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Cabinet Committee Meetings

Dáil Éireann Debate, Tuesday - 16 April 2019

Tuesday, 16 April 2019

Questions (7, 8, 9, 10)

Mary Lou McDonald


7. Deputy Mary Lou McDonald asked the Taoiseach when Cabinet committee E, health, last met; and when it is scheduled to meet again. [15014/19]

View answer

Brendan Howlin


8. Deputy Brendan Howlin asked the Taoiseach when Cabinet committee E, health, last met. [15023/19]

View answer

Joan Burton


9. Deputy Joan Burton asked the Taoiseach when Cabinet committee E, health, last met. [16348/19]

View answer

Micheál Martin


10. Deputy Micheál Martin asked the Taoiseach when Cabinet committee E, health, last met. [16669/19]

View answer

Oral answers (69 contributions) (Question to Taoiseach)

I propose to take Questions Nos. 7 to 10, inclusive, together.

Cabinet committee E last met on 22 November 2018. A date for the next meeting has not yet been scheduled. However, I met trilaterally with the Minister for Health, Deputy Harris, and the Minister for Finance, Deputy Donohoe, to discuss health issues last week. In addition to the meetings of the full Cabinet and Cabinet committees, I often meet Ministers on an individual basis to focus on particular issues. In this regard, I regularly meet the Minister, Deputy Harris, to discuss issues relating to our health service.

The Government's continuing commitment to improve access to health and social services for the people of Ireland through investment across community and hospital services is reflected in the significant increases in health investment in recent years. This year will see the highest ever level of health funding in the history of the State at around €17 billion. We have also committed €11 billion in capital investment over the next ten years in the national development plan.

However, in order to ensure meaningful and sustained improvement in the health service over the coming years, we also need to deliver a major programme of reform. The publication of the Sláintecare action plan for 2019, the first of what will be annual plans, sets out in detailed and measurable ways how the ambitious ten-year reform programme can be delivered and advanced this year. The first quarterly report has been completed and quarterly reports will now go to Cabinet.

An agreement has also been reached with the Irish Medical Organisation, IMO, on a major package of GP contractual reforms that will benefit patients and make general practice a more attractive option for doctors. This runs to a 40% increase in funding for general practice over the next three to four years.

The Minister, Deputy Harris, also recently launched the €20 million Sláintecare integration fund for new models of health and social care, which will help share and scale up examples of best practice and encourage innovations in the shift of care to the community. On 1 April, primary care enhancements announced in the budget came into effect. These include reduced prescription charges for people aged over 70 with medical cards and reduced drug payment scheme charges and ceilings for those who do not have medical cards. A 10% increase in the GP-visit card income thresholds also came into effect, meaning that more low-income families will qualify for free GP healthcare.

A new HSE board has been appointed and is being established in law to strengthen the management, governance and accountability of the HSE. Appointments to the board have been made on an administrative basis after these positions were advertised through the State board process operated by the Public Appointments Service. Following an open competition by the Public Appointments Service, Mr. Paul Reid has been appointed as the new director general of the HSE and is expected to take up the position on 14 May.

Finally, a new contract for staff nurses has been agreed with the Irish Nurses and Midwives Organisation, INMO, SIPTU and others following discussions at the Labour Court. This will result in an increase in pay for staff nurses, but also some important changes in work practices.

News broke at the weekend that private patients were now able to access cancer drugs that are denied within the public system. This is a disturbing and worrying development, not because those with private health cover can access drugs that they need, but because public patients will be denied equal access. The drugs approval process for public patients has hit a brick wall in recent years because the HSE's budget for new medicines is being underfunded. Political decisions have caused this - decisions made by the current and former Ministers for Health, the Taoiseach included.

The differential between public and private undermines the public health service and makes a mockery of Sláintecare, which has a focus on the elimination of the subsidy provided for private healthcare. We all know that the public health system is crumbling under mismanagement on the watch of the Minister for Health, Deputy Harris, and the public-private divide in the health services is growing.

The unfairness in respect of access to cancer drugs echoes the recent revelation that women in the public system are being left to wait for the results of smear tests for up to 33 weeks, while those who can pay get their results within three weeks. I again emphasise again this is not to grudge in any way any woman within the private system but to highlight the gross inequality and unfairness of the disparity between three and 33 weeks for any woman waiting for the result of a smear test. It is unacceptable. None of it is accidental. It is the outworking, logic and consequence of Government policy. Whatever the Taoiseach is doing at his meetings with the Minister, Deputy Harris, whether the meetings are bilateral, trilateral or otherwise, they are not getting to the root of the issues and inequities within our system.

SIPTU has begun to ballot 17,000 hospital support staff over the implementation of pay rises following the evaluation of individual roles. A firm commitment was made to SIPTU, which has abided by the terms of the Lansdowne Road agreement, negotiated freely in 2015. The roles of those members of staff were to be evaluated and that has occurred. My understanding is that the Department of Health and the HSE wish to fulfil the obligation. There has been a blanket refusal, however, by the Department of Public Expenditure and Reform to comply with the solemnly agreed terms of the Lansdowne Road agreement to the effect that this relatively low-paid grade of workers would have its skills re-evaluated by an independent mechanism and that the results of that mechanism would involve regrading. That has been done but it has yet to be implemented. It would be a disastrous decision to allow all these ancillary support grades to go on strike for want of the Government complying with its freely entered-into agreement.

My question is straightforward and direct. Will the Taoiseach ensure that solemn agreements, such as the Lansdowne Road agreement, which were important in maintaining public services through crises, will be fully supported by the Government and implemented to the letter of the agreement, as they have been by SIPTU workers?

What happened to the Fine Gael Government promise of a four-week turnaround for the fair deal scheme? The Fine Gael Government also promised farm families that the arrangements and qualifications for the fair deal scheme would be improved to give more farm families access to the scheme. While demand for the scheme has risen significantly, the four-week turnaround for the scheme that was promised seems to have vanished. We have heard nothing more about Fine Gael's promised improvements to the fair deal scheme for farm families. Many families experience serious distress when one of their relatives, usually an older person, is in need of a nursing home bed. As the Taoiseach will be aware, people cannot leave major hospitals until they are given such a bed, if their condition is serious.

In the Taoiseach's bilateral or trilateral meetings, or whatever they are, with Ministers, that is, not with the whole Cabinet committee or the civil servants who brief that committee, did he discuss the Government's promise to farm families? Did he discuss what is happening to the fair deal scheme? Does he appreciate that the fair deal scheme is likely to run out of money? I know the Taoiseach says there is plenty of money and that it is not a problem. If it is not a problem, why can the Government not deal with the issue?

Last week, it was confirmed that the final cost of the children's hospital will be dramatically higher than was predicted or evaluated, that a governance failure is at the heart of the increased costs-----

That is what the PricewaterhouseCoopers report stated.

To which page is the Deputy referring?

The entire report. The Taoiseach should go back to the recommendations.

It does not state that in the recommendations.

It does state that in the recommendations.

Oversight is mentioned.

There are references to missed red flags, fragmentation, a lack of co-ordination and so on. The Taoiseach, as well as some Ministers, lives on a different planet in respect of what reports say and his interpretation and presentation of them.

Unless it states "Leo Varadkar", he does not see it.

Unless it is stated in black and white, I do not see it.

The bottom line is that one of the central findings is an absence of any challenge of public infrastructural projects at Government level. That is stated in the final recommendations. There was a lack of challenge, with nobody questioning anything about the project because the Government was too politically invested. The Government line, which the Taoiseach has stated, is that it had nothing to do with him or the Minister for Health. The Taoiseach will remember that the Government reviewed the work of the National Paediatric Hospital Development Board last August and decided to reappoint the entire board. This happened more than nine months after the Minister became aware that a significant overrun of costs was on the way. It was at the end of a period during which senior Ministers seemed to spend half their time putting on branded hard hats and speaking about how everything was perfect at the hospital. Will the Taoiseach explain why last year he appointed a board which he is now reported in various newspapers to be angry with? Is he sticking to the line that a massive overrun on the project has no implications for any specific projects under the national development plan?

I listened to Deputy Howlin's comments. There is an air of unreality around many of the projects that have been committed. When one compares commitments and announcements with the reality of these projects' progress on the ground, there is a yawning gap between announcement rhetoric and delivery. The health system is in real difficulty and crisis. There is a consistent pattern at the accident and emergency department of University Hospital Limerick, while at Cork University Hospital, there was a code black alert. I referred to the fair deal scheme earlier and quoted from a letter in which it was stated that when funds become available, the funds can be allocated to an individual, but that was written six weeks ago. This is not the demand-led scheme that we believed it to be.

Similarly, €10 million was apparently included in the Estimates for new medicines. How realistic was that from the outset? There was never any prospect of new medicines being made available within the parameters of €10 million. The idea that valid and important forms of immunotherapy are only available to patients via private health insurance is a damning indictment of where we stand after all the advances we made in earlier decades in respect of clinical trials for cancer, developing new drugs and providing new therapies.

I have a simple question. Does the Taoiseach think it immoral that somebody who receives the devastating diagnosis of cancer but who happens to be a public patient who does not have or cannot afford extortionate levels of private health insurance, may have a less chance of surviving cancer because he or she may not be prescribed drugs that others who have private health insurance would get to improve their life chances? That is immoral. A two-tier health system is outrageous but two-tier cancer treatment is obscene. What will the Taoiseach do about it? It is just not acceptable. Professor John Crown expressed his disgust at how he will have to provide different levels of treatment, which will have consequences for people's chances of life and survival. It is shocking. Does the Taoiseach accept that it is immoral and share the sense of shock?

What will he do about it to ensure that people who receive a diagnosis of cancer have an equal chance of survival and equal treatment?

It is important to point out again that so far this year 23 new medicines have been approved for reimbursement. I do not know how many weeks have passed this year so far, perhaps 15 or 16, but that is more than one new medicine a week being approved by the HSE.

Some of those approved have not been funded.

They have been approved for reimbursement by the HSE. I do not know how there is a suggestion we have hit some sort of brick wall, as 23 new medicines this year so far, and it is only the middle of April, is quite a lot. They have been approved for reimbursement. Spending on medicines in Ireland by our public health service is not low. It is average to high. We already spend a lot of money on medicines in the Irish public health service. There is certainly scope for savings, whether it is better prescribing or greater use of generics. There are lots of ways in which savings can be made on our medicines bill. Any of those savings are retained in the medicines budget and can be used to approve new medicines. I understand from what was in the media over the weekend that one of the private insurers, the VHI, has agreed to fund some new medicines for cancer patients but this only applies to VHI patients in private hospitals. It does not apply to patients in public hospitals. Patients in public hospitals, whether they are insured or not, will continue to have access to medicines on the same basis. What happens in private hospitals is not under our control.

Hitherto, private insurers had waited until the HSE had made a decision on whether a medicine should be reimbursed and were no more willing than the HSE to fund medicines judged to be cost ineffective. This is a change. We need to examine the implications to see what can be done. I understand the other private insurers have indicated they do not intend to follow suit.

Deputy Howlin asked about the industrial relations dispute relating to support staff in our hospital. I understand engagement is taking place with the unions with a view to coming to a resolution and avoiding any unnecessary strike action.

On the fair deal scheme with regard to farm families, and this does not just apply to farm families but also to business owners, Government policy is to limit to three years the number of years for which somebody makes a contribution against their assets, that being a farm or business. The Minister of State, Deputy Jim Daly, is working on this. It requires primary legislation to change it. The current target is to have the heads of the Bill next month but targets have been missed on a number of occasions on that matter so I would not want to stand over that or may not be able to stand over that. The budget for the fair deal scheme is at its highest ever. It has increased by €20 million to €980 million this year.

The demographics are going up.

It certainly has not all been spent, or anything remotely close to it. The target time for approvals is still four weeks.

Deputy McDonald mentioned many of the problems and failings that exist in our health service and she was totally within her rights to do so. On the same basis, for balance and accuracy, it is worth pointing out some of the good things happening in our public health service and we should acknowledge the good experiences most patients have and the really hard work of our professional staff and health service. We should find some space to talk about some of the good things that are happening and I will give a few examples.

The reduced cost of healthcare will kick in this month. There are reduced prescription charges for those aged over 70 with a medical card and reduced drugs payment scheme charges for those who do not have medical card.

We have the progressive extension of free GP healthcare. We started with the under sixes and over 70s, then moved on to all children with severe disabilities and those in receipt of domiciliary care allowance. Last year, people in receipt of carer's allowance and carer's benefit were included. This year we have a 10% increase to the income limits, bringing in more low income working families to free GP care. We have signalled our intention to extend free GP care to children aged six and seven next year, eight and nine the year after and ten and 11 the year after that.

At long last, we have an agreement with GPs to increase resources and activities in primary care. We will have a 40% increase in resources over three to four years. GPs will take on new work, particularly in the area of chronic disease management, which I believe will make a big difference in the longer term. We have a new staff nurse contract that provides for pay increases for them and important work practice changes that we need to reform our health service. A patient experience survey shows that 83% of patients in our public health service state they had a good or very good experience of our health service.

We have had a considerable reduction in waiting times for operations if we compare where we were 18 months ago. The number of those waiting more than three months for operations is down significantly. I like to use the figures for those waiting for more than three months because no matter how well we run a health service we will always have people waiting two, four or six weeks. For the purposes of this, the figures I will use are for those waiting more than three months. The figure for veins has reduced from 2,000 to 724, down more than half. The figure for angiograms has also decreased by more than half, from 2,000 to 914. The figure for cataracts has decreased by half, from 8,000 to 4,000. The figure for hips and knees is down from 2,400 to 1,777. The number of children waiting to have their tonsils removed has gone down by three quarters, from 2,600 down to 764. There have been some real improvements.

Is that through the treatment purchase fund?

Yes; not entirely but in part. It is working in a very different model to what was done in the past.

That was one of the Fianna Fáil policies, of which the Taoiseach says we have none, that he adopted and it is having an effect. The Taoiseach never acknowledges it, he just keeps saying we do not have policies.

There is more to that story than Deputy Martin's negotiating team told him. I will tell him about it.

Extra beds are being provided in the system, again reversing a Fianna Fáil policy on this occasion of taking hospital beds out of the system. Fianna Fáil and the Green Party in government, as Deputies will remember, even before the financial crisis started to reduce the number of beds in the hospital system. We have been reversing that for the past couple of years. It is making a difference in terms of overcrowding. Yes, we did have some very bad figures two or three weeks ago-----

Does the Taoiseach have the outpatients waiting list figure?

We must make a decision now, if the Taoiseach is ready. We have seven minutes left for the next group of questions. I guesstimate that because of the length of the reply the Taoiseach will take a good four minutes. Do Deputies want to continue with these questions and have the next question as the first one tomorrow? It is with regard to the Taoiseach's Department's input into Brexit.

What is the alternative?

We will move onto the next question or what?

We can go to the next group of questions, and it will take the Taoiseach approximately four minutes to give a reply. Three minutes will remain for questions and there will be no replies to the supplementary questions.

Could we ask a brief supplementary on this question?

Do Deputies want a quick supplementary question on this question?

I have not finished my reply.

He has spent six minutes-----

He spent six minutes on it. Come on.

He is six minutes over time on his reply.

Extolling the virtues of his-----

Will the Taoiseach use it in response to the supplementary questions?

It does take longer to answer questions than to ask them, in fairness.

Six minutes over time.

I will give 30 seconds for a supplementary question to each Deputy who tabled a question.

The Taoiseach spoke about the cost effectiveness of drugs and cited the fact there is a procedure to establish the efficacy of any medicine and its economic value but I ask him to address the issue of that disparity between public and private cancer patients and whether he can justify the fact that a person, because his or her pockets are not as deep, will not receive the same care and, accordingly, his or her health and life are jeopardised.

I am trying to get my head around the actual attitude of the Taoiseach and whether he is completely oblivious to the real crisis in our health system. I spent a chunk of yesterday in Wexford General Hospital talking to staff. People who had been evaluated expect the deals they do with the Government to be delivered upon, given that they stuck with those deals through the hard times. Giving praise to people and saying everybody is doing a great job is well and good but when we shake hands and do a deal with people, and they stuck with the Government through the hard times, it really is important that we deliver upon the deals that are struck. In terms of my very straightforward question on the support staff in hospitals, will the Taoiseach tell me now that the deal struck with SIPTU under the Lansdowne Road agreement will be delivered this year as promised?

The Taoiseach said the Minister of State, Deputy Daly, was working on the legislation required to implement the Government's promise to farm families on the fair deal.

Will the Taoiseach tell the House if a memorandum on the legislation has gone to the Cabinet yet? Will he tell us how long it will take to finalise the legislation and when it will arrive in the Dáil and the Seanad so that farm families can get better treatment for relatives who urgently need a nursing home place and the fair deal promised by him, a promise he has now broken? Families are very upset over this.

On the outpatient waiting lists, I understand that there are more than 100,000 people waiting over 18 months for an outpatient appointment. When the Taoiseach was the Minister for Health he had a target for this figure to be zero by June 2015. The figure has, however, gone up 800% since the Minister for Health, Deputy Harris, came into office in 2016. Will the Taoiseach indicate why this is and what the Government's plans are to tackle this figure?

The National Treatment Purchase Fund, NTPF, has been somewhat effective in reducing the inpatient waiting lists, although not all the way and it has been slow to get off the ground. It is in the confidence and supply arrangement and in the last budget we asked for an increase to go to the NTPF to allocate funding to patients. Perhaps the Taoiseach will undertake to get for me - officially - the timeline for receipt of the fair deal scheme once an applicant is approved. I am aware of a case that is taking six weeks and other Deputies have told me this is similar to their own experiences from applicants. I would appreciate someone clarifying that timeline for us. Why is there such a delay? That timeline is getting longer for recipients who have been approved under the fair deal.

The Taoiseach did not answer my question, which was simple and specific. Does he believe it is immoral that a person who receives a cancer diagnosis would get a different level of treatment and access to potentially life-saving drugs depending on whether or not he or she can afford particular private health insurance plans? I believe this is medical apartheid. It is as simple as that. Whatever about the general debate around a two-tier health system, which is unacceptable, does the Taoiseach believe it is acceptable in cancer care? If he does not, does he think it is immoral? If so, what is he going to do about it?

There are two minutes left Taoiseach. Make the best of them.

I thought I had answered Deputy McDonald's question but I will give my answer again. In public hospitals, patients will receive the same medicines. Whether they have VHI or any other form of private health insurance will not make any difference in public hospitals. Patients will continue to receive the same medicines. What happens in private hospitals is not under our control. I do not wish to, nor do I believe myself qualified to, pronounce on morality but I believe it would be right, good and proper for us to continue to do what we have done until now, which is private insurers taking their lead from the National Centre for Pharmacoeconomics. If, based on clinical and objective criteria, the National Centre for Pharmacoeconomics judges that a medicine is not cost effective, the State would make an initial decision to not fund it and the private insurers would follow suit. That is the way it was previously. We will enter into a very difficult situation if private insurers decide on an arbitrary basis or a commercial basis which medicines should or should not be approved. Whatever we do, it should be done on an objective basis, based on clinical evidence and on a fair price, not based on insurers deciding unilaterally which medicines should be approved, which should be reimbursed-----

The drugs are approved. Are they not already clinically approved?

They are clinically approved.

The medicines are clinically approved by the respective bodies.

The Taoiseach, without interruption.

I believe it is the same. This is the record of the House so I do not think the Taoiseach should make commentary like that.

The Taoiseach, without interruption.

I do not think I would like it as part of the reason.

We must afford the Taoiseach the same opportunity.

My apologies, I meant reimbursed.

On Deputy Howlin's question on support staff, the Government will of course honour its agreements. There may be different interpretations as to what the agreement says and how it is to be implemented, but we will of course honour agreements made with staff.

Deputy Burton asked about memorandums. To the best of my recollection there was a memo last July but I may be incorrect on this. The Minister of State, Deputy Jim Daly, is working on the heads of the Bill and these will be ready to go to Cabinet in May. Given previous missed deadlines, I do not know if I can stand over that date. Once the heads of the Bill go to Cabinet, legislation will be published and then we are in the hands of the Houses. A lot of legislation has, unfortunately, been held up in this House and the other House by the Opposition.

Deputy Martin asked about outpatient waiting times and I acknowledge that they are very bad, very long and getting worse. The Deputy mentioned my time as the Minister for Health. I might also recall that during Deputy Martin's time as the Minister for Health he did not publish the outpatient waiting lists. They were kept secret and not published so the public would not know how long they were. We have adopted a different approach in being much more transparent about these things. The most important thing is what can be done about it. Obviously, additional clinic capacity-----

We are going back to Ardnacrusha.

Deputies will always talk over us when we talk about solutions. They are not interested in them-----

The Taoiseach, without interruption.

That is my experience anyway. There are a number of solutions to outpatient waiting times. There are issues to be looked at in the following areas: making sure referrals are appropriate; providing additional capacity in clinics; ensuring the ratios are correct in making an adequate number of slots for new patients rather than having patients returning more frequently than is medically necessary; and looking at validation. Almost 500,000 people do not turn up for their outpatient appointments, which is more people than the number who are waiting over three months. This is a huge problem. It is not as simple as saying that the slots are there but are not being filled. Clearly, there is a big problem when huge numbers of people do not turn up for appointments. I do not believe the people are to blame for that: there must be a systemic issue. We need to look at investment in primary care, although this will not happen quickly. The increase of 40% in funding for general practice will make a difference, but it will take some time to see that.

I will check up on the issue of waiting times for the fair deal. I am not aware of any significant deterioration over the last two weeks but some Members have raised the issue and I will endeavour to check it out.

That concludes questions to the Taoiseach. I remind the House that the third group will be taken as the first tomorrow.