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Dáil Éireann díospóireacht -
Tuesday, 19 Oct 2021

Vol. 1012 No. 7

Ceisteanna ar Sonraíodh Uain Dóibh - Priority Questions

Hospital Waiting Lists

David Cullinane


86. Deputy David Cullinane asked the Minister for Health the number of persons on hospital waiting lists, including lists not reported by the National Treatment Purchase Fund, NTPF, such as diagnostic lists; his plans for tackling waiting lists; and if he will make a statement on the matter. [50782/21]

My question is on hospital waiting lists. I am asking for the total number of people who are on waiting lists, including those not captured by the NTPF, which would include diagnostics. When I make my supplementary contribution I want to concentrate on children on waiting lists, which is of huge concern to me.

There are 760,394 patients on acute hospital inpatient day case, outpatient and gastrointestinal scope waiting lists, as published by the NTPF. I recognise that a higher figure of more than 900,000 is regularly used and it is important to note that this figure includes just under 150,000 patients who already have scheduled care. The NTPF figure we should be most concerned with is the 760,394 patients.

The Deputy asked what there is on top of that. With regard to the number of patients waiting for diagnostics, it should be noted that many of these are surveillance patients. That means these patients are due a scheduled diagnostic test at a future time. It also includes patients in treatment who need an associated diagnostic test and patients who are awaiting a diagnostic test for the first time. These are the patients the Deputy and I are probably most interested in. I emphasise that we have a diagnostics waiting list of 224,538 and that this is raw data. It includes all these groups and has not been centrally validated, which is why it does not form part of the NTPF’s published reports.

Regardless of the precise answer to the question, the figures are stark and we can all agree that they are unacceptable. They were unacceptable prior to the start of Covid-19 and, as we all know, they have been exacerbated by two big events. I have outlined my plans for dealing with waiting lists. I published the acute waiting list action plan on 7 October and the plan will run to the end of this year. It includes 150,000 waiting list-related interventions. I can give more detail in my supplementary response.

I have been in many hospitals in recent weeks. I have been in hospitals in Cork, Galway, Limerick, Laois, Sligo and many other places. I have met hospital management, campaigning groups and those on the front line and the figures are shocking. The length of time people are waiting is also a difficulty.

I want to home in on the matter of children with scoliosis because a promise was made not so long ago by the Minister's predecessor and by his predecessor that there would be a maximum four-month waiting time for treatment. There was a promise of outsourcing but that never worked if we are to be truthful. There was also a promise of extra clinics and new consultant posts but children are still waiting. The number of those cases has come into the public domain in recent weeks as the Minister knows. We talked about this when I moved a Private Members' motion and the Minister talked about a girl called Sarah. The problem is still there and it has not gotten better. What will the Minister and the Government do to better support children with scoliosis?

The waiting times for children with scoliosis are not acceptable and they have to be brought down. One of the first places I went when I was appointed as Minister was Our Lady's Children's Hospital in Crumlin and I met the orthopaedics team there for exactly this reason. Good efforts have been made and an additional consultant is in place. Things have been greatly exacerbated by Covid, as we know, and by the cyberattack but we cannot let that stop the progress that has to be made. I am working closely with the HSE and the Department and critically, with Children's Health Ireland, CHI, to look at the current barriers, be they the work force, surgeons, operating theatre capacity or operating theatre nurses. Some of the children, as the Deputy is aware, have complex cases that need a team of consultants and much pre-operative work. We have to be clear in Dáil Éireann that the current situation is not acceptable for these children or their parents and that everything that can be done must and will be done to help them.

I met parents of children with scoliosis on Zoom today and many of them said to me that their children have been left with lifelong complications because of the delays to their care. They also said they have seen this before and heard all the promises but that they have not seen the improvements. They said that we should aspire to do better for our children and to have a health service that does not have their children in those circumstances.

I accept the Minister's point that it is unacceptable but the Minister's predecessor and his predecessor sat there and said the same thing and the problem has not improved. The parents said to me that even the communication with them is not what it should be. They say that surgeons do not have access to theatre capacity and that there are no protected beds, for example. They say that because it is elective surgery the operations can be cancelled at the drop of a hat, which causes huge distress for families. What can the Minister and the system do practically to improve this? We have heard it all before and the problem has not improved.

I share the Deputy's concern. I had a long call last week with a parent of one kid with serious complications. What the children are going through is unimaginable, as is what the parents are going through as a result. I have told the parents that we will sort this out. We are working directly with CHI to understand exactly what the bottlenecks are. Some of this can be solved through resourcing. We have some fantastic surgeons in this country and we have to make sure they have the operating theatre time they need and that we have full theatre teams. These are highly specialised teams and we have to make sure the pre-operative and post-operative capacity are in place for these operations, particularly for the most complex ones. We also have to make sure that the multi-disciplinary teams are available. We both know that for some of these children it is not just about having an orthopaedics teams ready to go on the day; multi-disciplinary teams have to be in place. For me and all of us in here, this is a top priority. Funding is available and we are working to understand what the bottlenecks are to make sure these children get the treatment they need and deserve.

Disability Services

Duncan Smith


87. Deputy Duncan Smith asked the Minister for Health his intended approach to spending the funding for disability services as committed to in budget 2022; and if he will make a statement on the matter. [50818/21]

An extra €105 million was announced in the budget last week for people with disabilities and for disability services, which was welcome. We will talk about the disability capacity review and the amount that is needed to meet the unmet demand there when I come back with my supplementary contribution. I ask the Minister of State for more detail on how this money will be spent. I would appreciate that, along with everybody who is listening in to the debate.

I am delighted to have the opportunity to answer this question. I will break it down as quickly as I can. The first €50 million is for the existing level of services. Another €55 million is for new developments. These new developments will be made up of a suite measures in different areas. I want to talk about therapy posts and administrative work. Approximately €9 million has been left aside for that. That is, by and large, for therapy posts and administrative work. It seeks to ensure we can add to each of the 91 network disability teams. I am hearing on the ground that they are short of administrative staff and that we have therapists doing administrative work. That is why I want to leave that flexibility.

The other area of significant funding is for the 1,700 school-leavers. That is part of the transition planning for young people. This year I also introduced a deferral option for young people, so they have that choice. The other additional funding of more than €5 million is for under-65s in nursing homes. It is the first time ever we have had a line in the budget for this. Some €18 million was allocated for this last year.

This year, I have allocated four times that amount at €72 million. This will build up capacity and allow us to do more. Independent living provides an opportunity to return people home or have an independent living space.

While I might be proud of all of the budget, the one part I am especially proud of has to do with personal assistant, PA, hours. This was essential. I made a commitment that we would deliver in this regard, and we have delivered more than 3 million hours. In the budget last year, that number fell far short at 660,000.

Regarding residential respite, €9 million is being allocated to respite houses. The ambition is to have nine child respite houses and nine adult respite houses.

This year's disability capacity review stated that we needed €350 million. That figure would not be static and would instead grow in five and ten years' time to the tune of €100 million each time. How does the Minister of State believe the next budget and the one after that will get to that figure? We undoubtedly need to reach it.

Congregated settings have been mentioned. When we look back on this era of the State's history, I believe we will view congregated settings as a disastrous problem in many respects. Disabled persons and young people have to live in nursing homes and other congregated settings because they do not have the means to achieve independent or assisted living. Inclusion Ireland stated strongly in its response to the budget that a minimum of 7.2% of all new housing provision must go to people with disabilities, but we are nowhere near that.

The disability capacity review was written in 2018. Since then, €530 million has been allocated to the disability sector and €240 million has been invested in new developments. Given the difference between €240 million and €350 million, the Deputy can see exactly what we are short. This gives the House a guideline as to what my framework document is aiming for by, I hope, the end of this year or early next year.

Another line in the budget was the transitioning of 144 people as part of decongregation, which will add to the number of under-65s. Decongregation is part of our work under the UN Convention on the Rights of Persons with Disabilities. Decongregation must be person centred and take into account willingness, preference and choice. At our current rate, however, it will not happen in the lifetime of any Deputy, so it and the work in respect of the under-65s must be accelerated.

The disability capacity review document is very good and sets out what needs to be done and how to get there.

I will submit further parliamentary questions because we need more information, although I appreciate that the Minister of State is giving me a great deal of information in the short time available. One third of people with disabilities are at risk of poverty. There are many multifactorial pressures on this group. If there is one disappointment in the budget, it is that no one group got the lift it needed. We could have chosen disabled persons, childcare or housing. I am not saying that €105 million is insignificant, because it is significant, but we need to leap higher. I thank the Minister of State for her reply.

I am not waiting for the HSE service plan next March to tell me what its priorities are. I am outlining on the floor of the Dáil right now what the priorities are. I am indicating to the various CHO managers that they should start planning now and not to wait until next March. I am telling the HSE that we always need to be planning. I do not have a multi-annual budget. If I had one element of the disability capacity review that I could wish for, I would love to have multi-annual budgets for respite services, PA hours and therapy services so that we could build in capacity. At the moment, I cannot build in that sort of capacity. However, I thank the Ministers, Deputies Stephen Donnelly and Michael McGrath, for the support they have shown in giving me funding. I have been very open in how I would like to see it spent. I would like the HSE to embrace that, take it on board and not wait until next March to start planning.

Emergency Departments

David Cullinane


88. Deputy David Cullinane asked the Minister for Health his plans to prevent emergency department overflows from interrupting scheduled care this winter; if he will provide additional resources to the National Ambulance Service to boost emergency care in the community; and if he will make a statement on the matter. [50783/21]

We are seeing presentations in emergency departments at record levels for this time of year. It is concerning for hospital managers and the staff on the front line, who are burned out and exhausted and are now facing into what they believe could be a dreadful November, December and January. What will the Minister do about the crisis in emergency departments and its relationship with the lack of GP services, particularly out-of-hours GP services, and the NAS? I have met the NAS several times in recent weeks. It has capacity issues.

I thank the Deputy for his question. As he mentioned, emergency department attendances have reached 2019 levels and exceeded them in some places. In 2019, 1.34 million people attended emergency departments and approximately 350,000 of them were admitted. I acknowledge the work of our front-line staff in keeping the emergency departments open throughout the pandemic.

Our figures for attendances underestimate the seriousness of the situation. Not only are attendances at 2019 levels, but many of the people attending are sicker, they have deferred their care, they now need more treatment and their average length of stay is longer. All of this is contributing to very significant pressures on our emergency departments. It is only October and we are facing into a tough time.

Tackling the issue of patients having to wait on trolleys is a top priority. Last year, we deployed €600 million as a winter plan. Critically, we locked the majority of that in through the budget for this year. This meant more beds, more diagnostics, more alternative care pathways outside the hospital sector and more home care supports. All of that is still in place, but we are doing more again with the HSE and the Department this year.

The NAS has undergone a significant process of modernisation, but its 2016 strategy did not get the funding for the level of change that was required. I agree that there are gaps in the service and that they need to be addressed. This year, I allocated a full €10 million to the NAS in additional funding, including €5 million in enhanced community funding, which has helped with the see and treat, and hear and treat, alternative care pathways, allowing the National Emergency Operations Centre to manage the low-acuity calls and try to keep people out of hospital.

As the Deputy will be aware, the HSE and the NAS are developing a new five-year plan. To help with that, I have allocated €8.3 million in new development funding next year and I have protected some of the underspend from this year.

We have to examine why we are seeing this high level of presentations. The Minister is right, in that many of those attending are doing so with more acute needs, which is presenting more challenges for hospitals. Another reason is the lack of out-of-hours GP services. The NAS has told me that there is an absence of a treat and refer policy that is underpinned by clinical governance and that there needs to be movement in this regard. Many people are calling ambulances because they cannot get access to GPs, meaning that more people are presenting to emergency departments. We are still not managing enough people in the community, in particular people with chronic pain, respiratory illnesses, diabetes and other conditions that can be treated in the community.

Every hospital I have visited across the State has said that it has submitted a capital application for new beds in single-bed isolation units - 42 beds in Sligo, 98 in Limerick, 50 in Cork and the same in Galway and Laois - but that, apart from dealing with all of the other problems, there is no urgency to put capacity in place. That is why there is such pressure on the emergency departments, which is causing havoc in those hospitals and stress for the people working in them.

I agree with the Deputy's comments on out-of-hours GP services. As part of winter planning and in the spirit of doing everything we can to help keep people out of hospitals, specifically emergency departments, that is an area that we are examining.

The next parliamentary question deals with chronic disease management in the community.

I disagree with the Deputy that not a lot is being done. A significant amount of work is being done and there has been a lot of progress in that area, which we will get into in more detail in regard to the next question.

By the end of this year, we will have added to the acute system more beds than have been added in any year on record and we will have done that in the middle of a pandemic. I am working with the HSE on some of the local issues. I am aware that there are clinicians in CUH, GUH, UHL and other hospitals who are saying that we need more beds and more capacity. That is true. There are a number of capital applications in, but it needs to be appreciated that we have already added to the acute system more beds than have ever been added in any year on record. We need to continue to push forward in that regard.

That does not tally with what I am being told by hospital managers. Across the State, all of them, with the exception of the Limerick hospital manager because that hospital got a new modular unit, are saying that many of the beds the Minister talks about are beds that were temporarily open anyway. They did not get capital funding to build new units and they are being asked to cram beds into very tight wards, which is not what we need to be doing when we are in the middle of a pandemic as it is not good in terms of infection control. The Minister needs to be looking at all of those capital allocations that will make a real and tangible difference to those hospitals and provide the capital as well as the revenue funding, which he did not do in last year's budget or in this year's budget.

I did not say that there is nothing happening in the community. I welcome the community intervention teams, the community health networks and the additional home help services. My point is that we have not done that quickly enough and we are still not managing enough patients in the community. We are not doing enough community assessments as well. When you have problems in the emergency departments it is because everything else has gone wrong. There are so many things going wrong that, like a volcano, it erupts in the emergency departments. The people on the front line are telling me they have had enough. They genuinely dread and cannot sustain a winter without the capacity, tools and support they need.

In terms of capacity and revenue funding, this year has seen a record deployment in that regard. There is revenue available and there is capital available. I can assure the Deputy of that. However, capital applications are not only about new beds. New diagnostics, new operating theatres and new triage rooms have to be looked at and that is happening. Where capital funding is required, it will be provided. The tighter constraint is staff. There is no point putting the beds in place unless we have the staff. There was a very ambitious target for this year in terms of staff. We will be rolling much of that target into next year. Do we need more beds? We do. Do we need more ICU beds, more diagnostics, more rehab beds and more community beds? Absolutely, we do. At the same time, we have to hire and retain the staff to make sure the patients in those beds get the care they need.

General Practitioner Services

Róisín Shortall


89. Deputy Róisín Shortall asked the Minister for Health the steps he is taking to address the shortage of general practitioners; and the specific timescale to which he is working. [51198/21]

The Minister will be aware that over recent years there has been a growing shortage of GPs, to the point where it can only be described as a crisis. The Irish College of General Practitioners, ICGP, has found that 700 GPs will retire in the next five years. An ICGP poll this month shows that 60% of approximately 900 GPs surveyed were full to capacity or beyond. What precise steps is the Minister taking to address this issue to ensure that we have adequate levels of staff in primary care?

I thank the Deputy for the question. I agree it is imperative that general practice has the capacity we need because we have big ambitions for GP services, particularly as we move to care in the community. In that regard, the number of GPs has increased by about 12% over the past ten years. We need to look at that per capita as well. The 2019 figures show that we are at 82 GPs per 100,000, which is slightly above the EU average of 80. My view, which I think the Deputy shares, is that we need to go further and use GPs more in terms of community care.

I am very aware that there are workforce issues, including changing demographics, GPs nearing retirement and difficulties filling some of the GMS slots, which can be particularly impactful on local communities. The 2019 agreement with GPs is key in terms of a 40% or €210 million increase in investment in general practice between 2019 and 2023.  That is a very big increase. I am happy to say that in spite of the pandemic we are on schedule in terms of the delivery of those resources. Between 2019 and this year, we have seen an increase of approximately €144 million, with an additional €63 million provided in the budget for next year. We are on track in that regard.

The Deputy will be well versed with regard to some of the benefits of the chronic disease management programme and the roll-out in that regard in terms of chronic obstructive pulmonary disease, chronic heart disease, asthma and diabetes services, etc. I acknowledge the incredible work GPs have done to continue to roll that out in the middle of the pandemic. GP access to diagnostics has been increased this year. There are other initiatives as well, which I can come back to in my later reply.

In terms of capitation fees and increased supports for GPs in disadvantaged areas, there is a new fund in place. The question of maternity and paternity supports for GPs has been a real problem, particularly in some of the more rural areas and smaller practices. There have been moves to that end this year as well.

I thank the Minister. I wonder if he is listening to what graduates and trainees are saying because a huge proportion of them intend to emigrate. We do not have to guess at the reasons for that. We know from the regular ICGP survey that issues such as too many clinical sessions, onerous workload, management responsibilities and traditional responsibilities are unattractive. GPs are no longer prepared to work long hours. They want flexibility and better quality of life. Will the Minister accept that there is a problem with the career structure that is on offer now for GPs? Any change in that regard over recent years has been blocked by existing GPs, which is understandable because they have invested in their practices and so on, but that model does not serve the needs of younger GPs. Is the Minister looking at that issue at this point?

The short answer is "Yes". The first thing we needed to do was to provide more GP training posts. The change here is very impressive. In 2009, we had 120 people entering GP training. In 2020, we had 233. Step one has seen a very significant increase in the trainee positions. I take the Deputy's point that there is no point training these amazing people to be GPs only to see them leave the country. I am aware that many trainees are saying that they do not want to work in the old ways, and that they do not want to set up a practice on their own and work on their own. We know that many GPs want to work together and that they are interested in multidisciplinary teams and much more integrated care. One of the challenges we face in terms of some of the rural smaller practices is exactly that younger GPs want to work together. We are making various changes. Is there more that we can and should do? Yes, I believe there is.

The figures mentioned by the Minister are fine but the HSE claims that we need to have 250 training places every year for new GPs. I asked the Minister if he has any proposals with regard to the career structure. References to salaried GPs and the type of flexibility so many new GPs are looking for were seen as a threat to existing GPs. This does not have to be a threat. There is no problem with leaving existing GPs doing the business they way they are doing it, in some cases single-handedly in long-established GP practices in which they have invested and so on. That is all fine. That need not be interfered with, but will the Minister accept that there is a need for a new model for younger GPs who want that flexibility and better quality of life? Many GPs, including female GPs, want to job-share or work part time. They want that type of flexibility. Is the Minister considering salaried GPs? This was offered by his predecessor, but I know it was blocked for union reasons. Would the Minister consider it at this point?

Yes, absolutely, if that is what is required and if that ultimately leads to better care for patients. I do not think we should rule anything out. In terms of the trainees, as I said we are up to 233 this year. Real progress has been made, which is very encouraging. There have been changes. Some of the changes include more flexible GMS contracts, sharing of GMS contracts and GPs allowed to hold GMS contracts for longer, now up to their 72nd birthday. More supports for rural GPs are being rolled out this year, including maternity and paternity leave arrangements, as well as supports for GPs in urban areas such as increased GP access to diagnostics, which has been received very well by GPs.

Ultimately, the question for us all is whether there is an argument for thinking about a new GP contract. We know the old GP contract was put in place 40 years ago, or something like that.

Budget 2022

Mark Ward


90. Deputy Mark Ward asked the Minister for Health the way in which the €24 million announced for new measures funding for mental health will be spent; and if he will make a statement on the matter. [50784/21]

I, like the many people who advocate for better mental health care, waited with much anticipation for the mental health budget to come out this year. With the emphasis there was on mental health over the past 20 months, I was disappointed to see an allocation of only €24 million in new development funding for mental health. What exactly will this €24 million be spent on? Does the Minister of State believe it is adequate to meet the demand in mental health?

I thank the Deputy for his question. This year saw the largest budget allocation to mental health in the State's history at €1.149 billion. The year 2022 will see an additional €47 million for mental health services, comprising the €24 million the Deputy mentioned for new developments, €10 million for mental health initiatives in response to Covid and €13 million for existing level of service. The €24 million is being prioritised for the continued development of mental health services, including out-of-hours supports, child and adolescent mental health services, CAMHS, and mental health clinical programmes. I have clear priorities as the Minister of State with special responsibility for mental health. These include dealing with the primary care psychology waiting list. I am also very clear about trying to reduce the number of young people waiting for access to CAMHS appointments. I am very clear in relation to the continued roll-out of the clinical programmes, which have proven very successful to date.

The moneys I have secured, coupled with clearing the €53 million historical deficit I inherited last year, means I will be able to recruit 350 whole-time equivalent staff. Mental health services for older people will also be developed, in line with the model of care for specialist mental health services for older people that will be piloted next year. A sum €6 million will be used to continue to enhance the capacity of community mental health teams. It is very important we have these teams on the ground. There will be €1.4 million in new funding for crisis resolution services. I recently announced a new crisis resolution team for community healthcare organisation, CHO, 5, which will be based in Waterford, Dungarvan and south County Kilkenny. There will be 14 whole-time equivalent staff there. As such, there is €1.4 million because we are going to roll out those pilots, and another €1.15 million will be allocated to specialist eating disorder teams in CHOs 1, 3, 5 and 6. I am really happy that by the end of next year we will have nine full eating disorder teams in place. I will answer more in the next session.

I acknowledge the work the Minister of State has done on the €53 million in debts. That was very welcome and did say it would work in a tangible way. To put it into context, the budget she has outlined is the same amount of money that was in the 2008 budget. We have not gone forward since 2008. We are still playing catch-up in the provision of mental health services.

The Minister of State mentioned the €47 million figure. If you break that down and go into it, €13 million is, as she said, for existing service levels. That is basically maintenance money to keep things going the way they are. It is standing still money. The €10 million is, as the Minister of State mentioned, one-off funding that must be spent by the end of the year. It is not for new services, staff, buildings or anything like that. That leaves the €24 million. Mental Health Reform recommended €85 million. The Sinn Féin alternative budget recommended €114 million be committed to mental health funding. I ask the Minister of State again whether she believes €24 million is an adequate response to the mental health challenges we are facing.

Due to my past as a person who was in business for 17 years, I was, and still am, really good at figures. Last year the budget for mental health was €1.076 billion. This year it is €1.149 billion, an increase of €73 million because of clearing the historical deficit, which will give me 350 whole-time equivalents. Last year, the extra €23 million I secured only gave me 153 whole-time equivalents, so the amount of money I have this year will be significant because there are challenges, as we all know, with recruitment and retention. There is no doubt about that. We are working very hard to populate all those clinical programmes and get those staff in place.

You can pick out different areas in budgets but one area I am really pleased about is the new model of care for older people which will be advanced. We are all familiar with the integrated care programme for older persons, ICPOP, but they never include a psychiatry of later life element, so I will be able to roll out three pilots next year in relation to that.

Some of the challenges we have relate to our waiting lists. I noted Deputy Cullinane was talking about those for children earlier on. I got a couple of parliamentary question responses back this week. At the moment we have 8,832 people waiting on primary care psychology. Of those, 7,849 of these are children and 3,777 of these children are waiting more than 12 months for treatment. There are 302 children aged five years or under waiting more than a year for an appointment. That is almost 20% of their lives they have spent waiting for an appointment for mental health treatment, and we all say early intervention is key. CAMHS has another 2,625 children waiting for appointments, and in excess of 400 of these children are waiting more than six months. In the response, three months for a child to get treatment seems to be a target for getting an appointment with CAMHS. That should not be a target. When a child needs intervention, he or she should be able to get.

I am really glad the Deputy has given me the opportunity to talk about the primary care psychology list, because when I came into post last year I inherited the highest ever waiting lists in that area. I spoke at length with the Minister to see how we could deal with this. In the short term what I have put in place is as follows. For September, October, November and December of this year, €4 million was allocated to the nine CHOs. I asked them to come to me with a proposal. Would they do overtime on Tuesday, Wednesday and Thursday nights? Would they hire a locum on a Saturday? Would they go for private capacity? Would they try to put in a surge in public capacity to try to deal with this? I am glad to see the numbers are coming down and I will have a report at the end of October, which is midway through. We also need to put a permanent process in place and we will deal with that through working with the Minister. There will be many staff recruited within the budget process. We are also looking at a waiting list initiative. We want to clear this waiting list and we know each child might need, four, six, eight or ten appointments. It is not just about one appointment. We are working towards it.