Ceisteanna ar Sonraíodh Uain Dóibh - Priority Questions

I wish Deputies, Ministers and the staff of the Houses a very good and prosperous day as they get down to their work once again.

That is a very nice start to the day.

It is all downhill from here.

HSE National Service Plan

Stephen Donnelly


1. Deputy Stephen Donnelly asked the Minister for Health when a winter plan for hospitals will be brought forward; the reason for the continued overcrowding in emergency departments during 2019; and if he will make a statement on the matter. [41485/19]

Louise O'Reilly


2. Deputy Louise O'Reilly asked the Minister for Health when the winter plan 2019-20 will be published. [40975/19]

I ask Deputies to co-operate with the time limits to allow us to get through as many questions as possible. Questions Nos. 1 and 2, in the names of Deputies Donnelly and O'Reilly, are being taken together.

How does the Chair want to do it?

As Question No. 1 is in the name of Deputy Donnelly, he can introduce both questions.

We will all be aware of the severe overcrowding in our emergency departments. I am sure the Minister is aware of the case of a woman in her 80s who had to wait on a trolley in Limerick for four and a half days last week. Her daughter said that she was moved around and had to lie under a glove dispenser while people tried to get gloves. I think we can all agree that nobody wants to see so many people waiting and such a level of suffering having to be endured. We have never seen anything like it in Ireland. Why is this still happening, in spite of enormous increases in budgets? When will the winter initiative be brought in?

I thank the Deputies for tabling these important questions. This is happening because of years of decisions that there were too many hospital beds in the health service. As a result of the withdrawal of beds during that time, we need to continue to increase the number of beds. This year, for the first time since 2009, there are 11,000 open beds in the health service. We need to continue to increase this number while simultaneously reorientating the health service. I understand that a question tabled by Deputy Brassil, which we will come to later, relates to how we build up our community care.

On budget day, we announced the provision of €26 million between now and 31 December for winter preparedness. From memory, I think this is the largest sum we have allocated for the period from now until December. When I met the chief executive of the HSE, Mr. Paul Reid, on Monday, I made it clear that the HSE needs to get on with spending that money on increasing home care supply, increasing access to transitional care and providing extra funding for the fair deal. We are announcing the flu vaccine campaign today. We are fully funding that as well.

We are also looking at access to diagnostics. The Deputy and I were both present at last week's meeting of the Joint Committee on Health when it was told that, on an average day, there might be 30 people in the hospital he mentioned who could get home if they could access diagnostics such as MRI scans and CAT scans. The provision of mobile diagnostic facilities in places like Limerick is an absolute priority as well.

The emergency department task force, which is meeting today, is one of the many forums at which the issue of overcrowding is discussed. There will be an opportunity to discuss overcrowding with nurses, patient representatives, doctors and health service managers throughout the country. I am pleased that Anne O'Connor, who is the chief operations officer in the HSE, has been leading on winter preparedness. She has been working on integrated winter plans between the community care system and the hospital groups. These integrated plans will support the development of a single overarching winter plan from the HSE, which will be finalised in the coming days. I am satisfied that we have provided the HSE with significant funding to increase the number of social and community supports that are available to try to decongest some of our hospitals.

The hospital in Limerick to which Deputy Donnelly specifically referred has, like the mid-west as a whole, has been neglected in terms of bed capacity for many decades. That neglect stops now. A 60-bed modular unit is under construction in the hospital as we speak. A further 96 beds are outlined in the capital plan. This means the hospital in Limerick will see a net increase of approximately 150 beds.

I thank the Minister for his response. I want to put something to bed. I keep hearing him saying that the failures in healthcare today, the likes of which this country has never seen and cannot be seen anywhere else in Europe, are somehow the result of some beds being taken out of the system 15 years ago.

The reality is that under the most recent Fianna Fáil Government, the number of beds increased by well over 1,000. There were a small number of years when a few beds came out. Does the Minister believe that this is causing the current failures? He and his colleagues have been in government for nine years. They have almost had a decade in power. In the Minister's term alone, the health budget will have increased by almost €5 billion. We need to start solving these problems. It is not helpful to pretend that overcrowding in emergency departments today is caused by beds being taken out of the system over a period of two or three years 15 years ago. There is overcrowding today because we have the lowest number of doctors anywhere in the developed world, the diagnostic suites are not open often enough and the home care packages are not in place, which means that delayed discharges are pushing back onto the system. This is a whole-system issue.

I will endeavour to be helpful. In fact, the policies of both Fianna Fáil and Fine Gael have brought us to this point. Perhaps the Minister and Deputy Donnelly can take some time afterwards to divvy up the exact portion of blame between themselves. I think the Minister will agree that he should have published the winter plan at this stage. Anyone looking in here who spent last night sitting beside a parent or loved one on a trolley does not want to hear squabbling. Such people want to hear what the plan is. The Minister mentioned new beds in Limerick, but both of us know they will not help this winter.

This winter is coming. Nurses in Limerick have been already through the worst overcrowding they have ever seen in their long careers. They are at the end of their rope. The Minister is telling them they will get beds at some point in the future, but they know they will have to deal with the coming winter in the meantime. When will he publish the winter plan? Will it contain all the learnings that he said he would take from last year's failure to deal adequately with winter? Has he reviewed the value for money of private beds? Has he reviewed the value for money of the almost €1 million that has been spent on public relations? Has he reviewed the value for money of home care packages? Will that be incorporated into the plan? When will it be published?

I know the Deputy does not like squabbling. I would not call it squabbling; I would call it debating in a parliamentary Chamber on whose policies work and whose policies do not work. When someone is dealing with complex healthcare matters, one-liners only take him or her so far. Deputy Donnelly has characterised the current position by referring to "the likes of which this country has never seen", but that is not the case. Waiting times for hospital operations are falling. We do not know what the outpatient waiting lists were the last time Fianna Fáil was in government because they were never published until my party came into government. The Deputy used to agree with my analysis of Fianna Fáil's healthcare record, but he does not agree with me now, obviously.

We are all entitled to change our minds.

I will remind the Deputies opposite of Fianna Fáil's record in health. It slashed the health budget. Its leader set up the HSE in a way that did not work. During the Celtic tiger years, it built loads of motorways and deserves credit for that, but it did not build any acute hospitals.

That is the record. We are now working constructively on an agreed way forward on Sláintecare, but we need to hear whether Fianna Fáil is in favour of things like the de Buitléir report on taking private practice out of public hospitals. I know Deputy O'Reilly is.

I have heard Deputy Donnelly talk a lot about consultants. He wants to pay them more. They have a legitimate point on pay parity, but Fianna Fáil wants them to work differently. Does Deputy Donnelly believe it is right that private practice is happening in University Hospital Limerick while public patients are waiting on trolleys? I do not; I believe it is absolutely unfair and I want to implement the recommendations of the de Buitléir report. I hope Fianna Fáil will work with me on that.

Deputy O'Reilly is correct that the 60 beds in University Hospital Limerick will not be open this winter and I am certainly not suggesting they will. They are under construction and will open in 2020. That is important. It takes time to build a hospital extension and we now have funding for that.

In the absence of projects like that being ready for this winter, we need to look at how we can shift care into the community and decongest some of the hospitals. When I was in University Hospital Limerick on an unannounced visit recently, staff talked about the need for more home care. I credit Fianna Fáil with engaging on this and providing for more home care in the budget. A significant amount of funding is available for extra home care packages and extra transitional care. This is the earliest in any year the HSE has had clarity on its winter funding. I will meet the emergency department task force today where I expect to get an update on the winter plan and on the position of the chief operations officer in the HSE to finalise those plans in the coming days.

I thank the Minister for his reply. I would like to get into the detail. We can go back and forth and make political points, and I am sure we will have plenty of time to do that, but the reality is that we are facing into a winter where a very serious flu is working its way across the world towards us. I heard the Minister this morning quite rightly encouraging people to get the flu vaccine.

Last year was a crisis. This year there already have been more than 10,000 women and men aged over 75 years on trolleys for more than 24 hours. It is a crisis. We are already at overcrowding levels way beyond anything which was seen ten, 20 or 30 years ago.

What is different about this year's winter plan compared to that for last year? A winter plan last year had some limited success, but it was not enough even based on what is happening in our emergency departments today. What is different and better about the winter plan for this year? Does the Minister believe it will work? Why will it work this year when things did not work during the summer? What is different about it that will mean we will not see this crisis continue through the winter?

In response to a question from me, the Minister said that last year 75 public beds were opened. Perhaps we could get an indication as to whether they were left open or will be reopened. People want to know that.

When I say, for example, "The likes of which have never been seen before", they are not my words. Rather, they are the words of a nurse working in Limerick. Does the Minister have a plan to staff these hospitals? I will not get into a debate about whether a ban on recruitment is a moratorium or something else. At the moment there is difficulty recruiting. Nurse managers will tell the Minister they have difficulty recruiting at local level. Does the Minister have a plan to staff those additional beds?

In response to another question from me, the Minister told me a review on lessons learned to process information, the details of the actions and outputs of the winter plan, including a breakdown of the amount spent and the aspects of the plan, will take place at the end of the winter period. That referred to the money spent on PR.

On the money spent on private beds, the Minister said he would conduct a review. Have those reviews been conducted? Will the Minister share that information with us? Will that learning be incorporated into the winter plan, whenever it is published? I welcome that the Minister said we will have it in the coming days. I assume we will, fingers crossed, have the information before we return here next week.

Deputy O'Reilly knows that when she talks about money spent on PR, it is an attempt to make a connotation which does not exist. Money spent on PR is money spent on campaigns promoting vaccines, including the flu vaccine, and directing people to the appropriate places, including promoting our minor injury units. When I travel around the country, Deputies on all sides of the House bring me to those units and tell me they could be busier if only people knew about them.

As far as I know, the value-for-money reviews have been completed and I am very happy to ask the HSE to share them with Deputy O'Reilly and the health committee. I will also provide the Deputy with a report on the beds opened. To the best of my knowledge, they remained open but I will confirm that in writing for the Deputy.

I note the Deputy does not want to go back and forth on recruitment and we regularly debate the status of recruitment, but the published figures for the end of August 2019 compared to the end of August 2018 show 2,625 additional whole-time equivalent people working in the Irish health service. There are more doctors, nurses and therapists working in the health service than there were last year. Of course there is a need to do more, but more people are working in the health service.

Individual hospital managers, however, are not able to hire and recruit people for posts which are not funded. If we did that, Deputies would ask me on the floor of the Dáil about the size of the supplementary budget and how we arrived at that situation.

Recruitment is ongoing. I am using University Hospital Limerick as an example because it has been referenced today. About 68 additional people have been hired in Limerick in the past five weeks, 48 of whom are, I understand, nurses. We will put together the HSE service plan and the pay and numbers strategy. We have announced 1,000 additional staff for the community, and we will discuss that as Deputy Brassil has a question in that regard. Any beds that have been opened will have to be properly staffed in accordance with the safe staffing framework.

Deputy Donnelly asked what is different this year. In fairness to him, he acknowledged that the HSE made some progress last year in terms of how it co-ordinated its plan. It did not have a hospital and community plan; rather, it had integrated plans. There will be a continued effort to build on that this year, including using the national ambulance service. There is sometimes a challenge whereby people are ready to leave an acute hospital to go to a smaller or less acute hospital but are waiting for ambulance transfers.

I know Sinn Féin supports the National Treatment Purchase Fund, NTPF, which also will be a part of the plan. Last year it gave vouchers for 5,000 diagnostic tests, which helped to take the pressure off emergency departments. We will do more of that this year and I, in conjunction with the HSE, am happy to fully brief the Deputy on the plans once they have been finalised in the coming days.

Primary Care Centres

John Brassil


3. Deputy John Brassil asked the Minister for Health the status of the decisive shift to primary care pledged in the Programme for Partnership Government; and if he will make a statement on the matter. [41486/19]

I ask for an update on the decisive shift to primary care pledged in the programme for Government and reiterated in the Sláintecare document. Everybody accepts that the cornerstone of our future health strategy is to fully resource our primary care services and by doing so we may, in some way, make progress in improving our health services. Unfortunately, to date I see no evidence of this decisive shift.

I thank Deputy Brassil for his question and work on the Sláintecare strategy where it clearly came to the fore that funding community care and making that decisive shift is absolutely key. I want to assure him that we remain fully committed to the development of primary care. It is recognised that countries with a strong primary care sector have demonstrably better outcomes, lower mortality rates and lower overall health care costs.

As we have seen in recent years, there has been a significant investment in primary care centres around the country and 127 are now open. I want to be clear. They are not busy enough in terms of the volume we could be doing to provide services through primary care. That is not a criticism of the staff, who are excellent. We need to resource them to do more. That is why I am very pleased that in the budget announced this week we have received multiannual funding for 2020 and 2021 to hire 1,000 additional front-line staff to work in primary and community care. That means more public health nurses, speech and language therapists, physiotherapists, psychologists, counsellors, occupational therapists and the sort of people one would expect to be part of a community team. This will properly staff our network.

In line with Sláintecare, a rough estimate shows that about 4,000 additional staff are needed to work within the community if we are to make the Sláintecare vision a reality. This will enable us to deliver 1,000 additional posts, a quarter of what we actually need. We are committed to delivering the 4,000 additional staff over ten years. To be very clear, I have spoken to the CEO of the HSE about funding and there will be funding to hire staff for the 1,000 posts by the end of this year because of the commitment given by the Minister for Finance, Deputy Paschal Donohoe, on the floor of Dáil Éireann in his budget day speech. In the budget day book at www.budget.gov.ie there is reference to a €60 million full year cost for those staff. Any misinformation or confusion about that need not exist.

As Deputies know, given that I have been questioned about this very regularly, we have also reached a new agreement with our GPs. The agreement sees a decisive shift, in that from January people will be treated in GP clinics, rather than hospitals, for conditions such as asthma, heart failure and other chronic diseases. I want to do more with pharmacists and I may have an opportunity to talk about that at a future date.

I wish to bring the Minister back to one figure. He said €60 million was available for the next two years, but only €10 million of that is for 2020.

That is putting stuff into the never-never. A figure of €10 million will equate to 160 whole-time equivalents. This is minuscule compared to what is needed. The announcement sounds positive but stretching it out over two years will mean that its immediate effect will be minimal, which is the issue I continually have. We talk about the need for 1,000 extra GPs, 1,200 extra practice nurses and 1,100 public health nurses but we are nowhere near achieving those targets. Every time we make an announcement, it puts something over a period of two years and we just roll on. Who knows where we will be in 2021? The Minister and I might not even be here. We need action now. The figure of €60 million sounds positive but in reality, putting only €10 million into next year is window dressing.

Whatever about my future, I am sure the Deputy will be here continuing to make a positive contribution. I assure him that I fully agree with some of the latter end of his contribution because he and the other members of the Sláintecare committee having rightly been putting pressure on the Government to deliver multi-annual funding. If we think we are going to fix the challenges of the health service and bring about Sláintecare by just looking budget to budget, we will fail. That is why one of my biggest asks of the Minister for Finance in budget 2020 was to give me multi-annual funding for Sláintecare. Last year, I succeeded in getting multi-annual funding for the GP contract, which is making that decisive shift and has been accepted by 95% of GPs. My big multi-annual ask this year was for €60 million in a full year. It is not the never-never. As the Deputy is well aware, the recruitment process will mean that all 1,000 posts can be filled by 31 December. We will have 1,000 people there and the full year pay bill for that will be €60 million. If I did not get that full-year cost, the Deputy's criticism would be entirely correct but I have now been able to give Paul Reid, the CEO of the HSE, the certainty that on 31 December 2020, he can have 1,000 additional speech and language therapists, physiotherapists, public health nurses and others on his pay bill for the HSE. That will make a real difference and a decisive shift. The GP contract is already making that decisive shift with more patients, starting with older people, getting appointments with their GPs instead of having to trek to hospital. We must make community and primary care busier, which is what the investment is about.

I might go back a step. In reply to a parliamentary question from Deputy Donnelly during the summer, it emerged that if one compares the final budget spend for 2018 in primary care with the budget spend projection for 2019, one comes up with a reduction of €7 million. If one breaks it down into the community healthcare organisations, CHOs, one can see that there is a significant reduction in CHOs 1, 2, 3, 5, 7, 8 and 9. I have those figures and will give them to the Minister. They are factual. How can we roll out improved services if the spend of 2019 in every CHO bar two is less? It does not match up.

The Minister referred to the GP contract and the progress there. Stating my obvious conflict of interest in this area, I note that the Minister committed to rolling out a new contract for pharmacists and resolving the financial emergency measures in the public interest, FEMPI, by 2020. I ask him to hold to that commitment.

I will honour that. I had a good conversation with Darragh O'Loughlin, chief executive of the Irish Pharmacy Union, last week when representatives of the union came in to discuss some very important work it is doing on our Brexit preparedness, for which I thank it. I had hoped to begin initial engagement on some of the issues in pharmacy this year with a view to formal talks starting at the beginning of 2020. Pharmacists are coming up with solutions and ideas. We just need to make sure that what they are offering to do is added value or in other words, it is not duplication. We need to have that discussion about who does what in primary care and I am looking forward to having that discussion with our pharmacies. We must also have a discussion about contraception and the role of pharmacy vis-à-vis the role of the GP. I expect to publish the contraception report in the coming days.

Regarding individual figures at the end of the year, out of a budget of €16 billion, €17 billion or €18 billion, people can identify €1 million here and €7 million there - relatively small figures. This highlights the need for a multi-annual approach. We have €220 million for GPs over four years. That is primary care. We have €60 million for Sláintecare funding over 2020 and 2021. More money is going into primary care. We have so many primary care centres in all of our constituencies. We have the bricks and mortar; we must make them work in terms of taking that activity out of the hospitals and putting it into primary care. I genuinely believe that budget 2020, while only a start, is a real start in that shift.

The next question is Question No. 4 in the name of Deputy Barry.

I wish to ask the Minister about the cut in the rehabilitation training allowance-----

The Minister of State, Deputy Finian McGrath, is taking the question but is not yet in the Chamber.

Did the Minister speak to the Minister of State this morning?

I believe he is due to be here but I do not wish to detain Deputy Barry. The Minister of State has the documentation.

Could we hold on for a minute to see whether the Minister of State arrives?

If he will be here in the next ten minutes, we will hold. Otherwise, I need to ask the Minister.

Of course. I am more than happy to answer.

I cannot hold up the business of the House for ten minutes. I could give the Minister of State a minute or two to get here.

I am happy to go to the next question and wait for the Minister of State's reply later.

Unfortunately, Deputy Connolly has not yet arrived. Does the Deputy want the Minister to take his question?

If the arrangement is that the Minister of State will take my question, I am happy to wait for him.

We will wait for a short period of time. Deputy Connolly has agreed to take a written reply so she will not be here. Therefore, we will give the Minister of State two minutes to get here. If he is not here by then, I will move on to Other Questions.

I put down Question No. 25, which I could take now.

I have no doubt Deputy Brassil would like to take Question No. 25 but, unfortunately, I cannot-----

I have put down Question No. 11, which I could take.

I have Question No. 14.

Perhaps the Deputies should put all the numbers they mentioned into a lotto slip for Saturday night. Seeing as there are no budget discussions today, I thought the Minister of State would be here but, obviously, he has been held up somewhere.

Deputy Barry has put down Question No. 11. I suggest we swap the order of the questions so I could take Question No. 11 now.

I understand that Deputy O'Loughlin, who has put down Question No. 6, is almost here. If she does not arrive in the next few moments, I have no problem with taking Question 11 but I understand that a number of Deputies are coming so we should give them the chance. I understand Deputy Buckley has permission to take Deputy Jonathan O'Brien's Question No. 10 and will be next, if those Deputies do not turn up.

I need the permission of the House to move on to Ceisteanna Eile, that is from Question No. 6 onward. Is Deputy Brendan Smith willing to put his question to the Minister now?

We will go back to Deputy Barry's question when the Minister of State, Deputy Finian McGrath, arrives. Is that agreed? Agreed. I apologise for rushing Deputy Smith on this.