Vol. 704 No. 1
50 Deputy Willie Penrose asked the Minister for Health and Children the role her Department plays in interdepartmental actions to reduce the effect of poverty on health outcomes; if there is a strategy in this regard; and if she will make a statement on the matter. [10419/10]
There is increasing recognition that health outcomes are influenced by income, housing, educational attainment and other factors that fall outside the remit of the health sector. Within that sector, there is also a need to develop policies and services that address the particular needs of specific groups, such as Travellers, homeless adults, drug users and prisoners.
My Department participates in the senior officials group on social inclusion, which operates under the aegis of the Department of the Taoiseach and aims to improve the position of lower socio-economic groups and others at risk of social exclusion. It also works with the HSE and other agencies to provide more effective health services to marginalised groups.
By way of example, my Department established the Traveller Health Advisory Committee and has commissioned the all-Ireland Traveller health study, which we will have to hand later this year. It has also contributed to the development of the homelessness strategy published by the Department of the Environment, Heritage and Local Government in 2008 as well as working with the HSE to improve the provision of health services to homeless adults. It works closely with the Department of Community, Rural and Gaeltacht Affairs on the implementation of the national drugs strategy and with the Department of Justice, Equality and Law Reform in terms of forensic mental health services. It has also developed a policy on service users' involvement, with a particular focus on marginalised groups. It works with the HSE to ensure this is fully implemented.
The Department maintains a close working relationship with the Institute of Public Health in Ireland, IPH, which has a specific remit in respect of health inequality. The Department has just nominated the institute to be its representative on a three-year EU joint action programme on health inequality.
Reducing the effect of poverty on health outcomes is a common challenge for health systems around the world. My Department is committed to working with other stakeholders to tackle and reduce health inequality.
While we discuss the ins and outs of the health services, the greatest factor in whether a person will be healthy is the area and the type of family into which he or she is born. We do not spend enough time addressing the relationship between health and poverty.
I take the point that the Minister's Department is involved with other Departments and so on, but how does she get the other Departments to prioritise issues that affect people's health? I attended the launch of a document published by the Galway Travellers Movement regarding a particular halting site in Galway. The movement assessed the effect of the site's conditions on the health of those living there. In this context, to what extent can the Minister for Health and Children influence, for example, the Minister for the Environment, Heritage and Local Government to address these issues?
At Cabinet level, it is co-ordinated by what is broadly called the social inclusion sub-committee. The officials group, which involves several Departments, works on the social inclusion agenda, including health.
Regarding Travellers specifically, I recently attended a similar launch in my constituency. In recent years, we have funded a number of primary care workers for the Traveller community, where they are having a significant impact on health issues. We do not have the results of the recent census to hand, but it will provide us with a considerable amount of information, not only on the health status of the Traveller community, but on relevant matters. I hope to have the report quickly.
Our involvement with the Departments of the Environment, Heritage and Local Government and Community, Rural and Gaeltacht Affairs has been concerned with the drug strategy. The HSE provides many services that are sometimes policy priorities for other Departments, including direct health services to homeless people. As the Deputy stated, the health needs of the most disadvantaged will not simply be dealt with by the health Ministry. Housing, sanitation, education and the child immunisation programme have important roles to play in health outcomes.
I want to allow supplementary questions from other Deputies.
I want to make a few points.
Questions, please.
Will the Minister assure the House that the funding put in place to address the issue of Traveller health will be used for that purpose? Previously, money had been siphoned off into other areas. As alluded to by my colleague, Deputy Jan O'Sullivan, the HSE has a hold on policy in that when money is not spent in a policy directive area, it can use it elsewhere. There are ways and means to not spend money. We have seen it not only in this case, but in terms of palliative care and mental health services.
Given that income plays a large role in health outcomes, does the Minister intend to change the income threshold for the medical card, which currently stands at a little more than half the minimum wage? Anyone who is prepared to work full-time is not entitled to a medical card. Sometimes, part-time workers are not entitled to it.
In the current circumstances, the answer to the last question is "No". The reality of the economic situation in which we find ourselves is that an additional 200,000 people have recently acquired medical cards. If memory serves me correctly, as I do not have the data in my brief, 1.48 million people are covered by full medical cards and 98,000 have doctor-only cards. These figures constitute a large portion of the population. The cost of providing services to our medical card community is substantially higher than it is, for example, across the Border. This influences the amount of cover we can provide in any one year. To be realistic, in the current financial circumstances, I do not anticipate changing the threshold.
The resource allocation group, which will report later this year, is examining all of the issues in respect of how to allocate health resources to get better outcomes for patients. Where Travellers are concerned, we have provided a great deal of additional money. We have also provided an extra €33 million for health projects for the homeless community. A priority of mine is that we continue with investments in these areas, where the most marginalised have bad health outcomes.
What specific actions has the Minister and her Department taken on the back of the report published last October by the National Economic and Social Council, NESC, entitled, "Well-Being Matters: A Social Report for Ireland", which found that we were joint seventh last on the list of the 27 EU member states in terms of access to hospital services? In that report, some 76% of EU citizens recorded ease of access to hospital services, yet only 65% of citizens in this State recorded ease of access. It was clear that the 35% who did not respond were from the least well-off in our community.
The IPH and the Combat Poverty Agency's 2008 report recommended that greater health equity and reductions in health inequality needs to become Government policy and be fast-tracked as priorities. It called for a health impact assessment to be done in respect of key Government policy. What has the Minister done on the back of this report, which is working towards being two years in situ?
I am not certain that proofing every policy would deliver the types of result the Deputy anticipates. Currently, every memorandum that goes to the Government must be gender proofed, poverty proofed, competitiveness proofed and North-South proofed. There is a considerable amount of proofing. We also conduct regulatory impact assessments of all new policies and legislation. We must bring much of this together.
We have universal access to hospitals. We do not have universal access to primary care free of charge and the hospitals apply a small charge. The issue with hospitals is the length of time it takes to access services. A central feature of the new consultants' contract is that access to diagnostic services for consultants' outpatients is to be on the basis of medical need and nothing else. The resource allocation group, which is examining in an in-depth and robust way the manner in which we allocate resources not only to hospitals, but between hospitals and community care and so on, will provide us with good insights into this matter.
51 Deputy Bernard J. Durkan asked the Minister for Health and Children the comparisons she has made between the costs of running similar services in the public and private hospital sectors; the degree to which differences have emerged in the value of health insurance claims made by patients in respect of each of these sectors; and if she will make a statement on the matter. [10546/10]
As Minister, I am concerned to see that health care is provided in a way that is affordable and sustainable for the country as a whole and, most of all, that the resources we devote to health achieve the best possible outcomes for patients and the best health status for the population. I do not have a role in the day-to-day operation of either private hospitals or private health insurance providers, nor should I. The negotiation of fees between private hospitals and health insurance providers is a commercial matter for the parties themselves. It is not possible, therefore, for me to make direct comparisons of the type suggested.
It may be useful to note that the Department of Health and Children is currently undertaking a value for money and policy review of the economic cost and charges associated with private and semi-private treatment services in public hospitals. The review seeks to determine the extent of the gap between current charges and actual costs in public hospitals. The review does not seek to compare costs between similar services in the public and private hospital sectors, since it is not considered that this should be the key consideration in setting the level of charge in public hospitals.
It is also the case that the National Treatment Purchase Fund negotiates treatment prices with private and, to a limited degree, public hospitals. The Comptroller and Auditor General's report for 2008 examined the NTPF's arrangements for the procurement of treatment. It concluded that, relative to the casemix benchmark, procedures purchased from private hospitals by the NTPF generally cost less than those carried out in the publicly funded hospital system. However, for reasons of commercial confidentiality, the actual prices payable have not been disclosed publicly.
Where the HSE decides to purchase an element of service from the private sector, the executive satisfies itself that the price paid compares favourably with known costs in the public hospital system. Such arrangements are also of course subject to the normal rules on public procurement.
I take issue with the Minister when she says she should not have a role. There is a role for the Oireachtas and for someone within the public service in controlling the costs of medicines, medication and medical procedures. This should not be left to commerce, of itself. In view of the VHI monopoly there has been a failure to drive down the cost of medical care.
While it may be difficult to get information in the hospitals sector, a report by PA Consulting found that in the community sector private home care can be got for €21 per hour while public care costs €28. This is because the HSE pays €18 per hour and clients are charged €12. How can this be and what does the Minister intend to do about it? Will she take an initiative to drive down the cost of medical care?
Why do we have such medical inflation when drugs such as proton pump inhibitors, which suppress acid secretion in the stomach, have been developed? Years ago, people had major gastric surgery for this problem but this is no longer the case. We should be making savings. It is not all one-way traffic and it should not be.
We have been driving down costs. This year we will take €240 million out of the drugs cost, for example, by changing the manner in which pharmacists are paid and what we pay producers of medication which goes off patent. The nursing homes support scheme, A Fair Deal, is a good example of saving. The NTPF was asked to procure beds because it has a good track record in procuring services and getting value for money.
The HSE uses private providers of home-care packages. I support that although I am often criticised for it. If the money can go further and provide more services to people at home and if the quality of the service is assured, that is what we should be concerned about. I want to see more of that.
It is not appropriate for me, and it is against the law, to get involved in price negotiations with hospitals on behalf of insurers. I want to see insurers driving down their costs. The costs of some medical procedures are driven, to a large extent, by salary levels. On the public side, we must move to economic costing. The taxpayers cannot subsidise the cost of care for some while it is not accessible to others. The review currently being carried out is looking at whether public hospitals should move to procedure-based costing. In private hospitals the insurers negotiate a price for a procedure. In public hospitals it is based on the number of bed nights per patient. We need to bring greater clarity to this matter. The allocations group's report will greatly help us gain insights in this area.
It must be said that in some cases public provision is cheaper, is of better quality and gives better value than private. The traffic is not all in one way.
I believe progress has been made in patient-level costings, whereby insurance companies pay an agreed cost for a procedure rather than for a bed. I understand the HSE looked at the German system and I would be interested to know if we are to progress to that kind of system, which would facilitate moving towards a "money follows the patient" model. We are all interested in moving towards that kind of universal system, in which one pays for what is done rather than paying lump sums to hospitals simply because they happen to exist.
International evidence supports the opposite. Payment per procedure costs much more than the other method.
I am talking about a payment model.
Doctors who work out of hours are paid a fee per item or per patient. In the Republic that cost €108 million and in Northern Ireland, for the same number of people, the cost was £18 million. We must be very careful how we allocate resources. That is why we appointed a group of experts to advise in this area. This is important, particularly when resources are limited.
Public hospitals are paid by insurers on the basis of a bed charge per night. Doctors are paid separately. They are paid for every private patient who comes into the hospital, regardless of which bed the patient occupies. The hospital is paid only for the designated beds. Many issues arise in this regard.
We must drive down costs. I share Deputy O'Sullivan's view that many long-term patients in the public system have much higher levels of dependency and are more complex cases. We must be sure we are comparing like with like. A patient who requires more nursing care and support will cost more than one who does not require the same level of care. When we compare costs we must be fair in the comparisons we make.
The Minister mentioned the NTPF. How does it assess value for money of procedures accessed in private facilities? The Minister has given approval to 1,000 bed cuts in acute hospitals by the HSE in 2010. Will this not result in more people seeking access to specific procedures through the NTPF? If we are to close public beds in public hospitals we cannot cater for the normal throughput in those hospitals and people will be on longer waiting lists for specific procedures. This will place a greater strain on the NTPF and an additional cost on the taxpayers who fund it.
There have been recent reports that consultants are not adhering to the agreement to do 20% private work and 80% public. In some cases it is reported that consultants are doing 100% private work and are in clear breach of their contract. What monitoring is in place and what measures will the Minister take to ensure compliance by these consultants with their contracts?
On a point of order, how much time is allocated to each question?
Six minutes. We have spent nine minutes on this question and I stand admonished by the Deputy.
With regard to Deputy Ó Caoláin's last question, we now have key performance indicators which measure the number of new out-patients seen by consultants and the public-private mix. There are procedures under the contract for enforcing the agreement. That is under way.
The Comptroller and Auditor General, in his report, measured the prices paid by the NTPF against the casemix benchmark and the comparison is favourable. The fund does incredibly well.
52 Deputy Liz McManus asked the Minister for Health and Children when bowel cancer screening will commence; if it is intended that the hospital personnel who currently carry out symptomatic screening will implement the screening programme; if so, the way she will ensure that symptomatic screening waiting times are not affected; and if she will make a statement on the matter. [10446/10]
74 Deputy Andrew Doyle asked the Minister for Health and Children the details on the roll-out of the national colorectal screening programme; when screening will commence; and if she will make a statement on the matter. [10489/10]
I propose to take Questions Nos. 52 and 74 together.
I am pleased to confirm that work has already begun on putting a national colorectal screening programme in place. The programme will initially be offered to men and women aged between 60 and 69 years. Screening will commence in early 2012 following an intensive period of preparation.
Colorectal cancer is the second most commonly diagnosed cancer among men and women in Ireland. Approximately 2,200 new cases are diagnosed and approximately 1,000 people die from the disease each year. A successful national screening programme has the potential to reduce mortality from this cancer significantly.
The programme will be provided by the National Cancer Screening Service. The immediate focus in preparing the programme is on colonoscopy capacity, accreditation and training. Based on expected uptake and incidence rates, it is estimated that approximately 6,000 colonoscopies will take place each year within the screening programme. Approximately 59,000 colonoscopies are performed in the public hospital system annually.
Last December the National Cancer Screening Service invited 37 publicly funded hospitals, which provide endoscopy services, to submit expressions of interest to be considered as a screening centre. Between ten and 12 screening centres will be required by the programme. Some 28 hospitals have now expressed an interest in participating in a national programme. One of the criteria for hospitals wishing to participate in the programme is that they reduce waiting times for urgent colonoscopies to fewer than four weeks prior to the initiation of the screening programme.
The National Cancer Screening Service is now preparing to undertake a baseline analysis of each hospital endoscopy unit. The outcome of the baseline analysis visits will identify potential areas for improvement and additional investment and staffing requirements. The National Cancer Screening Service will report these findings to my Department. It has already been decided that additional advanced nurse practitioners will be trained to provide additional capacity in the colonoscopy screening centres.
The screening programme will not be allowed to adversely affect waiting times for urgent colonoscopies in the symptomatic services. The need to comply with the four week time limit for urgent colonoscopies has been emphasised to the National Cancer Screening Service and the HSE and I am satisfied that there has been an enormous improvement in the capacity to deliver on this commitment.
It is often pointed out to us that it is difficult for GPs, for example, to say whether a colonoscopy is urgent. The Minister should not just concentrate on urgent colonoscopies and the need to reach the target of four weeks. As I said, it is very hard to know whether a colonoscopy is urgent and all colonoscopies need to be carried out within a safe period of time. Will the Minister address that issue?
Is it intended that advanced nurse practitioners will do the screening? Will gastroenterologists be involved as well? There is a concern that the capacity will need to be increased considerably if the screening is not to affect the regular symptomatic colonoscopies required.
All cancer experts would say one must distinguish between urgent and non-urgent, not only in this area but in regard to symptomatic breast disease. Professor Keane has worked with the College of General Practitioners on referral protocols for doctors.
Professor O'Donoghue has been appointed as the lead for the roll-out of the colorectal screening and he is probably well known to most people in this area. The breakdown between consultants, doctors and nurses involved has yet to be determined but we want to empower nurses as much as possible. In many other countries, this service is provided by advanced nurse practitioners.
In regard to the hospitals that will be selected, a group which advised in the UK will be part of the advisory team visiting the 28 hospitals which have expressed an interest. There is no question of the screening programme being done at the expense of the day-to-day service and that must be factored in.
Will the colonoscopy service be expanded by 2012? I make the observation that this will all be hospital-based. Surely we are missing a golden opportunity to implement this as a community-based service which would achieve two things, namely, it would bring the service closer to patients and it would not allow for the possibility of interference with the symptomatic service because it would be community-based and a separate service. There is absolutely no reason colonoscopies cannot be done in the community.
I understand from speaking to several surgeons that suspected cases of breast cancer receive preferential treatment, in terms of being brought in to be operated on, over established cancers of the bowel and lung and other cancers in women and men. We do not want the same thing to happen with the colonoscopy. Perhaps the Minister will comment on that and on why the screening programme will not be community-based.
We are effectively going to provide a home screening service. The kits will be sent to people and, to a large extent, they will be providing the service for themselves. Some 6% will require follow up by way of a colonoscopy, so that is a relatively small number out of the 200,000 who will be screened every year.
It is not envisaged that we would extend it beyond 60 to 69 years of age in the initial phase. Every new programme must be phased in, as was done in Sweden, Finland and the UK.
It would not make sense to duplicate a service in the community which we currently have at hospital level. We want ten or a maximum of 12 centres nationally. All the advice from both the Health Information and Quality Authority and the National Cancer Screening Service was that for many reasons, these colonoscopies should be done at hospital level.
Given that bowel cancer is the second most commonly diagnosed cancer in men and women, that its incidence increases with age and that it is projected that the population for the 60 to 69 age group in 2012 will be in excess of 278,000, can the Minister guarantee that she will have the necessary roll-out to ensure a comprehensive screening of that population? Following on from that, will she have in situ the required treatments and supports for those who have been diagnosed with bowel cancer as a consequence of that screening exercise?
Where somebody requires follow up, either a colonoscopy or treatment, that will be integrated as part of the service as it is with the breast screening service or the cervical cancer screening programme.
On the population to be screened, initially we are talking about people from 60 to 69 years of age. Half of the cancers occur in that age group. The resources will be made available and I acknowledge the support of the Irish Cancer Society which is providing resources towards the implementation of this programme, which is very helpful.
We have learned from other countries that we need to invest hugely in advance publicity and information because it is a very different screening programme. It will be the first screening programme involving men and the first screening programme where much of the screening will be self-screening using the kit that will be sent out. We need to be involved in advance publicity and information campaigns and they are currently being devised.
53 Deputy Michael Noonan asked the Minister for Health and Children the details on the recruitment of the next chief executive officer of the Health Service Executive; the number of candidates who have expressed interest in same; the timeline for the interview process; and if she will make a statement on the matter. [10522/10]
67 Deputy Fergus O’Dowd asked the Minister for Health and Children if the salary of the new chief executive officer of the Health Service Executive will be paid less than the current post holder; and if she will make a statement on the matter. [10527/10]
I propose to take Questions Nos. 53 and 67 together.
The board of the Health Service Executive has begun the recruitment process for the next chief executive officer of the HSE as the contract of the current CEO, Professor Brendan Drumm, expires in August this year. In accordance with section 17 of the Health Act 2004, the HSE board is responsible for making the appointment. That Act stipulates that the recruitment process must be in accordance with the Public Service Management (Recruitment and Appointments) Act 2004.
I understand the recruitment process initiated by the board is being conducted in accordance with the code of practice issued by the Commission for Public Service Appointments. Much of the information about this competitive process is, by its nature, confidential, such as information about applicants and interviews, and it is not appropriate, therefore, for me to seek access to the details sought by the Deputy. However, I understand the intention of the board is to ensure the process will be complete in time for an orderly handover of responsibility.
Public advertisements for the position were placed nationally and internationally in December 2009. As part of the recruitment process, an executive search and recruitment company, Amrop Strategis, has been engaged by the board following competitive tender to conduct an international search for the position.
The salary rate for the post is €228,466. This is the same as the current salary rate for the Secretaries General of the Departments of the Taoiseach and Finance and is in line with the recommendations of the review body reports in 2007 and 2009 for the CEO of the HSE. A higher remuneration level was approved for the current CEO on his appointment to reflect the particular challenges for the first appointee to the post.
The Minister named the firm involved in the recruitment process. What will be the cost of the process and how much will the company in question charge? How many internal and external applications have been received for the position of chief executive of the Health Service Executive? When will the appointment be made? I presume the rumours that the vacancy is the subject of the recruitment embargo are untrue.
The cost will be €34,000, excluding VAT. I understand the company in question approached 113 potentially suitable candidates and subsequently met 25 of these candidates. I also understand 40 responses were received as a result of an advertisement placed in newspapers. A shortlist of ten candidates has been drawn up and it is expected that interviews will be conducted during this month.
The cost of the advertising campaign was €25,055. Advertisements were placed in The Irish Times, The Sunday Times, Sunday Independent, Irish Independent and The Economist. I am pleased to note The Economist was used.
The €25,055 cost is in addition to the €34,000 fee.
Yes.
While I do not expect the Minister to respond, I am curious as to whether Professor Keane was one of the applicants for the job. I welcome the decision to reduce the salary for the chief executive to the same level as the salaries of the Secretaries General of the Department of the Taoiseach and Department of Finance. Will bonuses be written into the salary?
With a Cabinet reshuffle pending, will the Minister scotch any concerns we may have by confirming her name does not feature on the shortlist of candidates?
Were that the case, it would mean a substantial increase in salary. It is not envisaged that a bonus will be payable to the new chief executive. A decision was taken recently on the payment of bonuses in the public sector.
54 Deputy David Stanton asked the Minister for Health and Children if she plans to develop a national plan for rare diseases; the consultations she has had with rare disease and genetic disorder patient support groups and other organisations in this regard; and if she will make a statement on the matter. [10543/10]
The term "rare disease" refers to conditions with a low prevalence of no more than five per 10,000 persons in the population. It is estimated that there are between 5,000 and 8,000 distinct rare diseases affecting in total between 6% and 8% of the population over the course of their lives.
I have met with the Irish Platform for Patient Organisations, Science and Industry, IPPOSI, which represents rare disease patient organisations and industry and the Genetic and Rare Disorders Organisation, GRDO, on issues relating to health care for patients with rare diseases.
Research on rare diseases is scarce and scattered in different laboratories throughout the European Union. Owing to the small market, investment in medicinal products and devices for people with rare diseases is limited. As a result, the price for many of the treatments is such that it is impossible for them to meet conventional criteria for cost effectiveness. Progress has been made on specific rare diseases such as haemophilia. Through the work of the Haemophilia Produce Selection and Monitoring Advisory Board, the cost we are now paying for blood products has reduced substantially in recent years.
I have asked the clinical director of the Health Service Executive, Dr. Barry White, to explore a mechanism whereby a ring-fenced drugs budget could be put in place to specifically cater for people with other rare diseases. Work has also commenced on other elements of rare disease policy such as screening procedures and the organisation of reference centres and clinical networks involved in the diagnosis and treatment of rare diseases.
In view of the low prevalence of rare diseases, there is added value in working collaboratively at EU level and Ireland has supported the EU Council recommendation on an action plan for rare diseases which was adopted in June 2009. Ireland has two years to prepare a national plan.
Is it true that 140,000 people in Ireland suffer from rare diseases? When will the action plan be published?
While I do not have a figure on the numbers involved, it is anticipated that between 6% and 8% of the population is affected by a rare disease. Support is provided for many rare diseases, for example, haemophilia. In a constrained budgetary environment it is difficult to make choices where one product may help 1,000 people and another product only ten people. I have had a good engagement with Dr. Barry White and we may ring-fence a sum of money each year to be allocated to budgets for rare diseases. This would avoid the challenge such budgets face from disease groups with much larger numbers of patients.
A call has been made to develop a national action plan.
Ireland must produce a national action plan and one is in preparation.
Written Answers follow Adjournment Debate.
