Wednesday, 3 July 2019

Questions (1, 2, 3, 4)

Michael Moynihan


1. Deputy Michael Moynihan asked the Taoiseach the number of times Cabinet committee E, health, has met in 2019; and when it last met. [25595/19]

View answer

Joan Burton


2. Deputy Joan Burton asked the Taoiseach when Cabinet committee E, health, last met; and when it will next meet. [26568/19]

View answer

Richard Boyd Barrett


3. Deputy Richard Boyd Barrett asked the Taoiseach when Cabinet committee E, health, last met. [26623/19]

View answer

Brendan Howlin


4. Deputy Brendan Howlin asked the Taoiseach when Cabinet committee E, health, last met; and when it is next scheduled to meet. [26685/19]

View answer

Oral answers (21 contributions) (Question to Taoiseach)

I propose to take Questions Nos. 1 to 4, inclusive, together.

Cabinet committee E last met on 22 November 2018. A date for the next meeting is being scheduled for later this month. In addition to the meetings of the full Cabinet and of Cabinet committees, I often meet Ministers on an individual basis to focus on particular issues. In this regard, I meet regularly the Minister, Deputy Harris, and his officials and advisers to discuss issues relating to the health service, and health is discussed by the full Cabinet almost every week.

This year will see the highest ever level of health funding in the history of the State in order to transform the health service to one that can meet the changing needs of the population and be resilient to challenges presented by changing demographics.

We have also committed close to €11 billion in capital investment over the next ten years in the national development plan, Project Ireland 2040, to provide the infrastructure required for expanded community and acute care.

While there is a need for increased investment in the health service, reform and productivity gains must happen as well. These gains are not always easily realised and require a long-term strategic approach.

The Government is advancing a significant programme of reform to ensure meaningful and sustained improvement in the health service in the future.

The publication of the Sláintecare action plan for 2019, the first of what will be annual plans, sets out in a detailed and quantifiable way how the ambitious ten-year reform programme will be advanced this year. The first quarter progress report for this year is completed and all 28 deliverables are on track.

The guiding principle of Sláintecare is to provide the right care, in the right place, at the right time. Recent advancements include the following measures. Reduced prescription charges, reduced drug payment scheme thresholds and increased GP visit card income thresholds all came into effect in April. This is a step forward in benefitting hundreds of thousands of people by reducing the cost of healthcare for them. On 11 June, Government approved the general scheme of a Bill to change how productive assets are treated under the nursing home support scheme or fair deal. This will positively affect families who have family farms and businesses but now require nursing home care. An agreement has been reached with the Irish Medical Organisation on a major package of GP contractual reforms which will provide a 40% in resources for general practice, benefitting patients and make general practice a more attractive career option for doctors. Last Friday, the new HSE board had its first formal meeting following the Minister for Health signing the commencement order for the HSE (Governance) Act 2019. The board had been meeting prior to this on an interim or administrative basis. The board will strengthen the management, governance and accountability of the HSE.

The Taoiseach will be aware that the Minister for Finance has explicitly ruled out the possibility of any Supplementary Estimate for the Department of Health later this year but, in contrast, when pressed by Deputy Donnelly on this matter, the Minister for Health refused to rule out seeking a Supplementary Estimate. The Taoiseach might be able to explain the contradiction between the two Ministers in that regard. The Taoiseach might be able to indicate what he believes the full year outcome will be in relation to the health Estimate. Does the Taoiseach also believe that there will be no question of a Supplementary Estimate being required? He might clarify that for me.

I note that up to 2012 the HSE demonstrated a strong ability to deliver within budget but that changed due to a new political approach to service plans introduced by the Cabinet. The Irish Fiscal Advisory Council has said that ministerial and governmental decisions in demanding services but not providing the funding at the start of the year have directly added to the end of year Supplementary Estimates - in other words, at the beginning of the budget year every year the Government knew full well that what was provided for in the service plan could not have been met by the Estimate that was provided and that there would inevitably be a Supplementary Estimate. That has been an issue for quite a number of years. Does the Taoiseach accept this, or is that another recommendation of the Irish Fiscal Advisory Council which the Taoiseach will ignore?

I put it to the Taoiseach that whereas he talked about Sláintecare and some of the issues around thresholds, etc., that are doable, at the essence of the health service at the operational level are fundamental difficulties with access to the health service as manifested in overcrowding in accident and emergency departments and excessive deaths as a result. Much of that is contributed to by the deficiencies in step-down facilities, nursing home beds, rehabilitation beds and facilities, and facilitating efficient discharge from acute hospitals. In my view, the demographic realities of health have not been provided for in recent times. As a people, we are living longer. That is a good development but the numbers of people who attend the services, particularly emergency departments, for example, those over 65 years of age, is quite significant. The issue around care of the elderly, be it home care packages or, as I said, the various facilities required once discharge takes place, have not been provided for in budgetary terms by the Government and have been fudged year after year. Does the Taoiseach accept that basic proposition that the Government has not met the challenges arising out of demographic changes in terms of the health service?

One of the many problems of the health service in Ireland - I do not know whether the Cabinet committee or the Cabinet has had an opportunity to discuss this - is the dysfunctional recruitment of doctors within it. We now have one of the lowest numbers of doctors per head of population in the EU. At the same time, we are increasingly relying on the recruitment of doctors trained outside of Ireland and coming to this country. Within a few short years, the service has become dependent on a category of junior doctors, most of them foreign trained and on the lower rungs of their medical careers. Ever more healthcare is delivered not by consultants or trainees who are in secure career structures, but by an ever-growing army of non-training scheme doctors. This is unfair to those in the medical profession who want to work as doctors and who have a completely uncertain career path, so much so that many of the foreign doctors ultimately end up going to the UK or other countries where, having gained experience in Ireland, they can get a career path in those countries.

My understanding is that there is a draft Health Service Executive report on this problem of recruitment which ties in with all the other problems the health service is experiencing but has a significant impact on patients and their families in terms of their access to care, waiting times, appointments, etc., in hospitals and service facilities around the country. Has the Taoiseach discussed this draft report?

Will the Taoiseach make a commitment to the Dáil to publish the report so that we can have a discussion? We do not want doctors in Ireland to be in a version of the gig economy, developing a career in Ireland, either because they are from Ireland or they have come here to work, only to find they are caught in a completely dysfunctional system.

I asked the Taoiseach this morning about the really shameful inequity in the cancer treatment available to people with malignant melanoma. Some people who have the right private health insurance can get access to pembro and other potentially life saving drugs, while others who do not have private health insurance or have the wrong policy cannot. It is shameful that money should dictate access to cancer care which could be potentially life saving. The Taoiseach said it is a complicated situation because the private health insurance company has taken the unprecedented step of moving ahead of the Government in providing cover for this drug. Telling us it is complicated does not answer the question. The national cancer strategy says we should have equitable access to cancer care. Morally, it is just obvious, is it not? What does the Taoiseach have to say to the person who wrote to me whose wife needs this drug and cannot get it? Should she just suck it up that she cannot get access to this potentially life saving treatment? That is just not acceptable. I want to know what to say to this man and his wife and to the many others who have signed a petition on this issue saying they need access to these life saving drugs. They deserve the same chance to live as anybody else, regardless of what private health insurance they do or do not have. What is the Taoiseach going to say to those who need this treatment now?

The vital and often hidden role of healthcare assistants has come to light in recent weeks. A report published on Monday which reviews their role and function is really important and worth noting. It recognises the crucial work of healthcare assistants in delivering high quality care across the health service and calls for a formalisation of the job title of healthcare assistant. It recommends the immediate establishment of a permanent forum which would deal with issues including education, recognition and registration. Has this important report been discussed yet at the Cabinet subcommittee? Will it be discussed? Has the Taoiseach had a chance to have a look at it himself?

On a separate matter, in The Irish Times today, David McConnell and Orla Hardiman raise serious issues about genomic medicine in Ireland, the influence of a Chinese-controlled company, Genomics Medicine Ireland, and the handing over of genetic data gathered in Ireland to this private company. These are matters about which general citizens are concerned. I ask the Taoiseach to examine the matter and to ensure that Irish genomics remain in the public domain and do not become part of a privately owned database for a private company.

There has been great mention of the absence of staffing and staffing levels in various areas of the health service. One of the key things for getting staff into place is having the proper infrastructure in place. That brings me to Sligo hospital, where a cardiac catheterisation laboratory, cath lab, has not been place but has been promised for almost 20 years at this stage. This is getting to be serious because the senior consultant is about to retire. There is great concern that it will be impossible to recruit a senior consultant without having a cath lab. It is a serious problem and needs to be resolved as quickly as possible. I know the HSE capital plan is soon due to come out and we are very much hoping that a permanent cath lab for Sligo will be in that plan. We are not looking for a second one: we are looking for the first one. That is different from other areas which I know are also under serious pressure. Two new wards have also been promised for a long time for Sligo hospital, which is under considerable pressure in regard to numbers and space. This is vital and needs to be in the HSE capital plan and to happen as quickly as possible.

Also part of the same issue of pressure on beds and hospitals are home care packages for the elderly. We have a serious problem with home care packages for the elderly in CHO 1. While it may not be officially stated that funding is frozen, it is effectively frozen. People cannot get access to new home care packages because there is no money to provide them. That is the answer we are getting when we look for them. Every constituency office in the country is meeting the same problem but it is particularly acute in the north west. A new emphasis needs to be brought to the areas that are going to provide the most relief for people. One of them is the home help packages which will have an immediate effect. Another is the infrastructure for University Hospital Sligo.

I thank the Deputies for their questions. On the possibility of the need for a supplementary estimate for the health service, I have not seen the precise comments of the Ministers, Deputies Harris and Donohoe, so I am not au fait with exactly what the difference is. It will not surprise anyone in this House that it is often the case that a supplementary estimate is required for health. That was the case long before 2012. It is not a recent development. It often arises because extra costs arise during the course of the year. One of the extra costs that has very evidently arisen during the course of the year is the cost of resolving the nurses' dispute. We are not going to fund that from cutting services so there are areas where we may need to provide supplementaries later in the year. In the meantime, the Department of Health, the HSE and the Department of Public Expenditure and Reform are working very hard to ensure that the HSE comes in on budget while still accepting that there may be additional costs that arise during the course of the year which will have to be funded.

As to what coming in on budget means, it is important to get this message across if I can. Coming in on budget in the health service this year means spending no more than €1 billion extra compared to last year. It means keeping the increase in spending to about 6%. A €1 billion or 6% increase more than provides for demographics. Perhaps they were not provided for adequately in the past but they are more than provided for this year and last year. The population is growing by less than 1% per year. The population is ageing but not to the extent that it should require an increase of greater than 6% in any one year. The increase for this year is €1 billion. It is what people protesting on the streets are demanding. It was done. We need now to try to come in on budget while allowing a degree of flexibility to provide a supplementary for additional costs that may arise during the year that we are not going to fund by cutting back services elsewhere.

Deputy Martin mentioned that up to 2012, there were never supplementaries in health. That is not true. Indeed, when the Deputy was a Minister himself one year there was a supplementary for €250 million. That was when the budget was a fraction of what it is now.

I was referring to the HSE.

In percentage terms, it was not dissimilar to the kind of overruns we have now. The record for the biggest health supplementary ever was under a Fianna Fáil led Government. About €1 billion had to be provided in a supplementary because of illegal nursing home charges, of which the Deputy will also be aware.

On the recruitment of doctors, all the questions asked by Deputy Burton were asked by Deputy Shortall earlier but I am happy to do her the courtesy of giving the answers again. The Deputy is correct that we have one of the lowest numbers of doctors per head of population in the OECD. Ireland has a relatively low ratio of doctors to patients. In contrast, we have one of the highest ratios when it comes to the nursing profession. We are in the top three, four or five in terms of the number of nurses we have per head of population. I agree that we do not have enough doctors working in our public health service but we do have more than ever before. This often does not come across but there are more doctors now working in our public health service than ever before and more doctors are registered with the Irish Medical Council than ever before. Sometimes the impression is given that there are more doctors leaving the public health service than are joining it but that is not correct.

There are more joining it than leaving. The HSE and Medical Council numbers show that. Overall, the number of people working in the health service has increased by 10,000 over the past three years. It is up from about 105,000 to 150,000 across the public health service. One of the reasons we have overruns in the health service is the recruitment surge rather than the recruitment crisis and the fact that extra people are hired every year beyond what is provided for in budgets.

On the number of consultants working in the public health service, as I said, this continues to grow year on year. The number increased by 109 in the past 12 months. There are, however, significant recruitment and retention challenges, especially in certain specialties such as psychiatry where we need to move to a more psychology based model. It will not be possible to find the number of consultants needed using the current model. In certain locations - some smaller hospitals - particular posts are no longer recognised for training purposes and probably never will be.

The HSE recently prepared a report in response to a request from the Minister for Health, Deputy Harris, and the Department of Health to consider the issues raised in the judgment of Mr. Justice Kelly and given the current recruitment challenges. I understand this report and recommendations were submitted to the Department of Health on 13 May and are currently receiving consideration. They will be published as soon as possible.

Several initiatives are being pursued by the HSE to advance consultant recruitment and retention, including improvements to the recruitment process, which is very cumbersome; offering contracts to the hospital groups rather than individual sites; and focusing on more family friendly arrangements such as job sharing and part-time contracts. The HSE has also established a tripartite working group, including the Medical Council, the forum of postgraduate medical training bodies and the HSE's national doctors training and planning unit, to examine posts where consultants are not on the specialist register and recruitment and retention challenges exist.

While several hundred consultant posts are difficult to fill at present, only 20 are currently being advertised. The reason is that many of the posts are filled on a locum or temporary contract basis to ensure the delivery of essential services. While we describe the positions as being vacant, they are not actually vacant in the sense that the job is being done by somebody on a temporary or locum contract rather than someone on a permanent contact.

On the issue of new entrant consultants' pay and the proposals of the Public Service Pay Commission, the Department of Public Expenditure and Reform has said that outstanding matters will be given full consideration by any pay review mechanism agreed by the relevant parties in the context of the next round of pay talks. In the past few months, we secured a new contract for staff nurses and staff midwives, with pay increases and changes to practices and terms and conditions. We have also successfully agreed a new contract with general practitioners to increase funding for general practice by 40%. In return for that, there have been agreed changes such as the adoption of new technology and GPs taking on new work, especially around chronic disease. In negotiations with consultants we will need to adopt a similar approach in which, in return for equalising pay, we ensure it is not just more pay for the same outcomes and changes are made that are patient focused. It must also deal with some of the very difficult and problematic issues around the mix of public and private practice.

Can I just get my question answered?

I asked about healthcare assistants.

There will not be a third round of questions. That should not be blamed on what happened earlier.

I deserve some answers.

As always, I am happy to continue.

We will not have time for a third round. That has nothing to do with the earlier-----

Perhaps the Taoiseach could come back to us individually afterwards. I asked about healthcare assistants.

I am in the Leas-Cheann Comhairle's hands.

The Taoiseach may continue.

It takes less time to ask a question than it does to answer it, as everyone can appreciate.

On Deputy Boyd Barrett's question, he will appreciate that at this stage I cannot comment on individual cases. We have a system for deciding which medicines are licensed and which are approved for reimbursement in the State. This is not done by private health insurers or the private sector but by public bodies, as it should be. The European Medicines Agency and the Health Products Regulatory Authority decide whether a medicine should be licensed in the State and for what purpose. The HSE, acting on the advice of the National Centre for Pharmacoeconomics, then decides whether a medicine should be reimbursed. Some 30 medicines have been approved this year by the HSE for reimbursement but others have not. If they are not reimbursed, it is often for very good reason. It is not a political decision and I do not believe it should be a political decision.

There is no good reason in this case.

Deputy Howlin asked about healthcare assistants. I am not familiar with the report he mentioned so I will have to check into that. I have not yet had a chance to read the newspapers today but I am aware there is an editorial from Professor David McConnell in The Irish Times today, which I will endeavour to look at. I must read the article before responding.

On Sligo hospital, I understand that a significant new development at the hospital received planning permission in the past couple of weeks. I may be mistaken. The project will be a major extension to Sligo hospital. On the issue of a catheterisation laboratory, I do not know if a permanent laboratory is intended for Sligo hospital. I understand a mobile catheterisation laboratory is provided but it is not the case that the provision of such a laboratory is directly connected to the recruitment of cardiologists. Connolly hospital does not have a catheterisation laboratory, yet it has three or four cardiologists because they do particular types of work, especially in the area of heart failure. I am not able to give the Deputy a detailed reply on that matter but I will ask the Minister for Health to do so.