The sole purpose of the meeting is consideration of the Revised Estimates - Vote 38 - Department of Health and Vote 39 - Health Service Executive. I welcome the Minister for Health, Deputy James Reilly, and his officials, Ms Bairbre Nic Aongusa, Mr. Liam Woods and Mr. David Smith, among other members of staff. A draft timetable has been circulated. Is it agreed to? Agreed. An explanatory memorandum on each Vote has also been circulated to members. I will insist on the discussion being confined to the Revised Estimates.
Vote 39 - Health Service Executive (Revised)
I am pleased to have the opportunity to address the select sub-committee on the Revised Estimates for 2012 and present the annual output statement on the Department of Health Vote group. A number of documents are before Deputies, including the Revised Estimates for the Department of Health Vote group, the annual output statement and briefing documents on the two Votes by subhead. As members are aware, the Government has decided to reconfigure the annual Estimates for each Vote along programme lines to ensure greater transparency in Government expenditure. As with other Departments, the Department of Health is working towards the development of programme budgeting and changing the structure of its Vote group to reflect this change. However, owing to the fact that the financial systems in the HSE have been set up to account on a regional basis, they will have to be adapted in order to account along programme lines, which will take some time. The HSE's financial systems operate on a regional basis and have not been configured to manage expenditure on a programme basis.
The annual output statement has been structured in line with the six new programmes in the Department's statement of strategy 2011-14 and the draft integrated reform plan for the health sector. It also reflects the programme for Government commitments on health reform and is indicative of how the Estimates will be reflected in the future. As in previous years, a single annual output statement is presented for the Department of Health Vote group. This is in line with long-standing policy of using one overarching programme framework for the health sector.
Before looking at the Estimates in detail, I would like to make a few general observations about the overall budgetary position. As members are fully aware, the Government is committed to tackling Ireland's very serious deficit problem in accordance with the broad fiscal framework of the EU-IMF memorandum of understanding. As both the Taoiseach and the Tánaiste have made clear, this will require the Government to take many hard decisions in the next few years. No Department can be exempted from this process. Health expenditure in 2012 accounts for 26% of gross current expenditure, which represents 39% of total tax receipts and 92% of income tax receipts.
As members will be aware, the recent performance report from the HSE shows an overrun of €144 million in the first quarter of the year. The Department has been engaging closely with the HSE and a high level group has been established to prepare proposals to address the emerging issues, particularly in the hospital sector. A number of other initiatives are also under way in the HSE, as the current rate of cash drawdown cannot be continued. It will be a major challenge for the HSE to meet its budget targets this year.
The impact of the retirements in the "grace period" will pose significant challenges for it in the coming months, with the latest indications being that approximately 4,700 left the sector before the end of February. To cope with service demand and the reduction in numbers, services will have to work more efficiently.
This means that we must continue to pursue strongly the change agenda in line with the Croke Park agreement. In particular, we need revised rostering, an expansion of the skill mix, the continued redeployment of staff and a reduction in the reliance on agency staff and overtime by reorganising the way services are delivered.
The extent of the financial crisis facing Ireland and the challenges this poses for the health system in particular at a time of growing demand means that the Government must press ahead with major health sector reform. The establishment of the Special Delivery Unit, SDU, is a core element of the Government's plan to reform the health system radically and to make it more efficient. The SDU is working to unblock access to acute services by improving the flow of patients through the system and by streamlining waiting lists, including referrals from general practitioners, GPs. The SDU has also had significant success in reducing trolley waits in emergency departments.
I will address the Estimates for health in some detail. The Revised Estimate for 2012 for the health group of Votes provides for gross expenditure of €14.142 billion. Of this amount, some €13.748 billion is for current funding and €394 million is for capital funding.
The Minister is half way through his time.
We will need to leave much of this detail for the general discussion. When account is taken of additional private health insurance income of €79 million, this is equivalent to a net reduction of €183 million compared with the 2011 current allocation of €13.748 billion. However, additional funding is required to meet unavoidable cost increases in superannuation, demand-led schemes and the fair deal scheme and to implement priority programme for Government commitments in mental health and primary care. In addition, there are further underlying pressures on the health budget, making the total known and quantifiable cost reduction required in 2012 of the order of €750 million.
Comparisons with previous years' Estimates are complicated by the transfer of functions between the Departments of Health and Children and Youth Affairs and the former Department of Community, Equality and Gaeltacht Affairs. However, it is important to note that significant reductions were applied to the Estimates for 2012, with a reduction of some €20 million applied to the Department's Vote, and reductions of €750 million applied to the HSE.
Regarding the executive, the savings measures agreed by the Government include further reductions in the numbers employed and in the volume of overtime, premium payments and agency working, an increase of €12 in the drug payment scheme monthly threshold, various measures to reduce drug costs, including the negotiation of an agreement with the pharmaceutical manufacturing companies and the introduction of reference pricing and generic substitution, various initiatives in respect of income collection and generation in public hospitals, extra efficiency targets for disability, mental health and child care services and savings in my Department's budget.
Additional funding of €310 million is required to meet unavoidable cost increases in superannuation, demand-led schemes and the fair deal scheme. A further €50 million is required in 2012 to implement priority programme for Government commitments in mental health and primary care. Therefore, the total savings required in 2012 are significantly higher than the apparent reduction of €183 million in the HSE Vote. The above savings and additional allocations have been incorporated in the HSE service plan, which I approved on 13 January, and are recognised in these Revised Estimates.
How much time have I remaining?
Three and a half minutes.
The funding for Vote 38 provides for gross expenditure of €328 million. Taking account of the full year effect of the transfer of functions between Departments last year and the movement of €15 million from the budget of the National Treatment Purchase Fund, NTPF, to the HSE to fund intermediate care for frail elderly people, the Department's Vote was significantly reduced in 2012 compared with the 2011 Revised Estimates Vote, REV. All health agencies funded by my Department were required to achieve further efficiency savings this year, with the Department's administrative budget being reduced in line with the moratorium on recruitment. The provision for legal costs and statutory inquiries was also reduced.
In addition, my Department took over responsibility for the drugs initiative last year, with the full year allocation showing for the first time this year. A total of €31.5 million has been allocated for the initiative under subhead B3, of which more than €29 million supports the work of the local and regional drugs task forces. The Department's allocation is part of a wider investment programme by Departments and agencies under the national drugs strategy. It is estimated that total expenditure on drugs programmes will be in the region of €250 million this year. The Deputies may be aware that I have undertaken a review of the drug task forces and the national structures under which they operate to assess their overall impact. Work is ongoing in this regard.
The gross provision for the HSE is €13.714 billion, comprising an Exchequer contribution of €12.161 billion plus appropriations-in-aid of €1.553 billion. In setting the Estimate for the HSE, tough decisions were taken in the context of the need to take corrective action in respect of public spending. The health service must contribute to the expenditure reductions required in 2012, but the Government's objective has always been to ensure that these reductions are achieved in a way that secures the best possible outcomes for those in receipt of services, with a particular focus on protecting services for the most vulnerable. To protect services, we need to reduce costs and improve productivity.
One of the areas where costs were increasing exponentially was that of drugs and medicines. Public expenditure on drugs provided to patients under the General Medical Services, GMS, scheme and other community drugs schemes has increased significantly in the past decade. The year-on-year increase in spending on medicines is among the highest in Europe. A number of factors drive this increase. For example, the number of items prescribed has increased in the past decade from 32 million to 68 million, doctors are prescribing newer, more expensive products and a greater number of people are eligible for medical cards.
At the end of January 2012, there were more than 1.7 million medical cards and more than 125,000 GP visit cards. These figures reflect an increase of approximately 102,000 medical cards and 8,000 GP visit cards in the preceding 12 months. Under the GMS scheme, 40.5% of the national population has free access to GP care. This compares with just over 35% of the population at the end of 2009.
The rest of my presentation contains a great deal of information on GMS and the fair deal scheme. I will happily take members' questions. The Government and I, as the Minister for Health, are committed to health care reform. Even if the country was not in these financial difficulties, we would still need to undertake these reforms. Despite greatly increased spending on health care in the past decade, we have not achieved the necessary improvements that our citizens deserve.
Would it be possible to get a copy of the Minister's speech so that members can read it? It was not circulated beforehand.
Yes.
As a matter of interest, are we that stuck for time that the Minister cannot make his contribution? Why could we not give him an extra few minutes?
I would have no problem if members wanted to do that.
I would appreciate it.
The Minister can continue.
We can supply copies of my speech to members. I apologise.
The Chair is happy to oblige.
Regarding pharmaceuticals, my Department and the HSE have taken a number of actions to control expenditure on drugs. Savings are being achieved through ongoing off-patent price cuts agreed with pharmaceutical manufacturers, the pricing mechanism for new products has been changed and we now have a review mechanism that takes account of price reductions in other countries. Furthermore, in 2009 and 2011 regulations were made under the Financial Emergency Measures in the Public Interest Act 2009 to address margins and mark-ups in the pharmaceutical supply chain. The combined full-year savings from these measures are €154 million. However, further efforts are required to control drug expenditure. As I stated in the Dáil yesterday, we must reduce the cost of old drugs to make room for new drugs.
The Department of Health and the HSE are in contact with the Irish Pharmaceutical Healthcare Association, IPHA, with the intent of securing a new pricing and supply agreement to replace the existing agreement, which expired on 1 March. The Department is committed to securing additional savings in the price of medicines in any new agreement. The Department is finalising the drafting of the health (pricing and supply of medical goods) Bill to provide for the introduction of a system of reference pricing and generic substitution. The Bill is listed to be published in this session of the Dáil.
The fair deal scheme is a system of financial support for individuals who require long-term nursing home care and applies to people entering public and private nursing home care. The budget for long-term residential care in 2012 is €994.7 million. Funding is allocated to individuals who qualify under the care needs and financial assessments on a first come, first served basis. This ensures equity of access to the scheme nationally.
Subhead B12 was reduced by €42 million during the Revised Estimates process. This adjustment was necessary to transfer funding for ancillary services, those being, drugs and therapies, that were not appropriate to that subhead.
I stress that this adjustment did not, in any way, affect the funding available for the nursing homes support scheme.
Additional funding of €55 million was originally allocated to the nursing homes support scheme for 2012. However, a decision was subsequently taken to transfer €13 million of the €55 million into subhead B13 for an innovative pilot scheme of increased and targeted interventions for the frail elderly in 2012. The special delivery unit is working with the HSE to develop and implement this pilot scheme with clinical care programmes. A further €5 million was transferred to primary care services to underpin overall government policy of shifting focus to primary and community services.
My key focus is to ensure that those who require nursing home care will be able to access it. At the end of March, 21,429 people were in receipt of financial support from the State towards the cost of long-term residential care. This figure includes people in receipt of support for transitional arrangements. The pilot scheme of increased and targeted interventions for the frail elderly being developed by the special delivery unit should reduce the number of people applying for the nursing homes support scheme by ensuring that as many people as possible are empowered to remain in their homes for as long as possible in line with their wishes and Government policy.
There is a clear need to ensure that in delivering services to a higher quality, they are also delivered in the most cost-effective and efficient manner. Given that approximately 70% of costs in the health system relate to the employment of staff, this will continue to be a focus in 2012. The HSE must achieve the employment reduction targets set by Government and this is part of the Government's overall strategy to achieve efficiencies in the cost of the public service. The HSE national service plan includes these number reductions targets while recognising that certain critical positions may need to be filled. The departure of about 2,500 individuals from the health service during the final two months of the "grace period" in January and February this year will contribute, in a significant way, to the reduction of health sector employment numbers this year.
The HSE, in its plan, seeks to mitigate the impact of these retirements through targeted investment and recruitment in a number of areas such as primary care, mental health and the national clinical programmes. The filling of the posts is subject to the overall HSE budgetary and employment targets for 2012 being met. The challenge to management and staff alike will be to make maximum use of the Croke Park agreement to ensure services can continue to be provided with fewer staff and lower payroll costs.
As I mentioned earlier, I am committed to major reform of the health system. My objective is to deliver a single tier health service, supported by universal health insurance, where access to health care is based on need and not ability to pay. In working towards this objective, we must aim to achieve more efficient and effective delivery of services. Fundamental to this is ensuring that appropriate care is provided in the most appropriate setting. Patients should be treated at the lowest level of complexity that is safe, timely, efficient and as near to home as possible.
There are a number of important stepping stones along the way and each of these will play a critical role in improving our health service in advance of the introduction of universal health insurance. I am pleased to say that significant work is already under way on these initiatives, which include the strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients; the work of the special delivery unit in tackling waiting times and establishing hospital groups; and the introduction of a more transparent and efficient "money follows the patient" funding mechanism for hospitals. Once these key building blocks have been put in place, the health sector will be ready for the introduction of universal health insurance. This system will give patients a choice of insurer and will guarantee that every citizen has equal access to a comprehensive range of curative services.
The scope of reform envisaged is such that careful planning and sequencing are vital. In February, I established the implementation group on universal health insurance, which is charged with helping in delivering detailed implementation plans for universal health insurance and in actively driving implementation of various elements of the reform programme. In conjunction with the implementation group, the Government has established a universal primary care project team to oversee the introduction of universal primary care. Capital investment in the health sector has brought about a significant improvement in the standard of facilities across all care programmes but very significantly in facilities which support services for older people. Government policy aims to maximise the health and social well-being of the population, with the primary focus being the promotion and protection of the health of the whole population, with particular emphasis in reducing health inequalities.
The Department of Public Expenditure and Reform published the findings of its review of infrastructure and capital investment on 10 November 2011. The review maintains existing planned levels of health capital investment at €374 million per year or €1.87 billion for the period 2012-2016. This figure includes €40 million per year or €200 million over the period in respect of ICT. In addition, the Minister for Public Expenditure and Reform, Deputy Howlin, has announced that the Government has decided to part-fund the construction of the new children's hospital with some of the proceeds from a new licensing arrangement for the national lottery. This arrangement would involve an up-front payment in exchange for a longer-term licence. The impact of the special lottery initiative funding will be dependent on the licence agreement and the specific arrangements for making the funding available to the HSE.
I will briefly introduce the annual output statement for the health group of Votes. This is the sixth statement of its kind attempting to match outputs and strategic impacts to financial and staffing resources for the financial year. The statement also reports on outputs achieved for 2011. The annual output statement also reflects the programme for Government commitment on health reform.
The health services had a lot of investment of taxpayer's money during the good years but there has not been the degree of improvement that the people have a right to expect. This Government fully intends to correct this, even in these difficult economic times. Our reform agenda, although ambitious, will be delivered. I thank the sub-committee for its attention and I commend the Estimates for the health group of Votes to it. I will be glad to answer any questions and thank the sub-committee for its courtesy in allowing me to finish a rather long text.
I thank the Minister for outlining the Estimates and the detail behind them. There are a few issues that come to mind when discussing the Estimates. I do not have them in front of me as the Internet link is not functioning on my computer, so I am working from memory and the Minister's speech. There were over-runs in the first quarter of 2012 which the Minister said were unsustainable, and it seems that has been a pattern for many years, going back to the old health boards and the establishment of the HSE. There are demand-led schemes and pressure on the HSE to deliver care when required. Nevertheless, the pattern has continued and there was a "fire brigade" action between October and December last year, when wards and theatres were closed and operations were wound down.
Has a profiling system been developed that could provide accountability on monthly basis? There could be a large over-run even in one quarter but if there is an over-run for a particular month, there may be more time to address issues. We can have a debate another day on the changes in governance structures in the HSE but in the mean time, budgets should be managed more efficiently. The Minister mentioned an over-run over €100 million already, which is a significant amount even relative to the health budget.
There is the broader issue of universal primary care, and a stated aim and policy of the Government is implementation of universal primary care and health insurance in subsequent years. Has any analysis been done on the costs? If we are talking about free GP care, somebody must be paying for it. There does not seem to be any detailed costing on the intended expenditure from the State on free GP care. The funding will have to come from somewhere else but budgets are shrinking. Will the measure be Exchequer or cost-neutral, and if there is a cost, what diminishing budgets will be affected?
I am not trying to raise an emotive issue. These are grand plans but we were counting incontinence pads in Kilkenny recently, so we should know how much the free GP system will cost. An initial 56,000 people who have long-term illness will receive medical cards and free GP care but the sting in the tail is that it will only apply to the long-term illness. If any other drugs are to be prescribed, they may not come under the medical card scheme. It is a key issue of concern.
We talk about providing care, and I acknowledge the need to retain people at home for as long as possible in the least complex and least expensive manner, but the strategy outlined in statements does not seem to be followed through. There has been a reduction of home help hours, home care packages have been capped and more cutbacks flow from such measures. If community beds are closed and the number of long-term beds are reduced in the system then the quid pro quo should be an increased number of home care packages, home help is beefed up and an increased allocation of public health nurses. All of that is required to monitor and keep people at home.
The Minister has spoken about technology and I complimented him on embracing technology that monitors people in their home. However, there does not seem to be much funding available in the Estimates for research and analysing whether technologies, software packages and diagnostics could be used in the home. It is one area where cost savings could be made in the years ahead and I have not seen a clear focus and funding of a strategy to promote that type of development. There are many excellent software and technology companies here who travel around the world promoting their products. We should embrace the sector and not only promote the companies. The technology would have a defined benefit and keep people in their homes for longer.
I am very concerned about the drugs task force and the drugs debate. I know that the Minister has a lot on his plate but combatting drugs has fallen off the agenda. I am concerned that the review of the drugs task force, their outcomes and outputs, indicates that the scheme will be downgraded. The issue has fallen off the political agenda. It is no longer part of the social discourse or considered a live issue. There is not even a designated Minister of State that has the responsibility to implement the scheme.
There is a Minister of State at the Department of Health, Deputy Shortall.
Let us be honest, there are a lot of issues on her agenda as well. I am specifically talking about drugs. It has fallen off the political agenda and I am concerned that it will fall of the funding agenda as well.
The roll out of the primary care strategy is a big undertaking but it has been so slow that it might seize. The Minister is committed to it and it is priority for him and his Department. Is the Department open to public private partnership and other forms of funding, for example, from investment houses, hedge funds and private investors? Is that view shared by the Minister, other Ministers and the Department when it comes to the funding of primary care? We all know that primary care is where health should be delivered. Primary care is the least complex, least expensive and most immediate setting and should be funded. Our resources will limit its roll out unless we get more funding. Is the Minister actively seeking funding for the primary care strategy, the development of centres and the establishment of primary care teams?
The fair deal scheme is being reviewed and I raised the issue on Question Time in the Dáil. Where does the Minister believe we can make savings? Do we use more private beds? He has stated previously that public beds are quite expensive when compared to private ones. Does he think we should shift our focus to private beds? Is that one of the reasons the HSE has taken up to 800 beds out of circulation in the community setting? I ask the Minister to examine those two issues.
Universal health insurance is down the road and we have difficulties at present in terms of the pressure that is being placed on the public health system due to the number of people availing of it. The headline figure of 76,000 leaving private health insurance is not the only story because a number of health cover packages have also been downgraded. Insurance companies are making it less attractive and more expensive for older people to join. We talk about a grand plan to provide universal health insurance but we have a struggling health insurance system. Another player has joined the market but many health cover packages have been greatly downgraded. People are no longer capable of paying the rates and equally health insurers are wiggling out of offering cover in traditional areas that older people might need such as orthopaedic cover. That is also an area of concern.
I welcome the Minister and his colleagues from his Department.
Once again we have what I can only describe as an unreal situation. It is six months since budget 2012 and we are only now discussing the Estimates for health here at committee. When the Minister was an Opposition member of this committee he repeatedly criticised this very flawed process. I raise this issue again, and recommend again that we try to ensure a better practise approach. It is a long time since 5 December 2011.
My sole concern, as Sinn Féin health spokesperson and as a Dáil Deputy, is to seek the best possible healthcare be provided for all of our people. I say that in case the Minister again accuses me, as he has done in the past, of scare-mongering and frightening sick people. Yesterday, the Minister of State made the same accusation in the Dáil chamber. I strongly refute, in advance, the accusation that has been employed and trundled out on a number of occasions.
Can the Deputy deal with the Estimates, please?
I have an opening statement
I know.
That is what I will read and my comments are in that context.
We are dealing with the health Estimates and not yesterday's Question Time.
I know and I am dealing with the Estimates. The accusation is a smokescreen to hide the real damage being done to our public health services by the austerity policies pursued by the Government, and the previous one, and are reflected in all that the Minister has presented to us this morning. Frontline services are being seriously affected by the cuts and will increasingly be so affected. That is not scare mongering by me. As the Minister well knows, the HSE National Service Plan 2012 states, "The bulk of the reductions that the HSE is required to deliver in 2012 will impact increasingly directly on frontline services". The Minister has made much of the savings and efficiencies being made and can be made. I am in favour of savings and efficiencies, particularly with regard to the excessive salaries paid to top executives in his Department, the HSE and among certain hospital consultants. The reality is that such efficiencies only go so far.
I shall again quote the HSE 2012 service plan on staff reductions when it state, "Efficiencies will not compensate for the loss of frontline healthcare delivery staff in such large numbers". We have to realise and recognise that is the reality. At present, we have over 2,400 public hospital beds closed and over 4,500 staff have departed from the public health services under the earlier retirement scheme, up to 29 February. Last week, the Minister told the INMO conference that none of the closed beds would be re-opening, a point that I made to him on the floor of the Dáil Chamber yesterday.
Yesterday, the Minister again quoted the INMO in acknowledging improvements in the trolley situation. I also welcome that, where it applies. However, the Minister did not cite the point made by the INMO president, Sheila Dixon, that there is overcrowding of wards with additional beds and trolleys while other wards and units in the same hospital are closed. That is a fact. There is also the increasing use of what the INMO president called the flawed and failed tool of the full capacity protocol by a number of hospitals throughout the country, effectively to hide the number of patients who are on trolleys due to excessive demand on most emergency departments.
As a Deputy who highlights this reality, I have had patients call to me to recount their personal experiences while in hospital for short-term periods at different locations, both in my HSE area and that of the Minister in Dublin North-East. I would be happy for the Minister to have the opportunity to meet one man and hear his account of how he, over a short time, was moved hither and thither and hidden away in the course of a visit by HSE forum members to a hospital site in our HSE area in order to give a false impression of the reality of the numbers there at that time. If the Minister wishes to hear it first hand, I will arrange it for him, lest he has any doubt that this is the case. It is not an exception, but an ongoing practice. We must confront it. It is absolutely wrong and the public is becoming more aware of it from the direct experiences of people such as the man I mentioned. If the Minister wishes to hear about it, as I have done, I will willingly arrange for it at a time of his convenience.
The Minister recently replied to a parliamentary question from me about delayed discharges. I received the HSE report on delayed discharges, dated 29 March. It showed 666 delayed discharges, that is, patients who have completed the acute phase of their care and are medically fit for discharge. They were delayed in hospital for periods ranging from one week to over 26 weeks. Incredibly, that is half a year. When there are over 2,400 hospital beds closed, and set to remain closed, and over 600 people awaiting discharge in a situation where public long-term care beds for older people are under threat and closing, it is a serious situation. I addressed that in the Dáil yesterday. I was criticised by the Minister of State for saying it but I will repeat it in the committee today. Despite what the Minister said yesterday in reply to questions on health, he has put public nursing homes of 50 beds and less under notice. They are told they are uneconomical and face closure. At a meeting of the Oireachtas Committee on Health and Children earlier this year HIQA representatives confirmed, when questioned by my colleague, Deputy Michael Colreavy, that there are no inherent safety or quality issues with homes with less than 50 beds. This is purely a budgetary measure.
From 2001 to 2010, the number of long-stay public nursing home beds for the elderly dropped from 10,000 to just over 6,000. Over the same period, the private nursing home capacity rose from well below 10,000 to over 20,000, supported by tax incentives. The downgrading of public care continues under this Government and it will be accelerated by the measures in budget 2012, as reflected in these Estimates. There is a better way. I have made that point to the Minister and yesterday I outlined a number of the measures that I strongly recommend and on which I believe he is of one mind on pursuing. I put them forward in our succession of pre-budget submissions.
The implementation of the full generic substitution of medicines under the GMS scheme and the clamping down on over-prescribing would yield an estimated saving of €200 million. Applying charges for the full economic cost of the use of beds in public and voluntary hospitals for the provision of private medical practice would realise or save €373 million. These are just two alternative budgetary measures I strongly urge the Minister to consider. Contrary to the characterisation that we only take a negative focus, I am taking a positive focus and running my flag firmly up the pole. These are measures I would support the Minister taking to realise the best possible front line service care for all who depend on our health services. I appeal to the Minister to listen and act accordingly.
I thank the Minister for his opening comments. I will refer to his outline of the health reform programme. All Members of the House are anxious to see this health reform programme being delivered. It is important that the Minister elaborate on what he considers to be the stepping stones to achieving it. I do not expect him to put specific time lines on it because that is difficult, but it is important that we see a clear path to reaching those targets in the future. The Minister has begun to do that in the presentation he gave today, but it needs to be elaborated further, first with regard to universal health insurance but also with regard to universal access to primary care. There is much concern about the transition process involved in this. If people see the timetable or steps involved, it will be easier for them to understand where we are trying to go and what we are trying to achieve.
The Minister mentioned the employment control framework. It is hugely frustrating for members of the public to see people being reappointed within the health service. At consultant level, in particular, there have been a number of appointments. In the case of some specialties, it will not be possible to fill a position immediately and it will be necessary to re-appoint an individual on a locum basis until the post is filled. In other cases, however, according to reports I have heard some people have been re-appointed to positions when there are capable people available to fill those posts. Will the Minister elaborate on that? Can he ensure that when such appointments are made, they are made on a temporary and short-term basis? It is hugely frustrating in the current economic climate to see people with substantial pensions being re-appointed on a locum basis to fill these posts.
The Minister spoke about the review of the fair deal scheme. However, a funding crisis has arisen and the last two speakers highlighted it with regard to long-stay public nursing homes. It is not just the funding structure under the fair deal scheme for long-stay beds, but little or no funding is being provided for respite or rehabilitative beds. It is the Government's stated objective, indeed everybody's objective, that people should remain in their own homes for as long as possible. It is not feasible to do that if respite beds are being closed and rehabilitation beds are under threat. Those beds give people the opportunity to stay in their own homes in the long term. Those community supports are being further restricted this year, above what happened in previous years.
Not only are there reductions in the supports in hospitals but also in home help. I have mentioned the reduction in home help hours to the Minister previously.
I will give a practical example. In one catchment area in May, one hour of home help was allocated for every 27,000 of the population. That does not include those who might have died or who no longer require home help supports so there is probably a new saving in the area. Hours are being taken back when they are no longer required but it is now almost impossible to get additional hours for a client if he or she needs them. This forces people to apply for the fair deal system again when the family and the person wants to stay at home. We are saying on the one hand that we need to keep people at home while the whole funding structure is forcing people into private nursing homes on a long-term basis.
What is happening with school leavers with an intellectual disability? The Minister of State has spoken about this issue but it will come to a head in the next couple of weeks and it is vital this is to the fore and is addressed. The Minister stated the objective is to ensure front-line services, as far as possible, are not impacted. The major difficulty, particularly in the primary care area, is that non-headline areas are getting cut back. In my own county, there are 783 children waiting for an eye test appointment, a total of one in every 18 children in County Roscommon. Health checks are taking place in schools but some of the developmental checks are being delayed because of backlogs and reductions in staff numbers. Where they are taking place and problems are identified, there are massive backlogs for follow up appointments. That has a long-term impact on the economy. For a child in that situation, where he has been identified as having eyesight problems, he or she will be lucky to have been allocated glasses by the time he or she sits the junior certificate. That is unacceptable in this day and age. It leads to further problems in education for those children. More significantly a more serious eyesight problem might be being overlooked and it will require expensive surgery further down the road.
Subhead F2 has been an ongoing saga for ten years. Ten years ago last April, the Department agreed to look at the feasibility of introducing a no fault compensation scheme for children who were damaged by publicly-funded vaccination programmes. We are ten years down the road, and have had a number of studies and analyses. Again in this year's Estimate, no money has been allocated. We are talking about people who are now in their 40s who were damaged by State-run vaccination programmes. They are still waiting for adequate compensation from the Department. We are now the only country in Europe that does not have a no fault compensation scheme in place for State-supported vaccination programmes and that is unacceptable. The State itself has acknowledged in at least 16 cases back in 1982 that children in all probability were damaged by the State-run vaccination programme. They were offered £10,000 at that point and for many of them such funding was grossly inadequate to meet their needs. Many of those children were profoundly disabled. Their parents are now becoming extremely elderly and are extremely concerned about what is happening to their son or daughter. It is unacceptable that this issue is put on the long finger for another year.
I ask the Minister to ask the Laffoy commission if it is possible for the documentation it collected on those vaccine trials that took place that could not be inquired into could be held by the commission and not returned to the original sources. For many involved in the vaccine trials, it is the only medical information available to them regarding the trials they underwent without any consent. Surely we should ensure those records are kept safe with the possibility that some of the information could be made available.
We are dealing with the Estimates, not questions to the Minister. The issues addressed by members can be addressed as part of the subheads and the Minister in his closing statement may make remarks but there will not be questions and answers on the opening statements. We will now move ahead to the individual subheads on the two Votes before us. Vote 38, Office of the Minister for Health, administrative heads 1 to 8, subhead 1. Are there any comments or questions?
I am happy to answer the questions put to me and to address the issues raised.
We have agreed a timetable and a schedule in keeping with the other Estimates. The Minister can as part of his closing remarks make reference to the questions. This is the Estimates meeting, there will be a quarterly meeting with the Minister in a couple of weeks.
The Estimates are an integral part of the outworking of policy. The points made by Opposition voices here are valid.
We are on subhead 1.
On subhead A1, on salaries, wages, allowances, travel and subsistence, there are significant increases, despite the departure of so many within the health services. I am sure the Department is no less effective. There has been an 11% increase in salaries, wages and allowances and an incredible 109% increase in travel and subsistence.
That is subhead 2, we are dealing with subhead 1.
The two are probably linked. The key point is what additional staff gave rise to these significant increases. Is it to do with the special delivery unit and the recruitment of special advisors? We know the Minister has not adhered to the Government's own salary cap for advisors and there are at least two that we know in this area. Will the Minister give an explanation for the increase and, particularly, for the travel and subsistence? Is this attributable in any way to the fact we are flying people in on a monthly basis to perform the role of special advisors in the special delivery unit?
Deputy Ó Caoláin is a little confused. The situation is clear. The outturn for the year-on-year expenditure is slightly up but we are well within budget and the budget has decreased because so many savings were made last year. People have been employed for the SDU and I would further advise the Deputy that neither Liz Nixon, who is a consultant to the special delivery unit, or Dr. Martin Connor, who is also employed by the special delivery unit as a consultant, are advisors. They are not advisors and to try to paint them as political advisors to me or to people in my Department is wrong. They are people who have been brought over here on contract to address a very serious situation in our health services. Since their arrival and the establishment of the SDU, they have achieved remarkable results and progress on this issue because of the cooperation of the clinical programmes and hard working staff at the front line. They bring analysis and fresh eyes to a situation that has bedevilled the State, with money thrown at it year on year but no improvement occurring until their recent arrival. Liz Nixon was responsible for achieving the four hour target from registration to either discharge or admissions in a hospital in 98% of emergency departments in Britain.
I have set out the facts. We have the good fortune to have such high calibre people, individuals with a track record of achievements to help us address the terrible situation that has existed for the past decade.
I call Deputy Ó Caoláin. Will he be brief?
I can assure the Minister that I am not in the least bit confused. I am well able to read the figures before us and the percentage increase in 2012 on the outgoing in 2011. We are looking at an 109% increase in travel and subsistence expenses and an 11% increase in salaries, wages and allowances. The Minister has not given an explanation, but has put up a serious defence.
I thought we were dealing with subhead A2.
One individual was described previously by the Minister as a policy adviser on the role of the special delivery unit. I think it is just semantics.
May I remind members that we agreed, before the meeting started, to conclude at 11.30 a.m. We have a great many items to deal with and I must be fair to all members.
I have answered questions on subhead A1. Are we now dealing with the next subhead as I have no problem dealing with subhead A2?
Are we finished with subhead A1?
In view of the depleted numbers, this is a very significant increase on the 2011 outturn.
I have explained very clearly the reason for the figures in subhead A1. If we are discussing subhead A2, there has been a significant increase in travel and subsistence. The insinuation that Deputy Ó Caoláin makes about the travel arrangements of one of the consultants concerned, Dr. Martin Connor, is for travel that he undertakes at his own expense because he gets no expenses from the State for it. These increases in expenses relate to the EU Presidency, which Ireland will host in 2013, and which we must prepare for. Officials must travel to Europe, and this will apply to all Departments, to get a handle on what is happening so that we can prepare and make our Presidency a success, as did previous Governments who hosted the Presidency in the past. The EU is depending on us to make progress in a number of areas such as on medical devises and other legislative areas, which will impact seriously on this country. We must ensure that we get the Bills through during the course of our period of the Presidency.
Any inference that these expenses are due to the special delivery unit is untrue and unfounded.
That was the question I posed. The Minister has given the answer that Dr. Connor funds his own travel back and forth for his fortnightly appearances, that is well and good, but we are now being told that in preparation for the EU Presidency, which we are hosting in January next year, we will increase spending on travel and subsistence by more than 100% in the current year. These moneys could be employed in front line service provision. Is it possible to recoup from the European Union the expenditure required for preparations to host the Presidency of the European Union? Is this money refundable? Can we get it back? Will this money be taken from the health budget?
Last year the budget for travel was €654,000 but we spent only €313,000. This year's budget is €654,000, the same as last year, but we will spend it because we must.
Do members have questions or comments on subhead 3?
I do not know if the Minister is accurate in the claim that he is making. Certainly from the documents provided to us, I wonder if that is indeed a valid claim on €654,000
I ask the Deputy to look at the same item in the 2011 figures, the expenditure was €313,000 from the allocation. As the Minister just said, the total allocation of €654,000 will be spent.
That is plainly obvious but I do not know that his claim that €654,000 was actually the Estimate for 2011. It does not show that here.
I ask Mr. Liam Woods from the HSE to make it clear for the Deputy.
Mr. Liam Woods
In the documentation we have before us, which is the current Vote, it does not show the budget for 2011, but in the annual Estimates volume, the figure for 2011 was €655,000 in budget terms. It is not visible in this document. The point is that the budget last year and the expected expenditure in 2012 are very close to each other, the outturn last year, to which the Deputy referred, the €313,000 figure is what was actually spent last year but the budget was higher.
The allocation will be used this year. It should be appreciated that members have a limited time to prepare, and if the information provided does not give the full picture, it is not likely that we will be able to refer to it with the same exactitude as the officials, who have a wealth of information before them.
I accept the difficulty the Deputy is having. These figures are set out in our Department as per the Department of Public Expenditure and Review. The figures are the same for all Departments. I am inclined to agree with Deputy Ó Caoláin, and I would prefer if the Estimates were done in a different way that showed much greater clarity about why things are the way they are. The budget is one thing, the spend is another. The budget has not changed but the spend may change, but one is still within budget. I think this is what is causing the confusion. I was not trying to barrack the Deputy when I said I thought the Deputy was a bit confused because I found it confusing at the beginning.
The other point I would make in relation to some of the increased expenditures - - - - -
Will we get the money back from the European Union?
No, we will not get the money from the European Union.
The reason for the increase in salaries and so on is that staff have moved from the Department of Community, Equality and Gaeltacht Affairs to work on the drugs initiative. We have had the full year introduction of civilian drivers for Ministers in the latter part of 2011. That comes out of our budget as opposed to coming from the central budget as it did before. We have made provision for additional funding for the EU Presidency and we also have extra staff employed in the special delivery unit. There is a rationale.
Have members any comments or questions on subhead 5?
Over the years IT and health services have not been crowning themselves in glory. Is this just a provision for office equipment and training programmes for internal staff in the Department of Health?
Yes.
Have members any comments or questions on subheads 6 and 7?
It is clear there is a significant increase from the provision in 2011 outturn of €832,000 for consultancy services and value for money reviews up to almost €1.6 million for 2012. How is that accounted for? An increase of 92% across the board requires an explanation.
Most of that expenditure is due to the Milliman report that we commissioned to look at the VHI, the structure, the best way to move forward and to prepare it for sale. It is Government policy to retain VHI as a public option. We did not have to spend the quantum of money that had been anticipated because the work on the sale and so on, never went ahead. Milliman was merely asked to examine the VHI, its current structure and how its efficiency might be improved. The money for this work was in the budget but it was not spent.
That is in the context of last year, but we are looking at a 92% increase for consultancy services and value for money and policy reviews. It is an almost a 100% increase from just over €800,000 to just short of €1.6 million. I do not think the non-utilisation of the provision for VHI explains the projected significant increase in the current year, for which I am seeking an explanation.
I have great sympathy with the Deputy on this matter because we are hamstrung by the presentation of this issue which is difficult to interpret. I assure him, however, that the budget for 2011 was €2.194 million, while the budget for this year is €1.194 million, a reduction of 45%.
Okay.
It is not okay, Chairman, with respect. Deputies have come to the sub-committee to participate in this discussion. We have taken time to prepare for the meeting and studied in detail the information provided. The figures the Minister cited do not have any relationship with those I have before me for subhead A7 - administration. For the life of me, I cannot make sense of this. It is beyond me that anybody could expect us to play our part in holding to account the Minister, the Department and the Health Service Executive on Vote 39.
The Deputy does a good job.
The task is made impossible by the most confusing release of information.
With all due respect to the Deputy, the Department of Public Expenditure and Reform produces a document containing all the relevant tables and figures. The officials present have the document, a copy of which is circulated annually to each member in advance of the Estimates debate. It was circulated approximately two months ago.
We will raise the points Deputies have made with the Department after the meeting.
Again, we can only work on what is provided in respect of Votes 38 and 39. Bully for Deputy Denis Naughten if he has other information to hand because I have not seen it.
Subhead 8 was discussed with subhead 1. Are there questions or comments on subhead B1?
What was the budget for this subhead in 2011? I would like to have a basis for deciding whether there has been a real increase. The outturn was €34.430 million.
Ms Bairbre Nic Aongusa
The Revised Estimate for 2011 for subhead B1 was €36.797 million.
There has not been a real increase in the budget year on year.
Ms Bairbre Nic Aongusa
No, there has been a decrease of 1.12%
To which bodies are research grants allocated? I am speaking in general terms.
Ms Bairbre Nic Aongusa
The Health Research Board is the main recipient of research grants.
Does Science Foundation Ireland receive funding from the Department of Health?
Ms Bairbre Nic Aongusa
No, it is not funded by the Department.
Are there questions or comments on subhead B2?
There is a straight line projection. This is part-funded by national lottery grants to health agencies and other similar organisations. Will the elongated setting into private hands of the national lottery announced recently provide for additionality in the funding stream to the Department of Health budget to increase the funding flow to those agencies being supported currently?
The fund available from the national lottery amounts to a few million euro, over which we have discretion for small capital, one-off spending projects. We do not provide revenue from national lottery funding. We only provide small capital grants, for example, to purchase a bus for a voluntary agency to transport people with a disability to and from their place of work, for outings and such like. That is the purpose of the fund. I am informed that revenue from the national lottery has declined overall from the Government's point of view. Under the licensing arrangement the Government has in mind, a large portion of the revenue will be allocated towards the national paediatric hospital. The money involved is considerable and will be welcomed, as it will allow us to proceed, even in a time of serious financial difficulty, with capital investments. While still recognising the price of everything, the Government has not become consumed by it and understands the value of things. Leaving a new paediatric hospital for future generations is something on which we place a very high value.
While our investment in a new central mental hospital may not excite a large proportion of the population, the areas of psychiatry and intellectual disability have been neglected for decades and are the Cinderella of the health service. It is time this was rectified. We are doing so through capital investment and by insisting on all primary health care centres having a mental health facility associated with them.
Are there questions or comments on subhead B3?
I seek an explanation for the significant increase in the allocation in 2012.
Ms Bairbre Nic Aongusa
There has been an increase in funding for drugs initiatives. More than €25 million of the allocation supports the work of the local and regional drugs task forces. The Department's allocation is part of a wider investment programme by Departments and agencies under the national drugs strategy. It is estimated the total expenditure on drug programmes will be in the region of €250 million this year. The work of the drugs task forces transferred to the Department from the then Department of Community, Equality and Gaeltacht Affairs about one year ago. The increase in the allocation is line with the national drugs strategy.
There are no questions or comments on subhead C. Are there questions or comments on subhead D?
The allocation for inquiries and legal fees has jumped from €15.6 million to €19.5 million. A 27% increase in one year is significant. I noted in an article in one of the national newspapers yesterday on moneys paid out in legal cases taken against the health service that in one case the applicant, the person bringing the case, was the recipient of a small percentage of the overall pay-out, the vast majority of which went towards the cost of legal representation. There is a serious problem that needs to be addressed. Will the Minister explain the projected significant increase in legal fee payments in the current year?
Rather than an increase on last year's allocation, there has been a decrease of 13% in the budget. As we cannot accurately forecast legal costs in a given year, a significant provision was made for last year. Thankfully, the funding was not used. Nevertheless, I concur with the core point made by the Deputy. The cost of legal representation is a matter of great concern to me and an issue I had intended to address in response to the concern expressed by Deputy Denis Naughten about what is known as "no fault" compensation for those who suffer consequences as a result of vaccination. Vaccines are produced, given and taken in good faith and it is not right that people should be required to mortgage their homes to seek justice for their children. The State Claims Agency is assuming responsibility for more and more of these areas of concern. While this keeps the cost down, legislation is required each time responsibility is transferred to the agency. The patient safety authority will be a major advance in this regard.
From anecdotal experience as a doctor, people want a number of steps to be taken when something goes wrong. They want an acknowledgement that they have suffered as a consequence of something going wrong. They also want an apology and a guarantee that it will not happen again, in other words, that things will change. In the 95% of cases in which no serious harm is done, this resolves the issue for those affected.
When they are met with a stone wall, secrecy and silence they become frustrated and resort to law and then matters take off on a different course. The figures from the time I was in opposition and recent figures show that one third of what we pay out goes into the pockets of lawyers. That is not right. If there is money to be made available for harm done it should go to those who have suffered the harm. This is an area we continue to examine at and the Minister for Justice and Equality, Deputy Shatter, is introducing a Bill which will address the issue. I heard this morning that the Taxing Master reduced by €200,000 the fee of a particular legal representative in a case involving RTE. We want people to have their rights vindicated in court but that right should not come at such a cost and one which is far too expensive.
On that issue and the 5% in regard to the settlements. In many cases people would settle much earlier if there was an annual payment rather than a lump sum payment. The difficulty, especially with a young person, is that one does not know how long he or she will live and their demands in the future. It is an issue the Minister has articulated in the past. It makes more sense to have an annual payment, especially for a young person, because if he or she passes away it is merely a windfall for the family. The compensation was paid to deal with the particular issues that individual would face throughout his or her life and if he or she lives beyond the projected lifespan the amount of moneys available are grossly inadequate. The checks and balances, if put in place, would deal with many issues including the level of settlements, settle cases quicker in the event of an annual payment rather than a large lump sum payment
I agree entirely with the Deputy. While we accept that families suffer through damage to one of their loved ones, a huge payment upfront is not the way we believe this should continue. A group is examining the issue, including the State claims agency, to address it in the manner in which the Deputy has outlined.
We come to subheads E1 to E4 Are there any questions or comments on subhead E1? Are there any questions or comments on subhead E2?
On subhead E2, safefood, the food safety promotion board, is one of six implementation bodies set up under the terms of the Good Friday Agreement. I understand there has been a delay in signing off on its work programme. I am sure the Minister is aware of some of those difficulties. Has the Minister had any direct engagement with his Northern ministerial counterpart, Edwin Poots, on the matter in an effort to resolve the difficulties in regard to the food safety promotion board?
Yes, I am happy to confirm I have had contact with Mr. Poots's earlier this week on the matter. We have talked about the issue several times. There is a concern that the body was duplicating work that was being done by other agencies on both sides of the Border. We are trying to find a way to refocus its energies into areas where we are not active in other agencies. Mr. Poots agrees that this is a very important North-South body and there is absolutely no intention of undermining it or removing it but we want to see it used in a more productive fashion. On both sides of the Border there are serious fiscal difficulties and we want to ensure the money is spent in a way that yields the greatest dividend and does not duplicate work being done by other agencies on either side of the Border. I believe we will resolve the issue. It is a bright and strong future.
Does the Minister have a projected timeframe for a resolution of the issues outstanding?
I cannot give the Deputy an exact timeframe but we are examining the issue because it is an important body and we want it to get on with a body of work on behalf of both communities.
safefood is an important vehicle that can drive food safety and the whole issue of a healthy lifestyle and alternatives. I welcome his comments. Are there comments on subhead E3?
The figures for the National Treatment Purchase Fund and the special delivery unit show a decrease of 18% over the outturn for last year. What was the projection last year for the National Treatment Purchase Fund? I appreciate the special delivery unit was not established until June or July 2011. What was the overall projection?
The outturn last year was €85 million and this year's budget was €85 million. The reason for the apparent reduction is that €15 million was put into the special fund of €28 million - €13 million comes from the fair deal fund - to address the issue of the frail elderly. This is a really important initiative - it is one of the clinical programmes - which will create a scenario where we will be able to address a number of problems. The Deputy and others and pointed out that when there is only one source of money or a large pot of money and less money is visible elsewhere, people tend to head in that direction. I believe that has been the case because a recent review of 1,200 patients by the HSE showed that 40% had never been assessed for a home care package, and it was not clear whether another 40% had been so assessed. Therefore, 80% of those patients did not have the option or an assessment for a homecare package rather than long-term care. That study also revealed that 25% of the patients were low dependency and 16% were medium dependency. That is 45% of people who probably should not be in long-term care yet. Perhaps I can be allowed a few minutes to explain it as it is an important initiative which will be announced shortly in greater detail. Its purpose is to allow the frail elderly, once admitted to a hospital, to go to a special ward where their acute medical care can be sorted out. Once that is done they will start immediately on a rehabilitation programme in terms of physiotherapy, occupational therapy and speech and language therapy, if that is necessary. If this requires a number of weeks of treatment, they will move to an intermediate care facility where they will remain for six to ten weeks. If, during the course of that time, it becomes obvious they will have to go to long-term care there will be a transitional facility until their place of choice becomes available for their long-term care.
The thesis behind the initiative is two-fold. First, it purpose is to give people the best chance of staying at home. In the past many people were assessed in hospital when they were still unwell and confused and that was not a fair assessment. Second, given that there was much variation around the assessment there is a need for greater consistency. Third, there are savings to the taxpayer. Moving people from the hospital bed to an intermediate care bed where they get the treatment they need is much more cost effective. Therefore, there is a win win across the board. I believe this will reduce the number of people going into long-term care who do not need to be there and reduce the number of people who need re-admission following an initial admission. We will have put in place performance indicators that will help us measure whether this has been a success in terms of the outcomes.
In terms of the reduction in the budget for the National Treatment Purchase Fund which, by and large, was purchasing treatments, I note a reduction of approximately €15 million. Is the Minister satisfied that €15 million transferred to the special delivery unit will increase the capacity of the public health system to pick up the shortfall of the National Treatment Purchase Fund? In order words, is the Minister confident that €15 million will provide more treatments than the €15 million provided to the National Treatment Purchase Fund?
Absolutely. It has always been my case that the National Treatment Purchase Fund would be used in a very different way, not just purely to buy from private providers or public providers specific items of treatment rather to examine the whole system to see how it can be supported. The obvious one is the situation in Crumlin hospital in the case of spinal deformities such as scoliosis. We found out, following a long chat with the team, that 0.4 of a wholetime equivalent nurse on the ward could double the output of the theatre. Issues such as that are not always obvious. The reason the special delivery unit has been successful is that it is co-operating with the clinical programmes and listening to the front line, those who know how the system works and who can see how they can improve it to make themselves more productive.
This is another initiative and it is purely for the elderly and will help them have a better experience. Hospitals are very busy places but these elderly people will move to a setting more suitable to their needs where they will get the treatments they want. Often, many of our public hospitals do not have all the facilities. I know one - I will not mention its name - that has only one physiotherapist. How are older people supposed to get the care they need in that sort of scenario if their discharge is delayed?
The Minister is going down the right road and this initiative will release significant capacity within the acute hospital sector. This is something that should have been done years ago and I welcome it. Currently, these funds are only being used to fund private nursing homes, but there are many excellent public facilities that have -----
I think the Deputy means private hospitals rather than nursing homes.
Some patients are being transferred from acute hospitals into private nursing homes, pending acceptance on the fair deal programme. The problem is that the public nursing homes do not have access to that funding. There are public hospitals with rehab and intermediate care facilities that are up to spec, sometimes with higher specifications than many private nursing homes, but they have not had access to that funding. They have sought access from the SDU, but it has not been forthcoming to date. This funding could help address the issue I raised earlier, with regard to funding for rehab beds. This is not part of the general pool. Many of these patients come through this stream and that funding could help address the issue and help streamline the whole process - it is the taxpayer who pays for many of these facilities anyway - rather than leaving the beds empty and trying to provide similar beds in a private institution.
What will happen to patients who were on the NTPF list before that fund was reprioritised? Some of those patients have still not been called for treatment, almost 12 months later.
We may be slightly at cross purposes so I will clarify again. The NTPF does not place people in nursing homes, whether public or private. All it does is negotiate prices on behalf of the Fair Deal fund. Historically, the NTPF has looked at cases where people have been waiting longer than three months for treatment and sought to have their treatment provided elsewhere. Before we came into government, the policy was that only 10% of that care could be provided in the public hospital system and 90% had to go to private hospitals. That policy is no longer in place and we go for the best value for money, wherever we can get it. Equally, we do not want to continue that as the sole modus operandi of the NTPF with the SDU. We want to look at other ways of using the fund that will bring us much greater results, and I have already gone through that.
I will have to revert to the Deputy with regard to the question about people who are waiting on an NTPF list for longer than 12 months. When we brought in the initiative last year, only two hospitals in Galway failed to make the 12-month cut. In other words, all patients who were waiting 12 months or longer were treated. We experienced a rise in the numbers again in January, because the foot was off the pedal a bit, but we have caught up again. I will come back to the Deputy with further information.
I have to go to the House now.
Are there any questions on subheads F1, F2, F3 or F4 ? Are there any questions or comments on subheads G, H or I? Are there any questions on the annual output statement? No. Good.
We will now move on to Vote 39 - the Health Service Executive. We will begin with subheads A1 to A3. Are there any questions or comments? We will move on to HSE regions, subheads B1 to B4, mid-Leinster, north-east, south and west. Are there any questions or comments? Next is subhead B5, which deals with grants. We now move to subhead B6, medical card and community schemes. Are there any comments or questions?
With regard to medical card services and other community schemes, is long-term illness included in this Estimate for 2012, specifically the 56,000 people who will move into this area when the primary legislation is passed? In the same context, the long-term illness list has not been updated since the 1970s. Is there anything built into the Estimate to provide for the updating of that scheme? In view of the fact that the long-term illness scheme is being reviewed and brought into the GMS scheme, is that happening? There are many long-term illnesses and it bedevils us why they do not qualify. We know the reason for this is the cost implication. However, Crohn's disease, certain bipolar disorders, asthma and other illnesses should be considered. Is there to be any review of what qualifies and is there anything in the Estimate to allow that happen?
The response by the Minster of State, Deputy Shortall, in the Dáil yesterday addressed this. It is about whether there is a two-step, four-step or multi-step - we are not talking about dances - move towards a roll out of full GP and primary care access for all. As an interim measure, I strongly commend to the Minister the inclusion for qualification for a long-term illness card of those who are not currently on the long-term illness list, many of whom are in serious health circumstances. This should be done, whatever the timeframe - which is not clear - as a first measure towards the roll out of full GP free access. We should extend the list to include a number of areas, including those Deputy Kelleher mentioned and others both I and the Minister could cite.
The Chairman agrees with that.
I was smiling earlier but was in agreement with Deputy Kelleher. There are many illnesses that should have been included in the long-term illness list, but they were not. Given the list has been there for 30 years and this Government has only had responsibility for it for one year, perhaps -----
We had great expectations of the Minister.
Can we deal with the Estimates before us?
Seriously, it is part of Government policy to extend free GP care. We are doing it as per the programme for government and are covering those who are in receipt of medication under the long-term illness scheme. There is no intention to extend that list and there is no need to because within the legislation we are providing, we will empower the Department to extend the list of people covered by the GP care card by disease group. This will achieve the same goal.
Some people might argue that is not the fairest way to do things, that there are very wealthy people who suffer with long-term illnesses and they will get free GP care ahead of those who might have a much smaller income. Given that this process will end by 2015 or 2016, when we will have free GP care across the population, it is an approach that has found favour. As the Deputy said, there are many people with long-term illnesses, like MS, asthma, rheumatoid arthritis, ulcerative colitis, Crohn's disease and so on, and these are the illnesses we will seek to cover as quickly as we can through the extension of free GP care.
With regard to moneys, we have allocated an extra €15 million, and we believe we will be able to achieve our goals with that amount of money.
All right. On subheads B7 to B14-----
May I comment on subhead B8?
Yes.
I thank the Minister for his responses yesterday to my priority questions on the hepatitis C victims and particularly that small cohort of women who have not yet been included under the terms of the Health (Amendment) Act 1996, which introduced the HAA cards. Organisations representing hepatitis C victims - including those who have tested positive as well as the small group of women who have not tested positive but show all the symptoms - have been subjected to much media criticism about the utilisation of their funding streams. Nevertheless, any utilisation had been pre-approved by the Department. I did ask the Minister yesterday if he would acknowledge that. In the grouping of questions that may have passed him by, but I offer him again the opportunity to reply. It is important to recognise that such organisations play an important role in giving support and assistance to those victims of past State failures, whom we cannot now abandon. I encourage the Minister to reconsider the position with regard to Transfusion Positive and Positive Action. I welcome the fact that he has indicated that he will meet with the latter organisation, as he has done with the former.
The funding of the groups is carried out through the HSE, so I will let Mr. Woods say a couple of words on that. I am happy to reaffirm that I will meet with the group. We are always supportive of organisations that support people who suffer from conditions, particularly those that are due to a failure of the State.
Mr. Liam Woods
These groups are funded by the HSE under a service level arrangement provided for in section 39 of our legislation, and we have done that for some years. We are in discussions now about service level agreements. I have met the three or four main groups myself, as have others in the HSE, and we are particularly sensitive to the points raised by the Deputy in terms of how we will manage that. We also need transparency about the use of resources. We will continue that relationship and we will, as in previous years, have service level arrangements with those organisations.
Does anyone have comments on subheads B9 to B12?
I have marked subhead B11 for comment, but we addressed it with subhead B8.
Yes.
On subhead B12, the reduction in long-term residential care capacity is an indication that although we say we are trying to move people out of the acute hospital system into long-term residential care or other more appropriate settings, including with home care packages or home help services, the actual funding provided does not allow for implementation of that strategy. I know resources are scarce, but there is a 5% reduction under this subhead, home care packages are stagnant and home help services are being reduced dramatically across the country. This does not indicate that our strategy is being supported by the financial resources required to move people from the acute hospital setting to intermediate care and long-term care.
Mr. Woods may have something to say about this. The fact that we have maintained the home care package element is a strong indication that we are supporting that strategy. There is a world of difference between care in the form of a person who helps one get out of bed, get dressed, have a shower and carry out daily bodily functions and that in the form of a person who comes in to light the fire and do a bit of tidying around the house. When we find ourselves in the situation we are in - that is, financially strapped - we have to focus on the former more than the latter. It would be nice if we could afford more of the latter as well because, apart from anything else, it represents company for older people living on their own, which is often important, but in the current economic situation we are focused on home care packages, along with the initiatives I described earlier.
Mr. Liam Woods
The service plan for the HSE shows an additional €55 million resource for the placement of people in long-stay nursing home facilities, and that is included in the figure of €994 million. The main reason for the reduction is actually a technical one, which the Minister referred to earlier. From memory, about €48 million has come out of the subhead because it relates to the provision of services that are not long-stay services but are validly provided to people in long-stay nursing homes. There is a technical issue there.
In addition, as the Minister mentioned earlier, €13 million, which is focused particularly on rehabilitation and step-down care, has come out of the €994 million, but it is available in the subheads above, which are set out on an area basis. The actual resources for the fair deal scheme in 2012 have increased by €55 million when we include that €13 million. The reasons for the fall are technical, and the format does not help in this regard. I can give a note on that if it is helpful.
I knew there would be a reason.
Does anyone have comments on subheads B13 or B14?
On subhead B14, there is a €15 million increase in the expected outturn on payments to the State Claims Agency regarding medical negligence. Would the Minister like to clarify what that additional provision is expected to cater for?
Mr. Liam Woods
That relates to payments made by the State Claims Agency, which is funded through the HSE vote, for medical negligence, as the Deputy has suggested. The increase reflects the large book of liability that exists. These cases take up to five years to come to settlement either in court or outside court, and there is a large tail of cases. The HSE's annual accounts show that there is a book of liability of up to €800 million. What we are seeing is an increase in the number of settlements, which are funded through this Vote under payment through the State Claims Agency from the HSE. Most of those claims - 70% or so - are obstetric cases.
Does anyone have comments on subheads C1 and C2?
I had a comment, but we covered it previously when discussing the national lottery.
Does anyone have comments on subheads C3, C4 or D? No. Would the Minister like to make some closing remarks? We must be finished by 11.30 or thereabouts.
I thank all the Deputies present for their contributions. Deputy Kelleher mentioned the €144 million over-run and asked if we had developed a monthly profile budget. I agree with his comments 100%, and we are doing that. We have taken on additional help from an individual working in one of the hospitals in an effort to start the profiling across hospitals. The accurate figure is €107 million of an over-run for the first four months, but the principle of the Deputy's comments was absolutely correct. We need monthly profiling, and in fact I want fortnightly profiling where possible. Not all pay cheques are fortnightly, but we can tell a lot from that and get a more complete picture at the end of every month. That is being established. In addition, a new IT system is being established to join all that up so that we can have an early warning when a hospital is going off-budget.
The Deputy also mentioned an analysis of the cost of free GP care and asked where the money would come from. I think we have covered that. The full extension of free GP care must be done within the existing health budget, so it will be based on savings that will accrue from elsewhere in the health budgets.
The Deputy made specific mention of the counting of incontinence pads in Kilkenny. I remember being down in the Carlow-Kilkenny area and being told about a room full of incontinence pads that were purchased because the people concerned had been told they must spend their budget or it would be cut the following year.
There is a balance to be struck. That directive has been corrected, in any event. It is not happening, as we heard yesterday from the Minister of State concerned.
I spoke about the €15 million that has been put aside for the long-term illness scheme. I have covered the question on home care packages.
I agree about the use of IT packages to help maintain people at home. What is going to happen will be a challenge to everyone in the system. Bigger hospitals will have to cede work to smaller hospitals, which will have to cede work to primary care units, which will have to cede work to the patient in the home. When I was in Denmark a couple of weeks ago at an informal ministerial meeting, we were shown two IT initiatives in this area. In rheumatology, patients are given training in telemedicine. They assess their joints and then go online, see their consultant, go through their symptoms and change their medication accordingly. There are pilot programmes in Cavan and Monaghan, Deputy Ó Caoláin's area, that can monitor a patient's blood pressure, blood sugar level and body weight and allow a patient to manage diabetes and even heart failure. That is the way forward. We are looking at different systems.
With regard to the drugs task force review, we are interested in evidence based information and policy so we have to assess what these are achieving and how they are doing their work. There is considerable unhappiness about much of what is going on and we need consistency. There is not consistency there. This is not off the agenda. We have a Minister of State whose duties are primary care and drugs. It is not as if she has thousands of other things to do. They are two very big areas with considerable responsibility.
Public private partnership funding for primary care is well in hand. I have spoken to two different funds, one in America and one in the United Kingdom, that are both interested in investing in primary care in this country. I would like to see a fund developed to allow GPs, physiotherapists, dentists and pharmacists to come together and borrow from the fund put leases in place and set up primary care facilities. Once a centre is built and leases are in place the financial risk is much smaller and it is much easier to refinance. If medical professionals can use such a fund to set up a primary care facility and get it going before moving on to a second one, that is the best outcome from our point of view. The more skin the professionals providing the service have in the game the better. We will not be fighting with them about staying open until 10 p.m. They will want to do so to sweat the asset. We are fully appreciative of the fact that we are going to have to build many of these units ourselves in areas of urban deprivation and rural isolation. We are providing for that. Bank of Ireland also has a €200 million fund in place.
Members raised the fair deal, universal health care and downgrading of insurance health packages. I would be concerned about cherrypicking through that sort of mechanism. The Health Insurance Authority must get involved in this. We are going to empower the authority to prevent this sort of thing from happening. There is a new fourth entrant in the insurance market. We want more competition and cheaper prices for our consumers, clients and citizens.
Deputy Ó Caoláin spoke about the long time between December and May in the Revised Estimates. I agree with him. I would like to see those processes brought closer together and more interaction on it. The Deputy says he is not scaremongering. However, when one uses words like disaster, catastrophe and calamitous, what else are people to think? Most patients say that when they get into hospital their experience is excellent, but getting into the bed is the problem. That is what the Government is working on and why we are bringing in universal health insurance.
Deputy Ó Caoláin made a serious allegation about figures being manipulated and patients being moved around to make things look better. That will be investigated. I am not interested in the perception. I want the reality. When one has reality and transparency one gets accountability. Most people, when they see the reality of their own situation and compare it with others, pull up their socks and get on with things.
We did not tell community nursing units with fewer than 50 patients they were on notice. I said units with fewer than 50 beds find it difficult to survive financially. There are, however, ways around that and we are exploring those ways with many of the communities concerned. Abbeyleix is a case in point. I will be speaking to the HSE to see how much progress has been made in this regard.
The Bill on generic prescribing will be introduced this session. Action is being taken there. Deputy Denis Naughten asked several questions and I think we have covered most of the issues he raised, except for the issue of one hour of home help for every 27,000 people. This must be some sum that is done, but it is not reflected in reality.
School leavers will be looked after. I have had this conversation with many non-governmental organisations that support people with disability. It can be done within the budget although that is tough, having had a 3.5% or 3.7% cut. If the cut went to 5%, however, they would not be able to cope. That is my understanding and I am sure the NGOs will live up to that.
We must finish by 11.30 a.m., so Deputies Kelleher and Ó Caoláin may have two minutes each.
I have very little to say that has not been said already. We know where resources will be allocated, in terms of long-term illness and the extension of free GP care to people with long-term illnesses. However, the provision of universal free GP care, in the current budgetary constraints, will mean huge difficulties in other areas. The provision of universal free GP care to every citizen is the stated policy of the Government. Has the cost of this been profiled? Are we to proceed on a wing and prayer next year and in subsequent years in the hope of getting our hands on a few IOUs, such as those the Minister found behind a radiator yesterday.
They were in a drawer.
He said he also found some behind a radiator. This is a huge policy shift. If we are to vote €13.8 billion to the Minister for Health while also providing free GP care on an incremental basis over the next number of years, there will be a great deal of counting of incontinence pads and everything else, because the resources simply will not be there. We need to know how much free GP care will cost.
The Minister referred to the language I employed. I was signalling situations that would arise and using language he himself has used in the past. It is the duty and responsibility of opposition voices to highlight the serious concerns of the wider community and challenge those entrusted with responsibility to oversee the delivery of a quality public health service on their inaction or inadequate address of specific areas. I will continue to do that.
The documentation on Votes 38 and 39 and the associated outline, which was provided to us, is the same as we receive every year. I do not know what Deputy Naughten was referring to. He implies that Mr. Woods has a copy of a document that was circulated two months ago and which, apparently, goes into even greater detail. If all of that was available, we could have had this exercise two months ago and would not have had to wait until the middle of May. Would Mr. Woods or the Minister ensure that all Deputies have access to whatever material this is?
We all got substantial briefing notes, in tabular and written format, in preparation for today's meeting.
I have them here, but there is some other book.
Here is the situation. From what he has done in opposition, the Minister is familiar with the procedure. This is the material we have to work on. We will have a more effective engagement on Estimates in the future if other material that would better inform opposition voices in preparing for the meeting is distributed in tandem with what we have. Surely, that best practice is easily taken on board.
That is a very fair comment, Deputy.
The implementation group is examining the introduction of free GP care and another group is looking at pricing it. I can assure Deputy Kelleher that the work is in hand.
In reply to Deputy Ó Caoláin, I note his use of language such as, "I merely point out things that would arise". I remind him they did not arise, so even if he changed his language to "could arise", perhaps we might have more tolerance of it. To say that calamity, disaster and catastrophe will occur is causing worry to people who are undergoing treatment-----
That is not the case.
(Interruptions).
I absolutely refute the Minister's assertion and that is why I addressed it in my opening remarks. That is the only defence-----
We are not rehashing the debate, thank you.
Sorry, Deputy, I did not interrupt you.
We must move on.
The truth can be hard-----
I will not tolerate it, not from you or from anybody else.
(Interruptions).
The Book of Estimates are there and the Estimates for all Departments are laid out in the same way. I will have a word with the Minister for Public Expenditure and Reform to see whether it can be made more clear. Like Deputy Ó Caoláin I am very interested in having more transparency and a better engagement.
I thank the Minister, his officials and the HSE for their attendance. I thank the members of the committee for their patience and also Deputy Kelleher and Deputy Ó Caoláin.