if there is a major backlog. I cannot see how it could be done otherwise. It is as simple as that. If a backlog has been developed for a particular reason and we have not identified the reasons for it in the first place, we must put in place emergency measures to clear it. It would not work any other way. There is no use in having one reason or another for not doing it and we must do it.
Before the Minister addresses those questions, I have one or two questions as well. The Minister stated that this year the anticipated level of overspend by the HSE is linked to the impact of 2017 pay agreements, which the health service has no funding for. I understand that. Deputy Durkan referred to the State Claims Agency requiring an extra €50 million so I know the Minister will address that. Expenditure in a number of service areas is over budget so will the Minister address what service areas they are?
Where is the funding for the cross-border directive procedures coming from?
Does it come from the Health Service Executive, HSE, or is it a separate fund? Will it be an increasing charge on the State such as the reduction in the payments coming from insurance companies, which I presume will intensify as time goes on because they will be advising patients on their rights as public patients as opposed to private patients?
The Minister referred in his statement to the provision of additional hospital capacity. He might outline the additional hospital capacity to which he is referring, which I presume is bed numbers. He referred also to measures in primary care. What are those measures?
I thank the Chairman and Deputy Durkan. On the issue of patient safety raised by Deputy Durkan and the Chairman in regard to the State Claims Agency, it is probably somewhat unusual to see the State Claims Agency as a part of the health Vote because it is an agency under the Department of Finance. I do not believe it happens for other Departments but the logic behind it is that by keeping it on the health Vote, it forces the system to continue to learn and be acutely aware of the impact of claims in regard to the overall resources available to our health service. It very much keeps it front and centre, and there is a logic in regard to that.
I am pleased to point out to the Deputy that we are making huge improvements in terms of our structures for patient safety. To give a couple of examples, when I became Minister, I had the pleasure of being able to open a new national patient safety office within my Department last December, which is almost a year old now. The idea is that we would have a dedicated unit within the Department of Health to drive patient safety initiatives. In terms of what they look like, I will bring forward legislation to Cabinet this month on the licensing of our hospitals. The best way this Oireachtas can absolutely ensure patient safety is to provide a licensing system. In other words, if a public or private hospital or a health service wants to operate in this country, they have to be licensed by a regulator, presumably the Health Information and Quality Authority, HIQAs, of this world. That gives the State a level, so to speak, that perhaps it has not had to date, which I believe will bring into sharp focus the issue of patient safety. I expect to make progress on that legislation this month, which will be important.
We also brought forward last month open disclosure provisions. Since I have become Minister, I have met many people who have had a bad experience in the health service. Thankfully, most people have a good experience but when I meet those who have had a bad experience, one of the comments they make to me time and again is that they just wanted to find out what happened, to be sure that it would never happen again and that people had learned lessons from it. They just want somebody to hold up their hands and say what went wrong, why it happened and what they are going to do to make sure it never happens again. Many of those people have found themselves with no other way of getting those answers other than going to court. Apart from the time burden of that, which is huge, it puts a huge emotional burden, strain and stress on those people in that they have to go through a very adversarial system just to find answers. The idea of the open disclosure provisions, which in fairness this committee considered at great length and for which I am grateful to the members, is to provide a safe space within the health service for clinicians or others to converse directly with people using the health service. That has been sought for a very long time and it is very welcome. Also, on the Mediation Act, the idea that we will not have an adversarial system in terms of them versus us or that the corporate entity protects itself at all costs is important.
On the idea of periodic payments referenced by Deputy Kelleher, people do not want to go to court for massive sums of money. They wish these things had never happened to them or their child. However, where they need support to address the issue is to help them care for their loved one who may now find themselves needing care for the rest of their life and they want periodic payments. They want to know that they will have those supports for the rest of their life.
I am glad Deputy Durkan raised the issue of the maternity hospitals. We had the first ever national maternity strategy published in 2016 under my predecessor, now the Taoiseach, Deputy Leo Varadkar. I find it incredible that before 2016 we never had a national maternity strategy. Thankfully, we have had cancer strategies and the likes for years and they are making great progress but we never had a maternity strategy. We now have a women and infants programme in the HSE to implement that strategy, which is mirroring the implementation structure of the cancer strategy. All our maternity hospitals now publish monthly incident reports. We can see monthly statements from each of our maternity hospitals so there is much greater visibility, which is very important also.
On the issue of waiting lists, the Deputy is correct. He will be familiar with the fact that I am using the audit function of the National Treatment Purchase Fund, NTPF, to ask it to audit our hospitals to see if they are adhering correctly to the waiting list management protocol. That protocol is clear that chronological scheduling is the most usual and fair way we treat people, but in terms of clinical priority, people who have been classified as urgent need to be seen above and beyond that chronological scheduling. I am disappointed that audits published to date have not shown that always to be the case. We have just gone through a comprehensive training process where the NTPF has trained hospital staff and administrators in terms of the classification.
The other point I want to make is on the idea of pooling lists. We have got to move beyond the idea that if I need a hip operation and I am to be seen by consultant X but consultant X cannot see me for 12 or 15 months, I have to wait until he or she can see me when consultant Y in the same hospital group might have capacity. There are parts of the public health service, and the Chairman and I have discussed this, that have capacity. The Royal College of Surgeons in Ireland, RCSI, group is a very good example in that it has pooled its lists. If someone is waiting for a scope in Beaumont Hospital but there is a long waiting list in that hospital, we can offer that person one in Cavan much more quickly. In the Ireland East group, if someone is waiting for a procedure in a busy Dublin hospital but we have theatre capacity in Navan, would they go there for the procedure? That must become the norm. I am pleased that it is beginning to creep into elements of the health service but it is not where it needs to be. That is a priority for me for 2018.
On the issue of public-private, I agree with the Deputy, and we have had many exchanges on that. The issue needs to be decoupled. Ireland is an outlier in that regard. We run the public health service for the benefit of public patients. They pay for it through their taxes and they expect to be able to access health services in a timely manner. That is not always the case in our country and, as a result, almost half the number of people in this country take out health insurance, not necessarily because they can afford it or want it but because they are worried that they will not get timely access. I want to see that lessen but it is important that as long as insurance companies are generating income from citizens in this country and insurance companies are utilising public facilities, there is a contribution from the insurance industry. We need to work our way through that issue.
I am glad to hear what the Deputy said regarding the NTPF. I agree there is no time for an ideological debate on that. We have got to use every tool at our disposal and contrary to mythical opinion, the NTPF also insources. It does not just outsource. In 2017, one third of its budget will have been spent on insourcing in the public health service, but I will give the Deputy an example of the difference that using the NTPF and investing in waiting lists can make. We have seen a situation whereby the number of people who were waiting more than 15 months for a cataract procedure was 1,694 in April and it is now 421. We will clear that list of people waiting more than 15 months. We talk about waiting lists in a global sense but there are particular procedures that make up a huge bulk of our lists, including ophthalmology, with cataracts being a big part of that, orthopaedics and urology. We have prioritised the area of cataracts and we are making real progress. That list has fallen from 1,694 to 421, and we will clear that. We must continue to home in on the specialties where there is a particular difficulty and life-altering impacts on our citizens.
On the issue of the cross-border directive, that is funded through the HSE. I will get the Deputy a note specifically on how much we have spent in recent years. I am informed it is approximately €14 million this year but if he would like to see a contrast with previous years, we can arrange that. This is an interesting one because in the past the HSE has been criticised for not making citizens aware of their rights in this regard. Sometimes we are criticised for making people aware of their right to go abroad for treatment, but the reality is that whatever country someone lives in, if they are a European citizen they have access to health services in other European countries. The cross-border directive and the treatment abroad scheme are two such examples.
Regarding other areas of overrun, it is fair to say they are scattered across a number of elements of the health service but the acute sector, perhaps unsurprisingly, is the largest proportion of it. I would make two points on that. First, when we were having this discussion last year, by the time that level of overrun crystallised in April, we would have expected it to be much larger than it ended up being. The HSE has shown, therefore, that it can redeem itself in some of these performance areas without impacting patient services.
Second, as a percentage of the HSE budget, which Deputy O'Connell alluded to, the Supplementary Estimate we are seeking is approximately 1.4%. I am confident, therefore, that the HSE has within its ability the opportunity to live within its budget.
I think it has to, but it has to do it in a way that does not alter patient services and that is where there should always be a healthy tension between this House and the HSE. You asked me a question about private insurance, Chairman. Have I answered that?
Yes.
In relation to additional capacity, a number of additional hospital beds will be opening. I will get the list of where they are. That includes beds in Cork. Additional beds will open in Galway next week. Additional bed capacity is also provided for in Our Lady of Lourdes Hospital, Drogheda, some of which have opened this week, including a new emergency department, which will open in May 2018. There will also be additional beds in Limerick.
What is the total number of additional beds?
I will have to revert to you with that, Chairman. In relation to primary care, we will look at it in two ways this year. I am hopeful that through the waiting list initiatives for 2018 we should pick a number of pilot projects to carry out procedures in primary care that we currently do in the acute hospital sector. The one that comes to my mind and the one I wish to prioritise is the primary care eye review. To go back to our conversation about cataracts, the ophthalmologists are very confident that they can do a lot more in primary care and free up the space in acute hospitals. The clinical lead in that regard, Billy Power, has done really good work with the clinical community. We can see some additional work done there through the waiting list funding available to me in 2018. I am holding back within the Department a budget of €25 million for new primary care initiatives during 2018 and I will detail them as part of the service plan.
I have one other question for the Minister. Is there any restriction on the number of orthopaedic procedures hospitals can carry out in a year? Once the target of X number of hip or knee replacements is reached, are hospitals limited in terms of carrying out additional procedures?
No, but obviously a hospital has to operate within its budget and the manager needs to decide how best to use the resources, namely, the theatres, consultants and surgeons. We have shown a real willingness through the NTPF to provide additional resources to public hospitals that have put up their hand and said they could do more, particularly in the orthopaedic area for hip and knee replacements, ophthalmology and scoliosis. I expect they will be a priority for 2018. The public hospitals that believe they can do more but feel they have been curtailed in the past by resources should engage through their hospital group with the NTPF.
I thank the Minister.
I have one last point. I generally have a last point. I know it is endemic in this place, but however. Given that legal costs are extraordinarily high in this country, there is a case for offers to be made without prejudice to patients who feel they did not receive adequate treatment. Full disclosure might be a help. That would be preferable to dragging cases through the courts and then having to determine cases when other costs are added on.
Quite a number of the cases that come to court in the maternity area seem to refer to deprivation of oxygen and consequent brain damage during birth. I have read about such issues and how they recur, but there are preventative measures as well. There are ways and means of ensuring that does not happen or at least does not happen on the scale it has happened in the past or in the same hospitals on the scale that it has happened in the past.
The only comment I would add in relation to the State Claims Agency is that it would not be in a position to discuss individual cases with this committee but there may be a benefit to this or another committee in hearing from it as to how it approaches these issues. The budget and costs of the State Claims Agency have a serious impact on the budget of the health service. If there are learnings the committee believes we should be considering in the context of that and the changes we are making through legislation on periodic payments and open disclosure, I would be very interested to engage in such a process and perhaps it would be worthwhile engaging with the State Claims Agency.
I thought we were going to go through the subheads as well but we are obviously not doing that. That is fine. I am not questioning it but I thought that was the way it would be done. We will not inflict that suffering. I will make some general comments then rather than going through each subhead.
The Minister referred to a couple of issues. I do not wish to have a full-scale debate. We will resume hostilities in the new year. I met some scoliosis advocacy groups yesterday. The target is a four-month wait for children with scoliosis. The difficulty is that the gatekeeper is the outpatient appointment and that is the point where there are huge delays. People are waiting an inordinate period for the initial assessment to allow them to move to the next stage, which is inpatient treatment. That is where the waiting list develops. We welcome the fact that waiting lists are reducing for inpatients but the reason for that is there is a slow flow of children moving from the outpatient list to the inpatient list for elective surgery. Does the Minister understand what I am saying?
I do.
That is a major issue. The Minister said there were 312 on the scoliosis waiting list at the start of the year but that is now down to about 159. However, a backlog is already developing again on the outpatient list. They will move to the inpatient list eventually. We must acknowledge the situation. I like to think I am reasonably fair but we must accept that the outpatient system is unable to assess patients in a timely manner. When individuals are assessed they are eventually put on the inpatient waiting list, surgery is scheduled and they might be treated on time. However, the issue is that they are not seen on time and that is of critical importance. Approximately 80,000 people are scheduled for inpatient care but 600,000 plus are on outpatient waiting lists of one form or another. That is a major issue of concern. The gatekeeper is not allowing patients to flow smoothly through to the inpatient scheduled elective surgery area. I was going to raise these issues under the various subheads but I will get them all out of the way now.
On the broader issue of health service funding, I acknowledge that this is a very small Supplementary Estimate. I accused previous Ministers of presenting wholly unsustainable budgets at the start of the year knowing full well there would be €500 million or €600 million plus rammed through at the end of the year in a Supplementary Estimate. At least we are getting to a more orderly management of the budget. Some of the need for additional funding has come from third parties.
That is my point on scoliosis and waiting lists in general. The Minister cannot say all the progress is due to the policies. It is equally due to the fact that we are failing at the front-of-house stage. In terms of the National Treatment Purchase Fund and the purchase of treatments, I cannot comment on this year but it was brought to my attention in previous years that orthopaedic teams in hospitals were unable to carry out procedures because they had run out of implants. If that is the case, is it possible for the NTPF to purchase the implants for hip or knee replacements? It is a shame to have highly specialised teams unable to carry out procedures due to a lack of implants.
I have one other point. I do not wish to delay the Minister because I am aware he has enough on his plate today. He referred to the cross-border directive and the treatment abroad scheme. The failure of Government policy is evident in what is going through the printing presses of the Oireachtas in the sense that every Deputy, mainly Government ones but Opposition Deputies as well, is highlighting the cross-border directive and the treatment abroad scheme. People should know their entitlements and rights as EU citizens and Irish citizens. A number of years ago we had some consultants who refused to advertise the National Treatment Purchase Fund in their clinics.
While the scheme is good, it is an indication of failure that we now have a situation where bus loads of people leave west Cork and travel to Belfast for cataract operations. Deputies now feel compelled to take their constituents to Belfast for procedures because they have waited extraordinary long periods for them here. On numerous occasions in the Dáil I have mentioned the case of a 90 year old man who lives in my constituency. He has waited years for a cataract operation and he has been told that he must wait another three or four years. The Minister can analyse all of the success he likes. Everybody likes to put a gloss on things and I will not take away from any of his achievements. The idea that the waiting list system has improved dramatically is not the case. The problem is at the front of house. That we have yet to assess and address the issue of outpatients having to wait between one and three years for appointments when we know that they should receive treatment is the new scandal.
I thank the Minister for the delivery of the HPV vaccination programme. The committee had tried to make traction in terms of the matter but his intervention was positive and very timely.
I thank the Deputy for his comment. I thank him and all politicians who are health spokespeople in this House for their leadership, which made a real difference.
In terms of scoliosis, I acknowledge that Deputy Kelleher has highlighted the issue of outpatients for some time. He is entirely correct that there is an issue with the outpatient waiting list. I should have said earlier that the scoliosis co-design team is considering a sustainable solution and will incorporate the issue of outpatients as well.
I disagree with the Deputy about one area. There has been no slowing down in outpatient appointments to accommodate more inpatient activity this year. I must say out of respect for the significant investment that has been made but, more importantly, the clinicians whom I have met that the volume of inpatient procedures they have carried out is dramatically up on last year. What we were trying to do this year was always somewhat different from what should be a sustainable service. It was more about throwing everything that we could at it to solve a significant backlog that had built up over many years and get the lists down to a much more appropriate place. What 2018 must be about, and I am happy to be held to account on this, is a sustainable service in Ireland that does not involve telling children and their parents that they need to go to Germany or France and instead involves us saying that effectively we here in the Republic of Ireland can provide enough orthopaedic procedures to look after all of our children who need various spinal procedures. We will get there during 2018. When I came to office, a brand new theatre in Crumlin was closed but that has been reopened. We have hired additional nurses. We will hire an additional consultant again and that process will start very shortly. By the end of this year every child waiting over four months will have either been treated or will have a date for treatment early in 2018. I want to clarify a point about the four month target today because I do not want it to be misrepresented, not by the Deputy but in any way. We must allow the clinicians rather than HSE managers or me to set an appropriate target. They have said to me that they want to see some children much more quickly than four months while they feel that for others it is better for various reasons to wait a little bit longer. We must empower the clinicians rather than impose an arbitrary deadline.
Deputy Kelleher is correct about the issue of orthopaedics and implants. To the very best of my knowledge, the NTPF has already resourced public hospitals to carry out more procedures. Sometimes the only thing that the public hospital might have been missing was the implants. They may have had the theatre time and the consultants. I am pretty certain that such work is being done and, yes, it can be done.
On the cross-border directive and the treatment abroad scheme, I agree with the Deputy that we do not want anybody to leave this jurisdiction to get health care, but under the European Union they can do so. We know that we are in a changing dynamic in terms of the North and the UK and the scheme at the moment.
Sometimes we can all highlight bad cases. It is absolutely appropriate that we highlight them. It is absolutely appropriate that the health service and I would be held account for them. It is also absolutely true that there are far too many bad cases. People on waiting lists who might be watching these proceedings or following the debate would be excused for presuming that everybody in this country must wait an extraordinarily long time. The NTPF's statistics, and not mine, show that over 50% of us will have an operation, procedure or inpatient day case in six months or less and over one third of us will have it in three months or less. The same statistics apply to outpatients. Over 50% of them will be treated in six months or less and over one third in three months or less. We need a rational debate where we say some elements are going well but some are going extremely badly and what are we doing to do about the situation. The Deputy gave cataract procedures as an example. I agree that people are waiting far too long for the procedure. Many more people waited far too long earlier this year and the number of people waiting far too long has significantly reduced. I want to see the long waits eradicated. I am sure we will have a chance to return to the topic again.
In terms of waiting lists, is it possible that when a referral is made to an outpatient department, an indication would be given on receipt of the referral of when the patient would be seen? Unfortunately, a referral is made and no information is given to the patient or the referring doctor about how long the patient must wait for. An appointment could turn up in six, nine, 12 or 18 months. If a patient knows he or she must wait 18 months, he or she may make alternative arrangements. If a patient knows he or she must wait three weeks, then the anxiety, tension and uncertainty that surrounds referrals disappears. A definite date allows patients to make choices.
I could not agree more. Part of my absolute priority in terms of waiting lists is to make sure that we have the maximum amount of information available to patients, their doctors and the public at large in order that we can make improvements where we need to while also knowing the scale of the challenge. Part of this is electronic records which enable GPs to hear back seamlessly. I will come back to the Chairman on the matter in the context of our plans for 2018. He is right that we will have to do this work differently or we will end up with massive headline numbers without a proper understanding ourselves as to where the challenges lie. As Minister for Health, I want to know where the challenges are in order that we can fix them rather than having a situation whereby people who are not waiting, in effect, in that they have a date three or six months hence because their doctor does not want to see them before then for medical reasons, is counted as waiting. I do not think they think they are waiting and neither do I think they are waiting.
I thank the Minister for discussing the Estimate. I thank him and his officials, Mr. Colm Desmond, Ms Fiona Prendergast and Ms Pamela Carter, for their attendance.