Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Thursday, 14 Feb 2013

Vol. 792 No. 3

Priority Questions

Medical Card Eligibility

Billy Kelleher


1. Deputy Billy Kelleher asked the Minister for Health if he intends to revise the criteria for issuing medical cards on the basis of medical need; and if he will make a statement on the matter. [7879/13]

The medical card scheme cost in excess of €1.9 billion in 2012 and, by the end of 2012, 1.85 million people were covered by the scheme, an increase of half a million people since 2008. It is expected that the total will reach 1.9 million by the end of this year.

Under the provisions of the Health Act 1970, medical cards are not awarded on the basis of having a specific illness or a specific disease. Rather, they are provided for persons who, in the opinion of the Health Service Executive, are unable without undue hardship to arrange general practitioner, GP, services for themselves and their dependants. The assessment for a medical card is determined primarily by reference to the means, including income and reasonable expenditure, of the applicant and his or her partner and dependants. The assessment guidelines were published by the HSE in 2009 and are publicly available on the HSE's website. Under the current legal framework, there is no automatic legal entitlement to a medical card solely on the basis of a specific illness.

However, under the Health Act, there is provision for discretion by the HSE to grant a medical card where a person's income exceeds the income guidelines. The HSE takes a person's social and medical issues into account in determining whether "undue hardship" exists for a person in providing a health service for themselves or their dependants. The HSE recently set up a clinical panel to assist in the processing of applications for such discretionary medical cards, where there are difficult personal circumstances. This approach recognises the need to have in place a standard process for considering applications in respect of people who, while over the income guidelines, require a discretionary assessment on the basis of illness or undue financial hardship.

There are no proposals to revise the criteria under which medical cards are granted. However, the programme for Government commits to reforming the current public health system by introducing universal health insurance with equal access to care for all. As part of this, the Government is committed to introducing, on a phased basis, GP care without fees within its first term of office. Legislation is currently being drafted by the Office of the Attorney General and the Department to extend access to GP services without fees to persons with prescribed illnesses and it will be published shortly.

I have raised this issue of the qualification criteria and the discretionary scheme on a number of occasions. Now, there is a clinical panel in place to assess and adjudicate on discretionary grounds. My concern is, and I believe every Deputy has had the same experience, that people who have been diagnosed with cancer are finding it more difficult to get medical cards on the discretionary ground of health needs. That is a problem. I accept there has been a major increase in the number of medical cards issued to the public. The reason for that is the economic downturn. People are assessed on financial means.

However, there must be greater flexibility with regard to qualification on medical grounds. Heretofore, if a person was diagnosed with cancer, he or she made an application for a medical card and was granted it, not on the basis of financial need but on medical grounds under the discretionary scheme. This clinical panel has raised the bar so high that people simply cannot access discretionary medical cards on health grounds. That is the indication I have been given. I raised this in the Dáil on a number of occasions and I passed the details to the Taoiseach, as he invited me to do one morning after Leaders' Questions. This issue is causing huge hardship for people who have been diagnosed with cancer.

The Irish Cancer Society and others are of the view, which I believe is correct, that there should be a mechanism whereby a person who is diagnosed with cancer can apply for and get a medical card, and that it would be timebound. Major advances have been made in cancer care, cancer treatment and survival rates. They could be granted a card for the duration of the treatment and any secondary aspects to that treatment, and once they have completed the course of treatment and received the all clear, the medical card could be withdrawn.

This is an important issue and it has been addressed. I can give the Deputy some further information on this important question. There are currently 62,987 discretionary medical cards in circulation out of a total of 1.85 million medical cards. New processes have been commenced in respect of applications for discretionary medical cards. It is important to recall that sometimes there is confusion between discretionary medical cards and emergency medical cards. They are different cards but occasionally there is confusion about that. We are discussing discretionary medical cards.

Under the process that has been put in place a medical officer from the Dublin/mid-Leinster region region has been appointed as the national lead with responsibility for managing the process. The national lead established temporary arrangements while appropriate medical personnel were being identified across the country. One of the issues is freeing up medical capacity to undertake the assessments and that has been addressed. A total of 12 medical officers are now involved in the assessment of discretionary applications. There are various needs assessments from region to region depending on the specific demands on the community medical service in that region. Training sessions have also been put in place for the medical officers involved in this important process. The current position is that, as with any new system, there have been some challenges during implementation. Each RDO has confirmed that where these difficulties have been identified they have been addressed.

All outstanding applications are being processed as a priority. The number of total outstanding applications has been reduced from 3,602 last December to 1,447 on 31 January.

The Minister must conclude. We are over time.

The current average turnaround time for discretionary medical card applications is now 20 working days. I have further information on the broader application of the scheme which I can make available to the Deputy.

There is no confusion on the part of the Minister or myself about the difference between emergency and palliative care medical card applications.

Deputy, the time for the question has concluded. We must proceed to the next question.

Graduate Nursing Scheme

Caoimhghín Ó Caoláin


2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will withdraw his scheme of two-year contracts on reduced salaries for graduate nurses; if he will enter talks with nurses’ representatives who have expressed willingness to discuss genuine savings while safeguarding the already reduced pay of their members; and if he will make a statement on the matter. [7763/13]

This scheme represents an opportunity for a substantial number of recently-qualified nurses to work in Ireland for a two-year period and to gain valuable experience and additional skills at a time when job opportunities in the public service are, regrettably, very limited. Graduate nurses and midwives are of course entitled to choose whether to participate in the initiative or to pursue their careers elsewhere, but I hope to see a steady increase in applicants over the coming months.

The recruitment of graduate nurses under this scheme, currently in train, will continue. The HSE will accept applications on an ongoing basis for Phase 1, covering registered general nurses for the acute hospital setting and the community, from 2012 graduates and also those who graduated in 2010 and 2011. Further recruitment will continue during 2013. Phase 2, which will cover mental health, intellectual disability, midwifery and paediatrics, will launch in the coming days. There will also be opportunities for those who graduate in 2013 to participate. The intake was always expected to be spread over a period, especially since the scheme was being introduced some months after most 2012 graduates completed their training last September.

The initiative will give nursing and midwifery graduates an employment opportunity and facilitate their professional development. They will be able to avail of a suite of educational programmes, including intravenous canulation and training in anaphylaxis treatment. It has also been agreed that participants will be facilitated in obtaining a certificate in advanced health care skills to cover areas such as health assessment and pharmacology. The Minister for Public Expenditure and Reform approved this employment initiative on the basis that participants would not be counted in health service staff numbers and that it would result in savings on unsustainable levels of agency and overtime expenditure. Given the requirement on the HSE to reduce numbers employed and to maximise savings, there is only limited scope to offer permanent posts at the starting point of the staff nurse scale at present.

I was a member of the Sinn Féin delegation which met recently with the troika. I was very conscious in that regard of the impression - widely reported in the media - the Minister gave that permission to introduce what many call a yellow pack scheme for qualified nurses was achieved in negotiations with the troika. It was made clear to us by the troika at our meeting that the scheme is entirely of the Government's doing. Will the Minister acknowledge that the scheme is his baby alone? Can the Minister tell the House how many applications have been received for what is an undermining of graduate nurses' qualifications and entitlements? They will receive two-year contracts at 80% of the salary of serving nurses. These nurses are fully qualified and will take on full responsibility within whatever setting they find employment. Does the Minister accept that nurses in general and psychiatric nurses have voted with their feet? Will he withdraw the scheme? Will he sit down with the unions as they have requested and discuss genuine measures for savings while protecting the already reduced pay and entitlements of nurses across the board thereby ensuring the highest standards of patient care?

The scheme is a major concession on the basis that the nurses will be employed outside the employment control framework which has been set and within which we must reduce numbers. It allows us to create what was previously known as a "nursing bank" which will include people with the type of skills we require. The current dependency on agency nursing means one has to take the agency nurse provided. An agency nurse might work one week in orthopaedics, the next in a cardiac unit and the following week on a rheumatology ward. One is not getting the ideal level of continuity. With a nursing bank, one has access to groups of nurses one knows are skilled in particular areas. They are the nurses who will fill the gaps which are created by maternity or sick leave. The scheme will enhance the employability of the graduates who go through the two-year programme. They will emerge with skills which are not as freely available among their colleagues. It will confer on them an advantage in competing for employment here or elsewhere should they wish to travel abroad.

Very briefly, Deputy Ó Caoláin.

The Minister's description of the scheme as a major concession does not, with respect, fit with what the troika said in response to my questions in the course of the meeting with Sinn Féin. Does the Minister accept that the scheme will involve the displacement of up to 1,000 nurses and midwives who are currently employed through agencies? Does he accept that no additional nursing hours will arise from the implementation of the programme? Does he accept that the starting salary for a new entrant nurse or midwife has already been cut by 24% since 2009 and that the programme has no specific additional educational component? Does he accept that the programme will see new graduates having to accept 100% responsibility as regulated, registered professionals while receiving only 80% of the appropriate pay rate? That is the bottom line. There is no guarantee in relation to the future career path of these nurses after the two years.

Thank you, Deputy. We are well over time.

Will the Minister, therefore, withdraw the scheme and engage with the unions directly?

Very briefly, Minister. We are way over time.

I know the rules of the Chamber do not allow me to respond and I have to move on to Question No. 3.

That is why so many questions are put in the manner in which they are, I suppose.

Not at all. You have the time to respond.

I reject what Deputy Caoimhghín Ó Caoláin has to say. The answer to his question as to whether I would withdraw the scheme is absolutely not. There is no question of it.

In relation to the next question.

Question No. 3 is in the name of-----

Wait a minute, Minister. The next question has not been called.

You have decided it yourself. You are not the Chair. You are the Minister who has to come in and answer questions.

I do not need you to tell me what the rules are. You have already pointed out that you have asked a load of questions and I am not allowed to respond.

You were not called to the next question. You were called to respond.

The Chair has let me respond to inform you. You have been informed. So be it.

The Chair did not call the next question.

Deputies, we need to move on.

You have chosen not to answer. Your choice.

I beg your pardon. The Chair can rule on this. You have asked a question in writing, I have responded verbally in the Chamber. You have a response to that. I responded to that. You have the final response.

That is the case. That is always the case.

The Minister has a response. You have the last word.

It is bizarre that the Minister would have recourse to that type of action.

I am quite happy to answer.

Ask your attending Minister of State, Deputy Alex White. You only declared a moment ago you know exactly the workings of the Dáil Chamber.

You are demonstrating that it is only as it suits you.

Let the Chair rule.

Deputy and Minister, can we move on to Question No. 3? There are a lot of questions we are hoping to get through.

Hospital Mortality Rates

Luke 'Ming' Flanagan


3. Deputy Luke 'Ming' Flanagan asked the Minister for Health if he will provide the mortality rates in the former coronary care unit at Roscommon County Hospital and the rates at University Hospital Galway; and if he will make a statement on the matter. [7764/13]

The Chief Medical Officer's office of my Department has been working on a report entitled Health Care Quality Indicators in the Irish Health System: Examining the Potential of Hospital Discharge Data. The focus of the report is the quality of the data not the care provided. One of the indicators examined in the report is derived from the hospital inpatient inquiry, or HIPE, data 2008-10 which recorded 30-day, in-hospital mortality rates following heart attack - that is acute myocardial infarction. This is the basis for the Deputy's question. It is important, therefore, that I restate what I said on 5 July 2011 which was: "Some of the statistics in the report, while rough, are so startling that they cannot be ignored." I further stated on 21 of July 2011:

I stand over these figures as does my Department and they will stand up to scrutiny because they were supplied through the HIPE data mix by the hospitals.

The analysis and rates I quoted on both dates were an accurate reflection of the data reported by the individual hospitals, including Roscommon Hospital, to the HIPE system. The information I recorded in the Dáil at that time is therefore correct. Following a period of consultation and further analysis, the aforementioned report on health care quality indicators in the Irish health system is being finalised with a view to publication in the near future.

I take this opportunity to draw attention to a number of changes to the structures and services being delivered in Roscommon. Roscommon Hospital falls under the newly established governance structure of the Galway and Roscommon University Hospital group. As a model 2 hospital, Roscommon provides the majority of hospital activities including extended day surgery, selected acute medicine, local injuries, a large range of diagnostic services and palliative care. Future growth is planned in the areas of ambulatory care, including chronic disease management and day surgery, diagnostics and rehabilitation.

I thank the Minister. The statement he made on 5 July 2011 in the Dáil and on 21 July 2011 before the joint committee on mortality rates in the coronary care unit at Roscommon Hospital was as follows:

A patient attending Galway University Hospital has a 5.8% mortality rate compared with a 21.3% mortality rate in Roscommon, which is four times greater.

That was not correct. At the time, the actual data was extracted from the coronary care unit register by Dr. Patrick McHugh, a medical consultant at the hospital, correlated by John McDermott of the Roscommon Hospital action committee and provided to Professor John Crown.

In his statement to the Seanad on 12 July Senator Crown stated that he had independently verified this data and that the figures that the Minister had provided to the Dáil were incorrect. When the correct figures are examined the average mortality rate for Roscommon Hospital between 2008 and 2010 is 4.92%. On this basis statistically Roscommon County Hospital was in fact a safer hospital in which to be treated than Galway, contrary to the Minister's comments. This was again acknowledged by Dr. Martin at the same meeting of the Oireachtas joint committee when she stated that subsequent analysis of the data compiled on Roscommon Hospital and work undertaken by the hospital highlighted limitations in the quality of data and had been more reassuring on the quality of care provided. The Minister needs to correct the record because what I have seen on the record is not correct.

I reiterate, "Some of the statistics in the report, while rough, are so startling that they cannot be ignored. They were gathered over the past three years, one set of statistics shows that a patient attending Galway University Hospital has a 5.8% mortality rate compared with a 21.3% mortality rate in Roscommon which is four times greater". That is what I said and I stand over it.

Since that time the number of people attending Roscommon Hospital has gone up. New surgeries and medical facilities are available. There is now plastic and reconstructive surgery present which commenced at the end of 2011 and was extended to two days a week. This service is growing with 50 patients booked for each day of the clinic, 100 patients per week, significantly improving access and reducing waiting times. Sleep studies commenced at Roscommon Hospital in March 2012 and already 204 patients have been assessed.

The urology services commenced at the hospital in May. I do not believe I have spoken for a minute. Have I?

Yes, there is just under a minute left in this slot and I want to let Deputy Luke Flanagan come in with a supplementary question and then the Minister can respond.

I will just mention that there is an endoscopy suite, a radiology upgrade, dental service, nursing initiatives around nurse prescribing and nurse x-ray, a medical rehabilitation service, which will be founded there, and the Mayo-Roscommon Hospice met with the hospital group in June 2012 and is progressing with its plans.

Needless to say as someone who represents the constituency in which Roscommon Hospital is situated I welcome anything new that comes to the hospital. Of course I do. Why would I not? It is obviously to my benefit and that of my family, my neighbours and constituents. The Taoiseach, Deputy Enda Kenny, promised us at the last general election that our accident and emergency department would be safe. The Minister's comments and his failure to correct them in the Official Report has caused irreparable damage to the reputations of the medical clinicians, the staff and the hospital. I am now requesting that the Minister correct inaccurate statements made in the Dáil which would at least go some way to restoring the reputations damaged by his original misleading, inaccurate statements on this matter. That must be done because the Minister has done damage.

As the Deputy knows full well he was at a meeting with HIQA and other representatives of his constituency, including Deputy Feighan, at which HIQA stated clearly that this service could not continue because it was not safe and furthermore it could not be made safe. During the course of that meeting the Deputy advised one of the officials of the HSE to go and get a rope and hang himself.

How many times does the Minister have to say the same thing?

For as long as the Deputy keeps bringing this up and misrepresenting the situation I will remind him of his own deficiencies and faults.

Does the Minister accept that he has deficiencies?

Health Insurance Prices

Billy Kelleher


4. Deputy Billy Kelleher asked the Minister for Health when he will act to stop the rise in the cost of private health insurance; and if he will make a statement on the matter. [7880/13]

On 28 January I met with the top management of the VHI. It informed me of its intention to increase premiums by 8% having previously communicated an 11% increase. I told it in the strongest possible terms that this was not acceptable to me. It has since announced that the premium increase will now be 6%. However, I remain very concerned about the cost of health insurance and have requested the VHI to submit a detailed cost containment plan, which is in preparation, with clear targets and timelines under each heading so as to minimise the need for any future premium increases.

I have repeatedly raised the issue of the cost of private health insurance with insurers and am determined to address costs in the sector in the interests of consumers. Last year, I established the Health Insurance Consultative Forum which comprises representatives from the country's main health insurance companies, the Health Insurance Authority (HIA) and my Department. This forum was established to generate ideas which would help address health insurance costs, whilst always respecting the requirements of competition law. I have made it clear to the health insurers that I believe significant savings can be made, the effect of which can be to contain the cost of health insurance premiums. Given the VHI’s very significant share of overall costs in the market, I will continue to focus strongly on the need for the VHI to address its costs and to address aggressively the base cost of procedures, including professional fees.

The programme for Government commitment to put a permanent scheme of risk equalisation in place in the private health insurance market has been achieved following the passing, in December 2012, of the Health Insurance (Amendment) Act 2012. The new risk equalisation scheme came into effect from 1 January, 2013 when it replaced the previous interim scheme. This is a key requirement for the existing private health insurance market and is designed to keep health insurance affordable for older persons, to maintain the stability of the market and to contribute to the protection of affordability for those who need it most.

The Minister is totally inconsistent when it comes to private health insurance, in what he said two years ago and what he has done since he took office. Families are under huge pressure to pay and retain private health insurance. When the Minister brought forward the Health Insurance (Amendment) Bill last November he said that the lower plans would not be rated at the high rating of risk equalisation but when it came to the passage of the Bill all plans were rated at the high rating. That went against what the Minister had said on Second Stage. It has already had an impact on people's ability to retain private health insurance.

The Minister talks about universal health insurance and all that will flow from that. His policies to date are driving people out of private health insurance and forcing more people into the public hospital system which is against everything that he stated previously. Would he please explain why all plans were rated at the higher level in view of the fact that he said they would not be and the Health Information Authority also recommended that 47 plans should be on the lower rate?

It is very difficult not to remind the Deputy that during his party's tenure the price of premia went up and up and up. Since last year we have made serious attempts but they are not enough - more needs to be done and I have made that very clear in my initial response. We are reducing consultant fees, there has been a 15% reduction in the past two years, and the price of procedures has been reduced by between 13% and 53%. This has already been done. A payment scheme for radiologists and pathologists was introduced, based on the national quality benchmarks which will lead to reduced lengths of stay and has the potential to save €42 million per year for the VHI. The reduction in length of stay and price for some high volume procedures saved €7 million in 2012.

I could go on but I have advised the VHI that notwithstanding that it is responsible for only 57% of the market it is responsible for 80% of the pay-out. It must reduce the cost of each procedure. Why are we still paying the same rate for procedures that used to take two hours but now take only 20 minutes because of modern technology? We must pay by procedure rather than average length of stay which only encourages inefficiency. We have to introduce a more robust audit because the audit has clearly not been robust enough. Finally we need to bring in clinical audit so that clinicians are challenged as to why they are performing and repeating tests that others with a more objective view might say are unnecessary.

This time two years ago the Minister was apoplectic with rage in this Chamber because the VHI had announced a moderate increase. Since he took office, however, we have had consistent increases, year in year out, month in, month out. The facts do not lie. People are dropping out of health insurance at an alarming rate. The legislation that the Minister passed and brought through this Chamber and the Seanad last year had a direct impact and forced health insurers to increase premia particularly on the lower plans.

Why did the Minister not take the advice of the Health Insurance Authority, HIA, and ensure the 47 lowest plans were on the lowest rate of risk equalisation? What changed in the meantime?

I have discussed this with the insurance companies. They require very little modification for all to fall into the lower rating. When the Deputy's party was in power there was a 23% increase in 2008, 11% in 2009.

I am talking about 2013.

Yes, but the Deputy has accused me of presiding over a rapid rise in premia.

Five years ago, the Minister nearly fell over himself about the rise in health insurance when he was on this side of the House.

The Deputy's interpretation of events is somewhat at variance with reality.

The Minister to conclude without interruption.

The Minister should look it up on YouTube.

I will conclude. The figures I referred to are well above the 6% premia increase that is currently planned. The applications I have put into the system should not increase the overall cost of health insurance. It is about community rating and transferring the risk from the older and less well back to the young who are more well. That was always the way. It was the same when I was young and paying my insurance. I was subsidising older people. Community rating is accepted on all sides of the House.

The problem is younger people cannot afford private health insurance.

Mental Health Services Report

Maureen O'Sullivan


5. Deputy Maureen O'Sullivan asked the Minister for Health if he will provide a breakdown in relation to the 477 posts allocated for mental health in the Health Service Executive's 2013 national service plan; the number of staff of each discipline that will be appointed; to which service, old age, intellectual disability, forensics and so on; to which geographical areas they will be allocated; and if he will make a statement on the matter. [7765/13]

The 2006 report of the expert group on mental health policy on the implementation of A Vision for Change is a priority for the Government. In this regard, budget 2012 and budget 2013 provided an additional €35 million each year for the continued development of our mental health services. The Health Service Executive, HSE, national service plan 2013 commits to a number of objectives including the further development of forensics and community mental health teams for adults, children, older persons and mental health intellectual disability and to the recruitment of 477 additional staff to implement these measures.

The additional funding provided in 2012 and 2013 is being used primarily to further strengthen community mental health teams by ensuring, at a minimum, that at least one of each mental health professional discipline is represented on every team. The professional composition of these teams will be consistent with the posts described in A Vision for Change such as consultant psychiatrists, psychiatric nurses, clinical psychologists, social workers, occupational therapists, speech and language therapists and social care workers.

To ensure the additional resources will be used to best effect, discussions are ongoing in the HSE, and in consultation with the Department of Health, to finalise the allocation of these resources. It has been agreed the allocation of staff will be subject to detailed business cases from the HSE regions for each objective. The following conditions should be met - all posts will be allocated to the community mental health teams for each objective and for no other purpose; all teams must discharge the team co-ordinator role to ensure effective working as a multidisciplinary team; all teams must implement the clinical programmes, as agreed; all teams must complete and return required key performance indicators, both existing and new; all postholders will work as part of a mental health services community mental health multidisciplinary team.

Additional information not given on the floor of the House

Each HSE region is being asked to submit a business case against each of the identified objectives detailing how the funding is to be spent and the type and number of WTE to be recruited. It is expected that this process will be concluded by end March 2013. Until that process is completed, I am not in a position to identify the type of each post and where it is to be allocated. I am assured that the matter is being given priority within the HSE.

In 2012, 414 posts were promised for community mental health. It broke down as 150 to CAMHS, child and adolescent mental health services, 220 to the adult mental health community teams, 34 to suicide prevention and ten for mental health primary posts. On 31 January 2013, of that 414 just 193 had taken up positions. Will the Minister ensure that the delays that occurred in 2012 will not be replicated in 2013? I am particularly interested in CAMHS because if we can have the proper teams in place at the childhood stage, it will act as a strong measure of prevention and ensure these children do not end up in adult mental health services.

I thank the Deputy for her question. Both myself and the Minister of State, Deputy Kathleen Lynch, have discussed this matter at length. We are both committed to ensuring these positions are filled. There were delays last year but we have been assured by the HSE that this will not happen again this year and the positions will be filled. We are concerned about having proper community mental health services to support people in the community. This forms part of a much larger picture in dealing with the modern scourge that is suicide.

Mental health has been the Cinderella of the health service. Within that, the area of intellectual disability and the mental health needs of people with an intellectual disability are even further down the pecking order. There is a need to address this as there has been a lack of progress in developing the mental health of those with intellectual disabilities. Will the Minister give me an assurance that this will get a priority and that there is no further watering down of A Vision for Change? This amazing document shows what needs to be done in the area but it seems to have been just chipped away at since 2006. While I am not putting all the blame on the Minister, mental health has not got the priority it should have.

Having worked for 20 years as a visiting general practitioner to St. Ita's, I know psychiatric treatment, intellectual disability and mental health services have been the Cinderella of the health services. We are doing everything in our health policy to address that. For example, primary care centres must have a mental health facility that will destigmatise this issue so that people will feel just as comfortable going into the centre with a mental health issue as they do with a physical health issue. All the newer hospitals have mental health facilities on their premises as opposed to the old way of separating people out. St. Ita's, for example, was put down the end of a peninsula. Originally, it was intended to put it on Lambay Island, out of sight and out of mind.

All sides of the House are committed to A Vision for Change. I, the Government and the Taoiseach are committed to it. The HSE has assured us the delays in filling the posts last year will not happen this year. We will monitor it to ensure progress is made in this regard.