The purpose of this meeting is to engage with the Minister for Health, Deputy Simon Harris, and the Health Service Executive, HSE, on health issues. We have a difficulty in that the Minister has to go to a Cabinet meeting at 9.45 a.m. We will allow the Minister and Mr. Tony O'Brien to make their opening statements and then take some questions from party spokespersons initially to allow the Minister to respond before he has to go. The Minister has undertaken to come back to the committee after the Cabinet meeting if we are still in session. Unfortunately it is a situation we could not avoid. I invite the Minister to make his opening statement.
Quarterly Update On Health Issues: Discussion
I apologise. The reality is that there is an additional Cabinet meeting today. In an effort to get straight into the meeting, I do not propose to go through my opening statement. We can take it as read. This is my first opportunity to acknowledge in the Official Report the incredible work of our health service staff and management in the HSE in recent days in terms of dealing Storm Ophelia, and managing to keep our hospitals and community health services staff during an extraordinarily difficult time. I wish to acknowledge the heroic efforts of people working in and planning for our health service in recent days. I am very happy to take questions.
I thank the Minister.
Mr. Tony O'Brien
On the same basis, I am happy for my statement to be taken as read. I thank the Minister for his remarks on the response of the health and social care system to Hurricane Ophelia and add my thanks for the tremendous efforts of staff around the country in responding exceptionally well in a very difficult situation.
I thank Mr. O'Brien. I will call on party spokespersons in turn to ask brief questions so that the Minister will have an opportunity to respond before he leaves.
Additional resources have been allocated for the winter initiative next year. How much of the winter initiative planning will be based around the fact that the HSE will have additional resources from 1 January onwards? Will there be the ability to increase capacity for the number of weeks which are very pressurised in our emergency departments? One can almost predict that the first Tuesday of the new year is chaotic in every emergency department across the country. Will the additional resources allow the HSE to enhance capacity and plan more efficiently for emergency departments in early January than heretofore? The Chairman asked us to be brief.
Yes.
I have two simple questions. One relates to the 1,800 additional staff announced in the budget. Given the failure thus far to reach any of the targets which were set - the Irish Medical Organisation, IMO, said recently there were only 13 additional staff - do the Minister and HSE have another plan? It is to be hoped that if so it is not just a restatement of whatever is currently being done because clearly that is not working. I would like to know where the staff are coming from and what the recruitment plans are.
My second question concerns children with scoliosis. There are 68 children with complex medical needs, whom we have discussed. Can the Minister and HSE confirm that agreements have been signed with the two additional hospitals in Germany and England and that there is a plan? I do not believe any of the 68 children have been assessed as yet by the hospitals with which the agreements have been signed. I do not think they will be treated by Christmas, although I hope they will. Perhaps the Minister and HSE could comment.
This is a quick-fire round. It appears that the capital programme will be eaten up by the children's hospital. Will there be provision to progress the maternity strategy, which I have spoken about numerous times? The mid-west is waiting for a couple of million euro just to keep things ticking over and cannot seem to get funding.
I note the internal letter on opening up the new accident and emergency department in the mid-west. However, by the looks of it the HSE is very upset by performance levels there. The hospital population ratio in terms of those ages over 65 and 70 is very high compared to other areas, which might explain the situation. Things are still at crisis point given the fact that Ennis and Nenagh were closed and the proper process was not put in place over many years to ensure Limerick could deal with the number of patients coming into it. The Minister and HSE might reflect on that.
I refer to the process for the alignment of community health organisations, CHOs, with hospital groups. I would like to hear comments on the court case between the HSE and the Health Information Quality Authority, HIQA, regarding Ennis. My question on the winter initiative was taken up by Deputy Kelleher. Is there any progress to date on the GP contract?
I presume the Minister is going to honour the dates he has spoken about in regard to orphan drugs, about which we have and many debates. That should kick in next month.
I thank Deputy Kelleher.
Freudian.
I will ask Mr. O'Brien to also comment on funding for this year's winter initiative. There will be additional capacity. There are a number of new units referenced, including the opening of step-down beds for Beaumont, the development of Our Lady of Lourdes in Drogheda and additional beds in Galway, to name but a few. There is also a significant emphasis on home care packages, social care and transitional care beds. In terms of funding for the winter initiative, while there is an allocation for 2018 there is also an allocation for now. As Deputy Kelleher knows, we received an additional €40 million for this year, of which €30 million will be spent on winter pressures and access issues. The remaining €10 million will be spent on waiting list initiatives. Next week the HSE will meet all CHOs and hospital group chiefs to hear about their plans.
I will ask the HSE to comment. Rather than Dublin telling hospitals what they must do, this year it was very much a bottom-up approach. CHOs and hospital groups were asked what they planned on doing and what they would take accountability and responsibility for delivering this winter. We will provide the committee with more details when Mr. O'Brien comments.
Deputy O'Reilly is correct. Recruitment and retention continue to be a major challenge in the health service. That does not come as a surprise to any of us in this room, regardless of our political persuasion.
Yesterday the Cabinet took a very important decision in terms of phase 2 of the Public Sector Pay Commission. As the Deputy will recall, all health sector unions and representative bodies who balloted their members on the new public sector pay agreement voted in favour of it, many by an overwhelming majority. They did so on the understanding that, in addition to the public sector pay agreement, there would also be a phase 2 which would examine the specific recruitment and retention challenges in respect of certain sectors.
The Public Sector Pay Commission did not accept that there was, in general, a recruitment and retention issue across the public service, but said there was one in regard to elements of the health service. I am very pleased that the Minister for Finance and Public Expenditure and Reform, Deputy Paschal Donohoe, and the Government moved very quickly on this yesterday. The deal was only ratified in recent weeks, and phase 2 of the commission can now commence. Health will be a particular focus, and rightly so. Ms Mannion might comment on the HSE perspective in terms of the current position regarding recruitment and retention.
The figure of 13 is somewhat of an outlier for a variety of reasons. There has been an increase in the number of nurses in the system. The Deputy is correct in that recruitment continues to be a challenge. Phase 2 of the Public Sector Pay Commission is part of the additional response. The Deputy said she did not want to hear me saying the same thing. Phase 2, which will examine the recruitment and retention challenges in the health sector, is very welcome. It will take an objective look at what we need to do to make sure we keep our workforce here in this country.
That is a very long-term strategy for a very short-term problem.
It is due next year.
Deputy Kelleher referred to the winter initiative and the additional staff who will be needed. There will be more waiting for people.
No. This year, unlike last year, every student nurse was or will be offered a job in the Irish health service. That has come after years of our nursing graduates having to go abroad because there were no jobs in this country. Measures are being taken now.
Nursing organisations and I would agree that there is a need to do more. In order to do more, we need to do things on an evidence basis and with an objective examination of the recruitment and retention challenges. That is why the Government decided yesterday to progress with phase 2 of the Public Sector Pay Commission which puts a particular emphasis on the recruitment and retention challenges in the health sector.
I refer to the opening of the new emergency department in Limerick.
Consider how we have recruited nurses to open and staff the new emergency department in Limerick. The picture is not all doom and gloom. More nurses are working in the health service this year than last year and there will be significantly more working by the end of the year. Ms Mannion will take the committee through how she sees that developing.
I will ask Mr. O'Brien to comment on the scoliosis matter and the signing of the contracts, but my understanding is that there is still a commitment to try to achieve the target of no one waiting for longer than four months. Yesterday's figures showed further progress in this regard. There will be 164 children, including the group to which Deputy O'Reilly referred, in need of procedures by the end of the year, which reaches the target of four months. The HSE has already identified capacity within the system for 131 and is trying to find more capacity for the remainder. The HSE-----
Does that include those with complex medical needs?
Yes, to the best of my knowledge.
Deputy Kelly asked a number of questions. As he knows, we received a significant increased capital allocation - the best part of €500 million - in the health budget. He is right, in that the national children's hospital consumes the bulk of our available capital, but more so in the early years. The HSE will conduct a reprofiling exercise and there will be scope to progress a number of projects. As the Deputy well knows, a variety of projects must go through a number of phases in terms of planning, design and tendering. When we reach the service planning stage, I expect to be able to show progress.
I also expect to be able to show progress on the national maternity strategy. Tomorrow, we will launch the implementation plan for the women and infants programme, which is the strategy's delivery vehicle.
Regarding the mid-west, I do not want to get this wrong. As the Deputy did when he was a Minister, I communicate with my officials several dozen times a day. Sometimes, intelligent and astute journalists make freedom of information requests for those communications and publish them, as is their right. When I see high trolley numbers for a consistent period of time in any hospital, I will ask why. That is my job. There are particular capacity challenges in the mid-west. Is that the email that the Deputy has?
No. These are the statistics showing the pressure that the mid-west is under compared with other areas.
Deputy Kelly's narrative on the reconfiguration in the mid-west in years gone by is a valid one, but neither he, management in Limerick nor I would accept that there is not more that could be done now. For example, weekend discharges had nothing to do with bed capacity but were not happening at the rate they should have been. A number of other things should have been happening but were not. It is not me saying this, but management.
The profile of over 65 year olds in the area is much greater. The Minister is right about discharges, but how and to where would people be discharged? Intermediate vehicles and ambulances are not present to do the job. Of course Ennis and Nenagh hospitals have bed capacity, but they do not have the necessary transport capacity. I have been raising this issue for a considerable time. There are no community facilities either. To where would some people be discharged?
The Deputy is right to advocate for a health area that he knows well and we are not going to disagree about the need for additional capacity and supports for the mid-west. My emphasis is shared by the hospital group's CEO, who is providing excellent leadership contrary to how people have been trying to spin my comments.
Glad to hear that.
I have met her a number of times. She is providing very good leadership and has put in place an action plan for the hospital. Since putting it in place, and as the Deputy will have noticed in the trolley figures for recent weeks, there has been a significant improvement. She needs to be supported by everyone working in the hospital and the clinical community. I did not think that opening a new emergency department would make all of the trolleys go away, but I did believe that putting additional nursing staff into the hospital and increasing its budget would create a benefit.
One would-----
Sorry, Deputy Kelly.
We are already beginning to see a benefit in that regard. The leadership in the hospital and the hospital group is well up for this challenge. It and I have a role to play and we are working collaboratively.
Regarding the GP contract, and as I mentioned on the recent budget day, there was no budget day funding allocation in the year that the free GP care for under sixes was introduced, which Deputy Kelly will remember, given that he was a member of the Cabinet at the time. When the then Minister of State, Ms Kathleen Lynch, and the Taoiseach, who was the then Minister, announced on budget day their intention to expand free GP care to children under six years of age, no one in this room would have been able to find where the funding for that was in the budget. It was not there. When the expansion was agreed, the Ministers reverted to the Government to seek specific funding. I am pleased that the current Minister for Finance, Deputy Donohoe, gave significant prominence to this issue in his Budget Statement on the record of the Dáil and mentioned that there would be a need to provide multi-annual resourcing to deliver a new GP contract.
This is an issue on which the Chairman regularly quizzes me. My message to GP organisations is that, although we have a primary care fund of €25 million in the budget, of course we will not deliver a new GP contract for €25 million. We can do something in this regard in 2018. If we reach agreement with GPs on a number of other measures that are ambitious and will make a real difference, I will be willing to revert to the Government and consider a multi-annual approach.
On the issue of orphan drugs, the timelines that I outlined and committed to Deputy Kelly in the Dáil still stand.
I thank the Minister. I will call three more members, who should try to keep their contributions short. They are Deputy Murphy O'Mahony and Senators Burke and Dolan.
I welcome everyone to the meeting. I would like to raise many points, but I understand the Minister's predicament and will be as brief as I can.
The Minister visited Bandon Community Hospital at roughly this time last year with good news that we appreciated. Unfortunately, and although the extension is ready to go, there is a staffing issue. As well as the new area not being open, no respite is being provided because it was agreed that there would be none until everything was up and running. Has the Minister a date for when it will open?
The Skibbereen Community and Family Resource Centre has moved buildings twice lately and is short on funding. Are there plans to guarantee this service a building and enough funding to stay open?
There are many issues relating to contracts at Bantry General Hospital, but I will discuss that matter with the Minister in private. Much is happening. There has been no progress on the rehab and endoscopy units that were announced a while back. What is the hold-up and when does the Minister envisage these services being up and running?
I wish to raise a question on gynaecological services in Cork University Hospital, CUH, and the timeline for the roll-out of additional staff to deal with the backlog. My understanding is that 42% of all patients waiting in the country are waiting in Cork. Where are we in that regard? When are we likely to make serious inroads into the waiting list?
My next question is on the fair deal scheme and how private providers find it difficult to provide high-dependency patients with the level of service that they require. Will there be further engagement with private providers with a view to providing more beds for high-dependency patients in the private sector as opposed to depending entirely on community hospital facilities? What is the timeline for this? As the Minister is aware, people are living for longer. Therefore, additional services in this regard are needed.
The Minister referred to budget 2018, additional front-line staff for the health service, disability and other areas. He included disability services when discussing better access to health services and mentioned that budget funding would be targeted on, for example, supporting disability services. How will we verify that that is happening? Maybe the HSE service plan sets it out. How do we get from those statements of intent to what they mean on the ground?
I will be very blunt. People with disabilities or with mental health needs in this country do not actually believe that things are getting better. I am not talking about whether things are getting better. I am just saying that people do not see it, believe it or feel it. It is all about giving reassurance. I have a number of questions but we are not going to be able to deal with them in detail this morning. There are 1,200 young people in nursing homes, but the great majority of them could and should be supported in community settings. I am also concerned about the issue of personal assistants, as well as section 38 and section 39 bodies. These are only some of the relevant issues. There are others in the area of mental health, such as the neurological strategy and so on. There is no need to rehearse all of that now.
I am concerned about whether the extra funding that is being provided for health is enough to meet the additional demands. Are we pumping water out faster than it is going in? That is a real issue and people do not feel that we have turned the corner and are moving in the right direction. It is important that assurances are given and that we can verify that through the work plans for next year and the following years.
The way we are dealing with matters this morning is less than ideal. I ask that the Minister and his officials would come back for a coherent session. The budget has just been announced and this is an important time in the year for getting ourselves organised for next year.
I ask the Minister to address those issues.
To start where Senator Dolan finished, I agree that this is less than ideal. That said, I alerted the committee as soon as I knew that there was a Cabinet meeting at 10 a.m. I was here three weeks ago and will be back again in November. I am happy to come back this afternoon, tomorrow, or whenever the committee wants me to be here. I am always available to this committee and these Houses. There is no issue in that regard. We obviously also have our colleagues from the HSE, including the director general, who can continue this meeting in the interregnum and deal with a lot of the questions being raised.
I visited Bandon Community Hospital last year with Deputy Margaret Murphy O'Mahony and was very impressed with the facility and the extension. I will ask the HSE to respond to the Deputy this morning or by way of correspondence on when that facility will be open. I was struck by the dedication of everybody there and the energy in the place. We are eager to get that happening and I will get a date for the Deputy.
On the issue of family resource centres, while there could be a health element, I do not know the details. I know that generally such centres are funded by the Department of Children and Youth Affairs. I also know that the Minister, Deputy Zappone, announced in her budget day speech some additional funding for family resource centres, so perhaps that might be an avenue worth exploring further. I will ask the HSE to respond to the Deputy directly regarding the rehabilitation and endoscopy unit.
I thank Senator Colm Burke for raising the issue of Cork University Maternity Hospital, CUMH, as it provides me with an opportunity to acknowledge the incredible clinical leadership that is being shown by the community in CUMH, by Dr. Cathy Burke, Dr. Keelin O'Donoghue and their colleagues. They came to see me last year, with the HSE and the hospital group, on the new women and infants programme. They highlighted the fact that women in the Cork region were waiting longer for procedures than was the average around the country. In some cases, they were waiting significantly longer. They told me that they were putting together a plan to address this issue, asked me to resource that plan and to support them. They assured me that they would deliver results and they have been true to their word. They have made significant progress this year which is why, when it came to the budget day announcement, I committed to moving on to the next phase of that plan. We will be engaging with the women and infants health programme and the South-South West hospital group in this regard as we move forward with the service planning. There will be additional resources and funding available, but obviously that is a matter for the service plan and our dialogue with the HSE in that regard. When people in the health service put up their hand, make a proposal, ask for support and then achieve what they said they would, it is very important that we continue to support them. I believe we will see significant further progress on this in 2018. Again, I thank Senator Burke for highlighting the issue.
Regarding the fair deal scheme, as the Senator will be aware, a review of pricing mechanisms is ongoing and these are issues that can be considered in that context by our colleagues in the National Treatment Purchase Fund, NTPF. The point the Senator makes is an important one in terms of the profile of patients in our nursing homes. That profile has changed quite significantly in recent years and is only likely to continue in that direction. Thankfully, as the Senator points out, people are living longer but often have complex conditions and a greater degree of dependency by the time they enter a nursing home. Thankfully, statistics show that people are largely staying out of nursing homes until later in life and are then spending less time there. That discussion is ongoing through the pricing review mechanism and I do not wish to comment much further on it.
Is there a timeline for the review?
We expect it to be finalised in the coming months. It should be finalised by 2018. I do not want to be too specific. I have a job to do for the taxpayer as well and I do not want to tie the State's hands in these discussions. That said, I expect the process to come to a conclusion in the next couple of months.
I thank Senator Dolan for his questions. I know that the Minister of State, Deputy Finian McGrath, will be here later to engage on some of these matters. The Senator has hit the nail on the head in terms of verification being such an important part of what we do. As Minister for Health, when I announce on budget day an allocation of so many billion euro, I must be very conscious of what that means to the man, woman or child at home in terms of services and access to services and supports for the year ahead. Frankly, such large global figures mean very little to any of us as citizens. People want to see the granular detail of what it will mean. Will it improve access to speech and language therapy this year? Will there be an increase in respite places? What will it mean for home care packages? People have a variety of questions like that. I can assure the Senator that this is something the HSE takes very seriously in terms of the service planning piece, on which we will engage shortly with a view to coming to a conclusion by the end of the year and the drawing up of service level agreements. In return for receiving taxpayer funding, the HSE will outline what it expects will be delivered in 2018. Making that as concrete and real as possible for people is very important.
Senator Dolan regularly poses the question, and he is right to do so, whether we are making headway in disability services. We are increasing the budgets and the Senator will acknowledge that funding has increased again. Funding was also provided for the decision support service and €3 million was provided for the Department of Justice and Equality to enable it finally to get on and ratify the UN convention. The budget for disability services will increase by about €75 million in 2018. What does that mean? Will that mean better services? Will it mean that we get ahead? Truthfully, the answer is that there continue to be demographic pressures in this area. These are good problems in a way, in the sense that people are living longer and are demanding, requiring and receiving better care. That obviously has an impact on the budget. I do expect that when we deliver the service plan we will see concrete commitments to improvements in a number of target areas for people with disabilities in 2018. I know that the Minister of State, Deputy McGrath, has prioritised and will continue to prioritise, through the service planning process, issues such as respite and emergency placements because there was a particular and growing challenge with that this year. We saw many cases of parents with a child - often an adult child - at home reaching breaking point. They then have to make that extraordinarily difficult decision to put their child into residential care. Often, the needs of the child are so complex, however, that finding an emergency place can be a very big challenge. The Minister of State has highlighted that as a priority. He has also highlighted the issue of speech and language therapy along with the flagship issue, which he is taking very seriously, of ratifying the UN convention. When we get down to the level of the service plan, the Minister of State will be able to engage further with the committee. The HSE may also wish to comment at that point.
Before I bring in Senator Swanick and Deputies Durkan and O'Connell, will the Minister clarify whether he and his Department accept that the disproportionate application of the financial emergency measures in the public interest, FEMPI, legislation to GP fees has damaged general practice substantially? What plans does the HSE have to recruit GPs? GPs are contractors and therefore fall outside the normal employment structures. As they come to retire, there is very little engagement with them on how their practice will continue after they retire. I ask the Minister to address those two issues.
I would like to echo what my colleague, Deputy Murphy O'Mahony, said regarding district hospitals. The Minister knows that I am a fan of the district hospital network and that I believe that it has a vital role to play in modern-day health service delivery. District hospitals should not be seen as a relic of a bygone era because, with adequate investment, they can prevent or reduce admissions to acute hospitals and facilitate discharges from same.
Specifically with regard to the hospital in Belmullet, with the recent storm the director of nursing was forced to evacuate the patients to the physiotherapy department for fear that the windows might blow in. We recently had a HIQA inspection there, which I welcome, because while the level of nursing care is excellent the building is crumbling. Could the Minister provide some information on the investment planned for the hospital in Belmullet, the building works due to be carried out there and, if possible, a timeline for that?
Many of my young GP colleagues are emigrating. The Minister is aware of that. We must look at reversing the FEMPI cuts to attract GPs and keep them in rural areas in particular. There is a surgery close to me where a GP leaves more or less every two years because there is no future for them there. I would welcome clarification on that if possible.
I call Deputy Durkan for a brief comment.
You will be glad to know it will be brief as always, Chairman. As far as I am concerned the big challenge currently is the budget. The current budgetary allocation is the first in recent years where extra money is available and it is being spent. We welcome that. The question is whether it will suffice. Given that we are in the higher cohort of spending among Organisation for Economic Cooperation and Development, OECD, countries, what measures will we put in place to try to address the issues that have caused problems such as waiting lists, overcrowding in accident and emergency departments, bed shortages and all the issues that arise from time to time? The question is also one for the HSE. What mechanism can we put in place to identify and address the problems that seem to obstruct the system? There is always a cause to which we can attribute a blockage at some stage. A system should flow freely. I know that is not the case in every country but in some countries it flows a lot more freely than here, including in countries where less is spent on the health service. There are issues we need to identify and address. Do we have a mechanism in place to do that currently? That is the crunch issue for everybody - the HSE and the health services in this country. The people are watching and they will come to a conclusion. If the system cannot deliver effectively and efficiently in a way that it has not done before then we have a problem.
I thank all the witnesses for coming in this morning. Does the Minister know the impact of the recent campaign on the promotion of the HPV vaccine? Are there any preliminary data to show whether we have addressed the decline from 87% to 50%? I know the campaign was recent but are there any data to show the plan is working?
With regard to primary care centres I heard the Minister speak recently about the number of centres that have been opened. I think we have gone from 43 primary care centres to 105. In light of that and of the Sláintecare report where we focused on the reorientation of the health service into primary care, perhaps Mr. O'Brien could indicate what plans there are for the expansion of primary care centres. I hate anecdotal evidence but I constantly hear that when people are on their way home from work the primary care centres are closed. One cannot run primary care centres without GPs. What are we doing to expand the services and the opening hours of primary care centres in order to line up with the purpose of the Sláintecare plan, namely, to effectively reorientate people into the primary care setting? I know you are looking at me with intent Chairman, that you want me to stay quiet.
I thank Deputy O'Connell. My body language is working. I call the Minister.
Let me state the obvious in relation to FEMPI. Of course it has had an impact on general practice, just like it has had an impact on so many contractors and public servants across the country. We all know the rationale and the reasoning behind its introduction. There was a national financial emergency. We know the economy is in a much better place now, thank God, and we know we are trying to move to higher ground in that regard. We are obviously engaged in contractual discussions with GPs. I have made it very clear - I will make it very clear again - that the totality of those discussions should not be seen to merely relate to the €25 million primary care fund in the budget. GPs have issues they want to discuss as part of the contract negotiations. I have issues that I want to discuss and that is the mechanism whereby we should discuss them. Let me be very clear though; the Government wishes to invest significantly in general practice on a multi-annual basis starting in 2018. There is an opportunity for GPs now to reach agreement with the State in that regard that will see more funding spent on general practice and more funding going into general practice, which will help address the issue of sustainability.
There would not be a need for negotiation in any situation if it was not the case that there are two sides often with different asks and different sets of priorities. There is a lot of overlap in some of the things GPs want to do if they are resourced and some of the things we want GPs to do and in primary care generally. There are also some issues on which we do not agree. That is the purpose of negotiation. I hope members hear me clearly this morning and send out a message, as the Minister for Finance did in his budget day speech, that the Government is willing to look at this in a multi-annual sense. The Minister for Finance is willing to see significant additional resources in general practice, starting in 2018 and for every year after that. We have a busy agenda of things to discuss. I do not want to say any more than that publicly but that is quite a significant and important message to send to GPs, namely, that we are deadly serious about wanting to deliver a contract that works for them and wanting to see them adequately resourced to do their job in a sustainable fashion.
On the issue of GP recruitment in general, I see the Irish College of General Practitioners, ICGP, is now running a very vigorous and visible campaign campaign in advance of the next intake of GP trainees. I have met the ICGP in that regard and I met with it at a careers day recently in Dublin Castle. I am very grateful for the ownership it is taking of the issue. The Irish College of GPs is speaking directly to GPs and GPs are encouraging new young medics to become GPs as that has an impact as well.
I agree with what Senator Swanick said about district hospitals and, more important, Sláintecare agrees with him. We need to find the right role for every part of our infrastructure across the health service and that includes a greater and enhanced role for district hospitals and doing what is appropriate to do in a district hospital. We agree with him on Belmullet. That sounds like it was a very difficult and challenging time for people there. I will ask the HSE to provide Senator Swanick with an update on plans for Belmullet. We will come back to him directly.
Deputy Durkan asked whether the budget will suffice. This is the age old question. I have a very clear view on this. One can have an old and fuel inefficient car and one can spend a lot of money on the car but the car is still old and fuel inefficient. It is the same with the health service. That is not in any way a disparaging comment; quite the contrary. It is a fact that we need to put in place a more efficient vehicle for the delivery of our health service. I heard the director general talk about that as well. It is not just a health service responsibility, politicians have a responsibility in that regard. Reform has been stop-start, confusing and at times incoherent. I assure Deputy Durkan that I see Sláintecare as the journey to getting that new vehicle. I really do. When we had the all-day Cabinet meeting in Cork last Friday we took a number of additional steps beyond the resourcing issues that took place on budget day in terms of the impact study Sláintecare asked me to do on public versus private, and appointing Donal de Buitléir to carry that out and report by next summer. That will include asking the public and those working in the health service how one aligns community healthcare organisations, CHOs, and hospital groups, because that needs to happen, and how to do it effectively, and also bring back a performance and accountability type structure such as a board for the HSE. I heard the director general talk about how the governance structures in the health service currently are not fit for purpose. They were only ever meant to be temporary or stop-gap structures. We cannot have a situation where we do not have a board to which the HSE is accountable. It is very important that we get the right skill set in relation to that. It will require primary legislation. It is a recommendation of Sláintecare. I hope with the agreement and co-operation of members that we could progress that very quickly through both Houses of the Oireachtas as well.
In response to Deputy Durkan, Ministers for Health long after me could sit here and talk about the health budget increasing, and that will result in benefits - I do not dismiss the need for resources. We need to see benefit in particular in areas like waiting lists. Huge resources will be spent in 2018. We have seen figures fall for two months in a row now and we need them to keep falling but increasing the budget is not going to be enough in and of itself, it must include the reform piece as well.
To address Deputy O'Connell's question on the HPV vaccine campaign, in recent days I asked the same question which she asked. I am told that it is too early to see the data. I do not know whether Mr. O'Brien has any data on it, but I have not seen any yet. There has certainly been a very effective campaign and I appreciate the support of everybody in this room in promoting that. I hope we will see a benefit from it but I have not seen the figures yet.
On primary care centres, the Deputy is right. We have invested a lot in the infrastructure, but if the lights are off at 5 p.m. people will still find themselves having to go to the acute hospital setting. Part of the discussions with the GPs - and I am not putting it all on their shoulders - is about how to keep these centres open longer, but there are also things we can do through the primary care fund such as community nursing, advanced nurse practitioners and helping with chronic disease management in the community. We can see progress on a number of those fronts as a result of the budget day announcement.
I have two questions before the Minister goes. On Sláintecare, there was a proposal to set up an implementation body. I do not think that was mentioned at the Cabinet committee. What is the position there?
There was a budget line in the budget book in respect of the €1 million, which is in line with the €10 million allocated to Sláintecare over ten years. There will be €1 million in the first year for a Sláintecare implementation office or a Sláintecare programme office. Issues in respect of the recruitment of the lead executive are being worked on and will be progressed very shortly. It is really important that we get the right skill set. I believe everyone would agree on that. I expect to be able to update the committee very shortly.
That is in train.
Yes, very much so.
There was one last question on HIQA's inspection of St. Joseph's Hospital in Ennis. Deputy Alan Kelly had asked a question on that situation.
I will ask the HSE to comment in that regard. Obviously HIQA has a role as an independent regulator. I do not wish to say anything which involves me in a space in which I should not be involved, but at the last meeting Deputy Kelly alerted the committee that the potential impact of this situation may be broader than any one facility. I will ask the director general of the HSE to give his view on that situation.
Members of the committee raised a number of important issues which the HSE might pick up on, including the issue of recruitment, which Deputy O'Reilly raised. Ms Mannion might be able to comment on that. The issues of scoliosis, HPV and the storm damage which may have been done to our facilities were also raised. I believe they were the main points but obviously members can direct any other issues they wish to raise to the director general.
Mr. Tony O'Brien
In respect of the specific locational questions, including those on Belmullet, Bandon and Bantry, I propose to forward detailed replies to the committee, which we do not have in our possession here and now, within a few days. We are completing our assessment of the impact and cost of any storm damage, although the damage to our infrastructure has thankfully not been as significant as we at first feared it might have been. In respect of the issues raised about recruitment, I will give Ms Mannion notice that I will be asking her to speak on those issues. I will ask Mr. Woods to give us the latest position in respect of scoliosis.
With regard to the question on drug approvals, nine drugs were subject to an approval process earlier this year. They were Erivedge, which is used to treat basal cell carcinoma; Brintellix, which is for depression; Entresto, which is used for heart failure; Lynparza for ovarian cancer; Gazyvaro for follicular lymphoma; Entyvio for Crohn's and ulcerative colitis; Opdivo for renal cell carcinoma and, separately, Opdivo for Hodgkin's lymphoma; and Otezla for psoriasis and psoriatic arthritis. All of these are either already available and listed for reimbursement or will be by the beginning of November in line with the announcements made during the summer.
On the HPV vaccine campaign, while it is too early to be quoting any data or statistics, the school-based teams administering and engaging with students who will be offered the first dose from September or October of this year and their parents are reporting a much better atmosphere and much more positive feedback. While we do not have hard data, we would say that we are now cautiously optimistic that we will see an uptick in the levels of uptake of the HPV vaccine, although it is no time for complacency in that regard.
Mr. O'Brien is referring to the cohort who are due to receive the vaccine and that they are perhaps more enthusiastic about it than the previous cohort. Does the HSE have any indication that the people who have not been vaccinated in the past, for whatever reason, are changing their minds?
Mr. Tony O'Brien
I do not have hard data, but again there is a degree of optimism that there is a better environment for the catch-up programme, which has been equally well-publicised in those schools. At this stage, however, it is just too soon to have data.
When would Mr. O'Brien expect to have data? I am not trying to be difficult but I know that when a pharmacist gives the flu vaccine, he or she enters the person's PPS number so that the doctor will know whether it has been given. It is there in a system. I can understand that we need a period of time to collect a data set, but once a period of time has elapsed I cannot see how it would be any more complicated than pressing a button or highlighting a column.
Mr. Tony O'Brien
We are still in the phase where the vaccine is being administered. We do not have any complete data in that regard. It is too live for me to provide the Deputy with any data.
Surely if somebody did not have the vaccine when she was due to it would be highlighted that she did not have it, and if she got it it would be fairly obvious. I can see how there is an issue with the data for the cohort which is due to receive the vaccine.
Mr. Tony O'Brien
In an individual case it is possible to establish whether a person did or did not receive the vaccine, but we do not have sufficient data at a national level for me to give the Deputy an indication in data terms as to what the uptake rates are. It would not be safe for me to do so.
When would Mr. O'Brien expect to have that data?
Mr. Tony O'Brien
I would expect to have it before the end of the year.
I am not being critical. If we have made slight inroads, that is great, but we need to ramp up what we did right. If, however, the activities of the immunisation people in the HSE, the Irish Cancer Society, the Minister and the members of this committee are not having an impact, we need to seriously consider what we are doing. There is no point in waiting two years. That is really my point.
Mr. Tony O'Brien
We will not be waiting that long. Before we get to the second dose phase we will know how the first dose phase has gone.
I am specifically referring to the catch-up people who did not receive the vaccine in the past. Does the HSE have any plans for another round of distributing information to try to address the issue?
Mr. Tony O'Brien
Yes.
Is there something in the pipeline within the HSE?
Mr. Tony O'Brien
Yes. There will be a continual programme of campaigning in respect of the HSE vaccine. It is not a start-stop thing at all.
When the Minister was leaving he referred to some questions. One related to recruitment and he indicated that Ms Mannion would have information in that regard.
Ms Rosarii Mannion
We are working very hard on recruitment across the system. At the end of August our whole-time figures showed an increase of 3,453 across the system. That is an additional headcount of more than 3,000 in comparison to this time last year. Of that figure, more than 400 are nurses. Health care is delivered by fully-staffed, multidisciplinary teams. No one grade is more important than another. We are very focused on recruiting all grades of staff where they are required including nurses, doctors, GPs, psychologists and staff for the mental health programme. We are doing very well on the recruitment of assistant psychologists. We had approval for 150 of them. That panel will go live in December and will be a significant help in respect of programmes and developments in mental health next year.
With regard to nursing specifically, members will be aware that we have been very focused. We are trying to grow the nursing workforce by 1,208 this year. We are doing well. We are very focused on retention measures. One such measure is a push on flexible working. I am really pleased to see that, across the nursing workforce, in excess of 60% of nurses are availing of flexible working of some description. That is a very good thing and we are actively promoting that. It presents a challenge in the reporting of our nursing figures because variation, increases and decreases will show up month on month.
I was slightly disappointed to see the figures in August but that was attributed to the numbers of more than 60% of nurses on flexible working. Between now and year end, we are focused on agency conversion. As the Minister outlined, we have permanent contracts for all our graduates. We are hoping the uptake will be very good. Feedback on the ground is that it will be. Part of the 1,200 nurses in question was a conversion of 736 agency posts. On any day in the health sector, we have in excess of 1,000 nurses working on agency contracts. We are very focused on achieving that conversion between now and year-end. Between agency conversion, permanent contracts for our graduate and other nurses in the churn, we are making our best and honest effort to achieve that recruitment.
If it is successful and we meet our targets, we will be happy. If it is not, we need to go back to the drawing board to see what else we need to do. There is no doubt that there are constant retention challenges across the health sector. It is a challenging area in which to work. There is competition out there. Many staff we recruit, both nurses and doctors in many specialties, are interested in travelling. We want them doing that by choice, not because there are no posts available.
Overall, that is the situation with recruitment. Suffice to say, we are doing everything possible and will continue to do so. Progress is good but we would like it to be better. Year on year, we have in excess of 3,000 additional staff providing services.
Is Ms Mannion disputing the INMO figure that there is not more than 13 additional nursing staff? It does not matter to the patient what is written on the payslip of the nurse standing by their bedside. While it matters to the nurse and to the HSE figures, conversion from agency does not actually add hours to the system. When the budget was announced, the INMO stated that, on balance, the actual increase was 13 nurses. I fully appreciate there is more to health care delivery than nursing staff.
Ms Rosarii Mannion
I am not disputing it at all because I actually prepared that report.
Does that mean the HSE will not hit those targets? I understand Ms Mannion is hopeful and working hard. I would not dispute that for a moment. However, in truth, the HSE will not hit those targets by the end of the year. It is missing them by a mile as it is and, more than likely, it will miss them by several miles by the end of the year. Instead of hoping, it would be more helpful if the HSE were honest. I do not actually believe Ms Mannion is hopeful the HSE will hit those targets.
Ms Rosarii Mannion
On the increase of 13 nurses, I prepared that report. That did not factor in the student nurses in the system or take into consideration the 1,500 graduates offered posts between now and year end. The actual headcount increase, the additional nurses, was in excess of 443. On any one day, there are 1,000 nurses in an agency who are not within that figure.
Will we get there by December? I do not know. Suffice to say, we will be making our best efforts. As I said, it was agreed 736 of the figure would be through agency conversion. Why has that not happened year-to-date? The final quarter is always the one where one sees conversion taking effect and being visible in headcount and on payroll. That is why I am optimistic.
I think Ms Mannion could say whether it will happen but I do not want to put her on the spot any further.
Ms Rosarii Mannion
Suffice to say, we will make our best effort.
The Minister referred to the pay commission. Is the agency funded for this pay commission or will it not see anything from it next year? Will it include section 39 agency staff who are considering a ballot for industrial action over pay equivalence with public service?
Mr. Tony O'Brien
We would not be funded at this stage for decisions the Government has not yet made.
It has announced it.
Mr. Tony O'Brien
The Government announces processes which can lead to decisions it will make. At that point, it will make the corollary funding decision. For example, in the course of this year, we have seen decisions made which have increased pay costs which have then resulted in subsequent decisions to address those pay costs. It would be strange for the Government to make those funding decisions in advance of having made the fundamental policy decision.
The question of section 39 staff is a matter of public pay policy. Persons employed in section 39 agencies are not regarded as public employees but there is a process, some of which the Deputy will be aware of, under way on those. I do not know what ultimate decision will be made on that. This year the HSE was not funded to provide funding to section 39 agencies to facilitate them in making similar pay awards to those which were made available to section 38 employees.
Has Mr. O'Brien any estimate of what it could cost if they won their case?
Mr. Tony O'Brien
I do not have it with me now but I will provide the committee with the information.
What is the situation with scoliosis treatment?
Mr. Liam Woods
The tender and the engagement of hospitals outside of Ireland in the treatment of scoliosis was completed. Three hospitals were successful, St. Franziskus-Hospital, Münster, Germany, Capio Polyclinique du Parc, France, and Portland Hospital in London. We are already working with Stanmore in London, which is a public facility and we can trade on a parallel basis with it. There are four external facilities, as well as our own in Cappagh, the Mater, Temple Street and Crumlin. Outpatient clinics are being arranged and, in some cases, have been arranged. We had to cancel one on Monday for obvious reasons. They have been arranged to clinically assess the appropriate location of treatment for the children in question. This week, two children will be treated in Germany. The three tenders were completed last month and will now wrap up in terms of delivering care.
Will that encompass the 68 children in question?
Mr. Liam Woods
Yes.
Are there plans to run the theatre in Crumlin on a five-day basis?
Mr. Liam Woods
We want to expand to maximum capacity in Crumlin as quickly as we can. We remain cognisant that other work is also done in Crumlin and there is a trade-off in that respect. We have been deliberately seeking to move some cases to outside of Crumlin to allow the most difficult cases to be treated there.
Is the HSE confident it will hit the targets by the end of the year?
Mr. Liam Woods
It will be dependent on the choice of families. We will have offered treatment to all of the people waiting. We have treated 272 to date and we have referred 173 to go to hit the target. We will certainly have offers for all of those. The volumes overseas will grow, both based on experience and the arrangement of clinics. That is happening at the moment.
Can I get an answer from Mr. O'Brien on HIQA and Ennis?
Mr. Tony O'Brien
I recognise HIQA has an important and often difficult job to do in exercising its regulatory functions. The fact we find ourselves from time to time on different sides of those discussions does not amount to a criticism of HIQA from the HSE. We respect the role of HIQA. Sometimes, however, the exercise of its regulatory functions and the exercise of our care provision or care funding functions bring us to different sides of licensing questions, as is the case with St. Joseph's Hospital in Ennis. The law governing this provides for a court process to resolve those differences. As this matter is before the courts, I want to be cautious in what I say about it. I am fully prepared to provide a more detailed written answer because it is far easier to be careful with them than it is with verbal answers.
The Deputy is correct the issues that arise are important, not just for those who receive their care in St. Joseph's Hospital. Potentially, it could have wider implications for the provision of care through public facilities in the State. That is why, through the community healthcare organisation in that area, the HSE has taken a stance which necessitates the involvement of the courts to mediate in this process. I do not want to ventilate the issues.
I understand Mr. O'Brien does not want to ventilate the issues. However, that is what this committee does. With all due respect, Mr. O'Brien, we need a better answer than that.
Mr. Tony O'Brien
I do not-----
I have not finished. I do not expect Mr. O'Brien to cross into the line of a legal case. For the information of the Chairman and public, I asked the Minister the question earlier and he has passed it on to Mr. O'Brien. Mr. O'Brien has now said he is going to send in a written answer.
Mr. Tony O'Brien
Yes.
There is scope for Mr. O'Brien to answer the question without crossing into the legal area. I presume he fully supports the local HSE's actions.
Mr. Tony O'Brien
Let us be clear; when the local HSE enters the court, it can do so only with my authority.
I do not need a grin from Mr. O'Brien. I need him to support it fully in its actions.
Mr. Tony O'Brien
I do not know why the Deputy thinks I am grinning at him because I am not. I would like to be very clear about the fact that no part of the HSE can enter into legal action if it does not have my support.
That is fine.
Mr. Tony O'Brien
Therefore, unambiguously, the HSE, through its community healthcare organisation, is a party to this case before the courts.
Good. The issue for me really is that this is a very important test case. The Department has issued regulations in regard to multi-occupancy rooms covering the period to 2021. There are many other regulations also. We discussed this matter here and we did so at a meeting of the Committee of Public Accounts for different reasons, concerning the spending of money. The point, however, is that the Director General will, depending on how this materialises and comes through the process, face Armageddon when it comes to the provision of beds, particularly public nursing home beds, across the country.
I support the HSE in what it is doing. What it is doing is correct. Obviously, there are many lessons to be learned from the HSE in this process also. They have been learned.
Mr. Tony O'Brien
I welcome the Deputy's support and I had not doubted it. The key issue for me is not to do anything that would in any way make it more difficult for the HSE's position to be sustained by the courts. In that regard, we have full respect for the role of the committee. I propose to give the committee a written answer in which I can be certain I will give accurate information while at the same time not complicating in any way our relationship with the court that will make the relevant decisions in this matter.
Some of the issues I would like to raise have been touched on but I would like a little more detail on them. The funding this year for the National Treatment Purchase Fund, NTPF, is €20 million. From what I can gather, that will increase to €55 million next year. In the context of the assessment of who should be treated through the fund and the contracts that will be entered into with the private health care providers providing treatment, what size contracts will be awarded financially, procedurally or otherwise? What is the cost of providing the same treatment in a public facility by comparison with that of providing it in a private facility? We are trying to compare how much it costs to provide certain surgeries or procedures publicly and privately. There are varying views, including that the private sector can provide treatment more efficiently. Others argue that the public system can do so more efficiently. If we do not have any detail on it, how can we adjudicate on which is more efficient? Ultimately, public money is being spent. Where unused capacity in public hospitals funded by the National Treatment Purchase Fund is concerned, is what is occurring not just shifting money by way of an accounting exercise as opposed to increasing genuine capacity in the public health system?
On the section 39s, which have been referred to already, a considerable issue arises in terms of pay awards to employees across the broader health system. They are also awarded to section 39s. No provision is being made, however, in the bloc grants from the HSE to the organisations concerned. I refer to very large ones of which I have reasonable knowledge, such as COPE in Cork and St. Joseph's Foundation in Charleville. There are many across the country that do amazing work for the amount of money they are being given. There was a cost-benefit analysis of the various section 39s. They were asked to find savings and they did. Many made substantial savings but there seems to be no acceptance that they cannot keep cutting services to fund public pay increases. What the HSE is effectively asking people to do is to cut services to fund public sector pay increases that they are not party to. HIQA is now investigating these same organisations saying that they are providing substandard care in some cases, yet there is no provision by the HSE to fund the increased number of staff required to comply with HIQA regulations. Could I have Mr. O'Brien's observations on those issues?
Let me go back to my original question, on the issues that attract public attention and upset patients and the general public and which actually demoralise those working at the coalface in the health services. The first is overcrowding in accident and emergency units. Can the HSE put in place trouble-shooting systems that will find out precisely the cause in each case, as it arises? There are not so many that they are beyond enumeration, but they are of sufficient importance to require an immediate response such that the public and patients can see something happening. The question that comes to mind is why there is so much overcrowding at accident and emergency units. Is it because people bypass their general practitioner? Is it because they have been on a waiting list for general hospital services or elective services for a long period? I am just asking these questions off the top of my head. I have dealt with such cases myself. What are the issues? How can one put in place a system that would identify the cause or causes, isolate them, set them aside and deal with them? This is a major issue for the health services this year. Without doubt, the public in the health services will become depressed as a result of implied criticisms. There is actually no criticism but the fact of the mater is that the system is not flowing smoothly, which is a problem.
Another issue is waiting lists for various procedures in general hospitals or public hospitals. Again, there is a need for an urgent appraisal of the causes of the stoppages and slow-downs. Is it a lack of personnel, consultants, hospital doctors, theatre staff or theatre availability? A criticism I hear from consultants is that, in terms of procedures, there could be a 15% difference in the amount that could be done in a public hospital by comparison with a private hospital in the same day. The questions that arise in this regard are why this is the case, why we cannot identify the problems and why we cannot address those issues. Let us not forget that there are theatres, including clean-air theatres, that have never been used. They have the most sophisticated technology in the land, or in Europe, in fact. To restore public confidence in the system - this is not a criticism of the HSE or any personnel anywhere - we simply have to address this. If we do not do so, we will have failed and I will have failed as a member of this committee. The health services will have failed if we cannot address these issues.
What is the most effective use of consultants throughout the public health system? Are they effectively engaged? Are we diverting towards them a steady flow of patients that they can deal with daily without having a hiccup and having to wait for two or three days for the next patient to come along? What are the causes? Can we address them? How soon can we address them?
I thank the deputations for appearing before the committee this morning. I have tabled question 5, which is a specific question on orthopaedic services in Cork, in particular those in the South Infirmary Victoria University Hospital. I note from the reply that there are 456 people waiting for a first appointment for more than 24 months. I am raising the question because of the case of one patient who is on the urgent waiting list. I was advised in March this year that the patient would be seen by June. Then in June I learned that the patient was eighth on the waiting list but would not be seen before the end of September. At the end of September I was told that it would be at least another three or four months before the patient is seen. This patient is on the urgent waiting list. I am concerned about how the list is managed and why the goalposts are constantly being changed. Will any action be taken to deal with the 456 people who are waiting more than 24 months for an appointment?
My second issue relates to orthopaedic services in Cork. I was advised that six people were referred for hip replacements under the National Treatment Purchase Fund. This was some time ago, not recently. The HSE paid for the procedures to be carried out. A total of four of the patients had private health insurance, but yet the HSE paid for the treatment. What checks and balances are in place for the NTPF? How does that arise?
Another issue relates to retention of management in our hospital structure. If we have a system whereby managers keep changing, then we do not have continuity of management within individual hospitals. I know of one hospital where there have been ten managers in 18 years. Therefore, there is a problem with either the payscale or how the position is created. Will there be a review in respect of the whole issue of continuity of people in particular roles? This is fundamental. There are doctors and nurses in place for 15 or 20 years and that brings continuity. However, if we do not have continuity in management, there is a problem. Will that issue be reviewed? Is there a need to review the case of smaller hospitals and the status of managerial positions? If the positions are being under-graded, do we need to look at that rather than having constant rotation of managers and lack of continuity? Is there any review of that area at the moment?
The final issue I wish to raise relates to the recruitment of non-consultant hospital doctors, NCHDs. Of the 6,000 NCHDs currently employed how many are under agency contracts? What do we need to do to make those positions more attractive and to try to move away from agency contracts? If we can move away from agency contracts then it would cost less. What do we need to do? Do we need to improve training grants or additional resources for the educational process they are going through? Is that being reviewed as well?
Mr. Jim Breslin
Deputy Kelleher asked about the process under the National Treatment Purchase Fund for securing value. There are two aspects to it. The first relates to the arrangements whereby private hospitals are procured. Private hospitals are invited to express interest in the work. They submit the basis on which they carry out the work. The submission is then assessed by the NTPF and drawdown contracts are put in place. The reason for the drawdown approach is that where the patient goes is determined by the specialty of procedure required and, to some extent, by the location of the patient. Depending on where the patient is to be dealt with and the condition that needs to be addressed, the patient will be funnelled to relevant private hospitals. This happens against a properly procured price arrangement.
As the Minister has said before, we can determine the precise amount of activity delivered by the NTPF in return for the funding. The reason is that the funding flows on a per-patient basis. Private hospitals only get paid if they treat the patient in line with the arrangements in place. The Minister has said that between 17,000 and 18,000 additional procedures will be performed as a result of the funding put in place for the NTPF next year - that is why we can say that.
The activity taking place funded by the NTPF in any public hospital is additional activity and it has to sit firmly additional to and above what is already in place. Particularly relevant arrangements are those for the Royal Victoria Eye and Ear Hospital and Cappagh National Orthopaedic Hospital. The funding made available has allowed these hospitals to increase their capacity. Had they not got the funding, they would have been unable to carry out the additional activity.
The question of whether this complicates funding flows was asked. It does complicate funding flows somewhat. Again, it gives transparency to the fact that those hospitals have to carry out additional activity. If they do not carry out the additional activity, then they will not get the funding.
Overall, we are moving towards a place within the total acute hospital system where the budgets for hospitals will be far more related to the activity they undertake. However, that is a gradual process and we do not have full activity-based funding in our public hospital system. This is a means of incentivising hospitals to undertake additional activity.
One recommendation in the Sláintecare report related to trying to look at greater separation of elective and emergency workloads. It is quite possible that a hospital will come under pressure from emergency demand and will see its elective activity reduce. This is one way in which we can try to maintain a separation of elective activity, especially in hospitals such as Cappagh, the Eye and Ear and Our Lady's Hospital, Navan, which are unaffected by emergency pressures to the same extent, and reward them for doing more emergency activity.
It is more difficult in the large general hospitals, where the two pressures feed in to each other. That will be one of the things to address in the implementation of the Sláintecare report. The question is whether we can get capacity within our public system that is firmly dedicated to elective activity and waiting lists and does not get buffeted by seasonal and other pressures to do with emergency workloads. Some of the experience in the NTPF is of use to us in doing that and developing our total system of hospital funding.
Mr. Tony O'Brien
A question was asked about section 39 agencies. It is certainly the case that when public pay was being cut, high-level reductions were made to the gross funding of section 39 agencies as a corollary. In many instances, though not necessarily all, they would have dealt with this by imposing equivalent pay cuts on their staff. As pay has been restored, however, the HSE has not had funding restored in respect of the likely cost of equivalent pay awards in section 39 agencies.
It is not the case that the HSE has made a decision to treat the section 39 agencies differently from others. It is the case that the HSE is the recipient of funding that does not allow it to provide that level of funding to section 39 agencies. Clearly, that is a challenge for those section 39 agencies and for the staff who work in them. Several of those agencies and their staff are engaged with the Workplace Relations Commission and similar processes in an attempt to get decisions. In turn, they will discuss those with us and we, in turn, will discuss them with our funders. We are not unsympathetic to the situation, but, at the same time, there is an equivalent public policy issue. In other words, section 39 agencies are not public bodies and their employees are not public sector employees. The way these things progress could have an impact on the application of that policy.
It is above the HSE's pay grade. I think I would put it that way.
Is it the president of HIQA that should answer that question?
Mr. Tony O'Brien
Just to be clear; I should say that neither the Department of Health nor the HSE were funded.
Did Mr. O'Brien instruct the section 39 agencies when the funding was cut to cut the pay of their staff either implicitly or explicitly? I took several cases to the Labour Court in relation to that and the feeling at the time was that they were following HSE and Department of Health advice.
Mr. Tony O'Brien
The formal position at the time and now is that funded bodies, particularly ones which are substantially funded by public moneys as opposed to those which are only marginally funded, should have general regard to public pay policy and I think that is probably the context in which that would have been argued at the time. That is not to say that they are obliged to follow public pay policy.
Mr. Jim Breslin
From what I recall people were told to look at their cost base across both pay and non-pay areas at the same time as was happening in the public sector but there was not a definitive proposition put to them that it should be X% in regard to different salary bands. That does present a problem in terms of restoration that, unlike the public service, where there have been agreements with everybody around the table and they get either partially or fully restored based on a particular day and a particular percentage. I think the sector will have approached this in somewhat different ways in different circumstances and the resolution to it is probably likely not to be as uniform as in the public service.
I will leave it at that. Does Mr. Breslin not accept that some of the section 39 organisations are quite large employers, very large employers in some cases, providing significant services in areas, in particular intellectual and physical disability, and there seems to be no appreciation either from the Department or the HSE of what they have to do on a daily basis to try to comply with HIQA's enforcement and to provide safe services to people? When one meets some of the people who are volunteers in many cases on the boards, they are in breach of their fiduciary duties, they are not far off trading recklessly and their auditors are at their wits' end trying to address their accounts. Pension provision is being funded out of current expenditure. Is there anybody looking at this strategically to see whether something could be done either to rationalise the services and force them to co-operate more or to do something to help them? If we allow the situation to continue people will have diminished services. We are talking about very vulnerable people whose families are under huge pressure. I am beginning to think there is no system in place to assess the services and examine the broader supports that are required in the areas of physical and intellectual disability.
Mr. Tony O'Brien
There were specific questions about orthopaedic services in Cork which I will ask Mr. Woods to address.
Mr. Liam Woods
I would be happy to get details from Senator Burke on the question about the patient and to follow it up individually. The point about the NTPF hip replacement operations and four patients having private cover, as the Senator is aware, is that it is every citizen's entitlement to access hospital services so that is entirely within the legislation.
On the point about the retention of managers, I took the question to refer to small to mid-size hospitals where there may be a lot of flow. It is an observation well made that managing a small hospital is a complex management task. There has been a history of staff grading levels that attract people to move based on the fact that they can be promoted at a higher grade elsewhere. That is something we have to look at in terms of career structure. There has been some experience recently of upgrading those posts to provide better longer term career opportunities. The Senator's point about stable leadership is well made and understood in management theory and practice and in fact is reflected in health literature.
On the question about non-consultant hospital doctor, NCHD, recruitment, from a hospitals' perspective we are up 178 NCHDs since the start of the year. Our medical agency number, which is the point to which Senator Burke referred, is still relatively static. There has been a small drop and it is very close to the change-over so we will have to assess our own data.
What proportion of the 6,000 are in agencies?
Mr. Liam Woods
I do not have the numbers in front of me so I will come to the Senator with that number if I can do that. Is the Senator's question about retention of NCHDs?
No, I am wondering how many of the 6,000 are on agency contracts. It is important that we deal with that issue.
Mr. Liam Woods
The whole-time equivalent number of NCHDs - the actual number may be a little higher - at the moment in the system at the end of September is 5,308. We normally have an 85% relationship between the two. That is the actual number at the moment. I can come back with more data on the actual numbers that are on an agency basis at the moment.
On the management issue, the hospitals I am talking about are not small hospitals. If something has gone on for 18 years I am concerned about the fact that no action has been taken. I accept that over the past five to six years it has been difficult to do that but it needs to be given priority. It cannot be allowed to continue.
On orthopaedic surgery and the treatment purchase fund, it is a huge waste if someone is on private health insurance and someone else who is waiting on the public health system is pushed even further back. Have we put in place any checks and balances to try to deal with that issue?
Mr. Tony O'Brien
We need to be clear that a person who is on a public waiting list, which is the only basis on which one gets treated by the NTPF, has elected to be treated publicly, which is his or her legal right, irrespective of his or her private insured status. There are many people who pay private health insurance premiums who are treated as public patients. We would not have the right to say to them or even necessarily to know that they have private health insurance and that they should be using it.
\it is an issue.
Mr. Tony O'Brien
In emergency departments there is a specific procedure where patients are asked the question. They exercise their right, first whether to tell us, and second whether to be treated publicly or privately.
Could those involved in the National Treatment Purchase Fund not be asked to make the same inquiry of patients regarding private health insurance?
Mr. Tony O'Brien
They may well have been asked but if they choose either not to say or not to use it then that is their absolute right.
I accept that but I find it difficult to understand how someone who has private health insurance will wait 24 months on a public list and then get in under the National Treatment Purchase Fund.
Mr. Tony O'Brien
That is a complex psychological question which is not related to the management of waiting lists.
It is a complex psychological issue but I still do not understand why out of six patients who were referred, four had private health insurance.
Mr. Tony O'Brien
If they initially elected to be treated publicly and were prepared to wait the requisite period of time so that they were next in order to be treated then they would be treated. They could not not be treated simply because they had chosen not to use their private health insurance.
Could I ask that the issue would be looked at?
Mr. Tony O'Brien
In truth, there is not much point because they are entitled to do that. There is nothing wrong in law or in their rights or in our application of our treatment processes that says that we should not have treated those patients publicly merely because they had private health insurance and chose not to use it.
Is it in the public interest for the HSE or the Department of Health to encourage or advertise the fact that people who have private health insurance may be entitled to treatment under their private health insurance?
Mr. Tony O'Brien
I would have thought they knew that.
Mr. Jim Breslin
Health insurers are advertising that people have a right to be treated as a public patient even if they have private health insurance. We could advertise that if people have insurance they can use it and not use their public eligibility. This is hugely complicated.
I accept that.
Mr. Jim Breslin
It is the core of the issue that the Sláintecare committee considered in terms of private health care.
What can we do in the short to medium term given that public resources are scarce? What Senator Burke said is correct. Some people may not fully comprehend what they are entitled to in their health insurance.
Mr. Jim Breslin
On the face of it, it is a very strange decision to make if there is an option to be treated privately and people wait for two years in order to go with the NTPF and not be treated privately when they could have exercised their insurance ahead to that. The director general is correct in that our requirement under law is to deliver public services to public patients and once people declare themselves a public patient we cannot take that away from them. There might be a case to be made for the information being made available to people in a fuller way but, fundamentally, that is the choice of the patient if he or she wants to be treated as a public patient.
Are there other issues that we are not being told about?
Mr. Jim Breslin
That is a question to which I would love to know the answer.
That is why I am asking it.
Mr. Breslin and Mr. O'Brien might answer a question about Sláintecare. One of the fundamental recommendations of the Sláintecare report is that there be a reorientation of our health service away from hospital-based services towards primary care ones. However, there is a difficulty in how GP-led primary care is delivered, given the GP manpower crisis. We have difficulties recruiting new GPs. Despite the Irish College of General Practitioners, ICGP, advertising and promoting entry into general practice to new graduates, they are patently not doing so because of the GP contract and the financial model of GP care. How does the HSE or the Department propose to address the manpower crisis in general practice? It is growing more acute month on month. Jobs are not being taken up except by locums and people are not getting the same level of service and continuity of care that they would if they had established GPs. There is a difficulty in recruiting for general practice, but because GPs are contract holders and, as such, fall outside the employment relationship, how do the HSE and Department propose to develop the primary care service and attract GPs into it?
Some 33% of GPs are over 55 years of age, so there will be retirements, but there is no active component within the Department or the HSE to engage with those GPs and determine how they will organise their retirements. Can mechanisms be put in place to help them to move from their principalship to the next generation of GPs? Is there thinking within the Department or the HSE on how this can be done?
Mr. Jim Breslin
We have turned our mind to the challenge of implementing Sláintecare, which is not just to approach each recommendation individually, but to determine the critical success factors that need to be put in place to realise the vision set out in the report. We will return to the committee in November, but it is fair to say at this stage that there is a view that the Department of Health always sees money as the answer to every problem. In this ten-year review, however, the critical success factor will be the workforce and our ability to create conditions in which people want to take up the opportunities that we will make available over that period. This applies to GPs and right across the workforce. Some of it relates to remuneration, but it is also about trying to create conditions in which people can see that the types of career we have in Ireland are those that they are interested in and that are at least as good as, if not better than, those available elsewhere around the world. Much of this goes beyond simple remuneration issues into the workplace climate, how we evolve our health service, the types of arrangement that we put in place for people to structure their working weeks and careers, and trying to work with and listen to people who are currently facing the question of whether to continue their careers in this country or abroad. The Chairman is well aware of how many of our GP trainees face that decision at the moment.
A critical piece of work to be done as part of the implementation structure for Sláintecare will be workforce planning and addressing the issues that are causing us difficulty in recruiting and retaining our workforce, particularly graduates, so that when we put people through publicly funded educational programmes to turn them into health professionals, we get the benefit of that. I do not have all of the answers today, but this will be one of the chief components of a successful implementation of the Committee on the Future of Healthcare's report. It not only applies to GPs, but to so much else as well.
May I briefly-----
Sorry, but I will ask one question before the Deputy contributes. In terms of workforce planning, does the Department have a vision of how it will approach recruiting? We all know that we need to recruit. Mr. Breslin referred to a satisfactory working arrangement. It is not all about money, but about career satisfaction and progression as well.
This issue has a knock-on effect on our waiting lists. If we have a functioning GP-led primary care service, the number of patients who need to be referred and are on waiting lists will drop according to the level of care that they get within the community. That is the purpose of, and thinking in, the Sláintecare report. If we reorientate our services towards primary care, fund it properly and create proper structures within it, we will reduce the number of outpatient referrals and accident and emergency admissions and the pressure on our health service.
The key recommendation of the Sláintecare report is to reorientate the service towards primary care, but what is the thinking in the Department and the HSE on how that can be done? Everything else flows from this core issue in the report.
Mr. Jim Breslin
The Department will shortly publish a workforce planning framework, which will set out the methodology for planning a workforce within the health service in total, but also within individual components of same. We have researched how other countries have done this. We will embed the framework in the HSE and the Department. It will have elements of a demand analysis, that is, how many staff of a certain type are needed, a supply analysis, or how many are being trained in the education system, and how to address on a systematic basis those workplace issues that we need to work on to try to create the type of opportunities to which people will respond.
We have started working on general practice in that regard, but we will have to apply the full framework to primary care and GP practice and work on that over the full ten-year period. It will be a rate-limiting step in terms of how quickly and how far we progress. There is no point in discussing this matter as needing hundreds of millions, or even billions, of euro if we cannot get staff. The fundamental piece of implementation will relate to the workforce and the key components of same, particularly given that we are trying to shift the model of care. Continuing with programmes based in certain settings is no good when one is trying to shift out of those settings. We need to develop new programmes for the type of work that we want to do. In particular, we should train people to work in a multidisciplinary way as well as in their traditional unidisciplinary way.
We will publish that framework shortly. We also have a global workforce conference in Dublin next week. We would be happy to forward the framework to the committee and have officials discuss it. Ms Mannion and colleagues in the HSE had a great deal of input into the framework and are working to try to progress the agenda of improving our planning and implementation of workforce plans.
Did Mr. O'Brien wish to comment on that matter?
Mr. Tony O'Brien
There is no misalignment between the Department and the HSE on the Sláintecare report and the opportunities that it provides. As the Chairman is aware, I believe that all of the key clues as to how we move from our current health system to the health system that we need are contained within that report. The report is clear, in that this will not be a case of being free with just one bound. A series of steps need to be taken sequentially over an extended period in order to make that transition. Deputy Durkan in his questions-----
I wanted to add a further question, as my other question was slightly gazumped by the Chairman. What has happened to GP services that have made them so unattractive recently compared with 25 years ago? Everyone wanted to be a GP and became successful ones. We are spending far more money on the health services now than we were then.
For some unknown reason, we can, if we are lucky, get only one applicant for most advertised positions in general practice. I ask Mr. O'Brien to respond on that issue and to my three other questions.
Mr. Tony O'Brien
The Deputy has definitely turned this into a would-be master class in how to fix the health system. As I stated, much of the diagnosis and prescription is contained in the Sláintecare report.
On the functioning of the hospital system, as the Secretary General correctly pointed out, we have a relatively undifferentiated hospital system which has two channels seeking to be serviced within one set of architecture. The elective or scheduled care programme is competing directly and head to head with the unscheduled or emergency pathway in hospitals that are often operating at 115% bed capacity versus an international norm of 85%. This year, for example, we are seeing a 7% increase in attendance at emergency departments, with a higher percentage among the over 65 years cohort who typically have a greater requirement for admission and stay. Until we do some of the things that are specified in the Sláintecare report and have the benefit of the capacity review the Department is progressing and which is near conclusion, and begin to implement it and, consequently, bring a degree of rationality - not rationalisation - to the way we provide elective care, on the one hand, and emergency or urgent care, on the other hand, with a differently organised application of resources, we will not have a truly efficient hospital system.
In addition, we need to shift to more effective delivery of primary care and greater utilisation of primary care hubs - I prefer to think of them as diagnostic facilities, rather than primary care centres, in which allied health professionals can deliver therapies and so on - and remove much of the burden that is being inappropriately assumed by the acute hospital system, typically at greater expense than could be delivered elsewhere. The Sláintecare report talks about the transitional funding needed to achieve this and I do not believe we will get to the type of health care system we need until we do this. The Committee on the Future of Health Care does not believe this either. We and the committee are, therefore, saying we agree with each other.
As the Minister indicated, interim steps can be taken. We have the discussion about appropriate levels of discharge at weekends. The vast majority of patients who are discharged from hospitals are discharged to their homes, not another care facility. We need to make sure in every case that this flow is optimised. This is a constant battle in which hospital managers and clinical directors are engaged to ensure patient flow is constantly attended to, day in and day out.
General practitioners, in common with all heath professionals, have experienced a change in the nature of demand and expectation from patients and the health system. They see particular demand and, as the Chairman indicated, we have a particular age profile that is against us. There is no doubt that a degree of disenchantment arises. Let us accept that there is a strong perception of unfairness in the way the burden of the financial emergency measures in the public interest were aligned. I hope all of these matters can be addressed through the ongoing talks and dialogue. All of the issues I outlined play against us, however.
The general practitioner has probably the most important and difficult job in health care and the term "general practitioner" downplays the importance of the role. The generalist, as the gatekeeper, is the most important person in the entire health care system. I occasionally use health care services and I have relationships with some specialists as well as a general practitioner and I have always said my most important health care relationship is with my general practitioner. That is true of the entire country. Strategically and tactically, we need to go through the process that the Secretary General has described, bring that process to a conclusion and create an optimism about the future of general practice that will need more general practitioners to stay and fewer of them to go. This will not be an easy or quick process, however.
May I comment?
Other members are waiting to contribute.
I asked my question for a reason and with no disrespect to Mr. O'Brien, I did not get an answer. I am not new to this game and I have been at this a long time. My question remains. If I were to attend an overcrowded accident and emergency department tomorrow morning, could I find out why it is overcrowded? I guarantee I would find out whether patients are bypassing their general practitioners, there is a lack of services or there are either no GPs or not enough of them. Are these the reasons? I will give an example of a case I dealt with in recent weeks involving a patient who had been referred again and again to an emergency department while awaiting a major orthopaedic procedure. The person was repeatedly referred to the hospital and discharged again, which is crazy. We will never solve our problems if continue to act like this. I have reason to believe that this is not the only such case. While I do not want to be critical, we need to do something to address the issues.
As regards age profile, Ireland does not have the worst age profile in Europe by a long shot. This argument is trotted out regularly. Romania probably has a better age profile than Ireland but we have far more young people than many other countries in Europe.
On bed capacity, I remember being in the health system when bed occupancy exceeded 100% and some wise guy asked whether there were two people in one bed. That was not the case but turnover was faster, more effective and more efficient.
Bed occupancy rates of 100% or more spread infection, distress staff and are dangerous. As Mr. O'Brien pointed out, a bed occupancy rate of 85% is the norm.
With no disrespect to my colleague, I am fully aware of that. What I am saying is that 25 years ago, we were able to deal with these issues effectively and we are no longer able to do so. We appear to be muscle-bound in the sense that we are spending more money per capita on health than many other countries in Europe and globally but we are not delivering. As a result, the quality of service is declining, public confidence in the system is waning and those at the coalface in the health service are being abused daily by virtue of the criticism directed at them for issues that are not their fault.
I do not intend to listen to the same story over and over again at meetings as I could be better occupied elsewhere. I ask that my questions be dealt with as a matter of urgency.
I acknowledge the arrival of the Minister of State, Deputy Jim Daly. The next speaker will be Senator John Dolan followed by Deputy Kate O'Connell.
I tabled four questions, including one on how the health service engages with areas outside health care. I very much appreciate the response provided, which focused on employment, the national disability strategy and housing. Other areas could have been mentioned but I asked for three areas to be highlighted. I will watch to see how the health service, namely, the Department and the Health Service Executive, advocates and follows up on these three areas because real value can be secured in health when people are able to operate outside the health system.
I also asked about the 1,200 young people with disabilities who are in nursing homes, the section 38 and 39 organisations and personal assistance services. On the 1,200 young people in nursing homes, I appreciate the HSE engagement in this area in recent times, including the work it is doing with the Disability Federation of Ireland and others. Referring to this group, the response states that while a substantial level of this vulnerable group falls into the above category, it is critically important to note that this intervention can also be an appropriate care option where persons concerned have clinically assessed complex medical and social care needs requiring this form of support. I am not comfortable with this response. I fully accept, however, that many of the individuals concerned have complex and critical clinical and medical needs.
We are putting people aged 30, 40, 50 and 60 into nursing homes where the average length of stay for a resident, who is typically in his or her 80s and beyond, before death occurs is some two years. Such settings are absolutely inappropriate for younger people who have an expectation of many years of life ahead of them. I asked about the necessity of ensuring there is a programme of decongregation from nursing homes for such patients, the response to which took off in the direction of discussing the decongregation process in respect of patients with intellectual disabilities. That is not what I was asking about, although, in fairness, the response does refer to the identification in the report of the number of people inappropriately placed in nursing homes. There seems to be a fixation on the notion that decongregation relates only to intellectual disability services. The latter is undoubtedly an issue and progress in that regard has been slower than any of us would have anticipated, although I understand some 200 people are being moved. However, we have an utterly ironic situation where somebody working in one HSE office is doing his or her damnedest to get a person out of a congregated setting while, at the same time, a staff member in the next office is offering a congregated setting placement to somebody who has never lived in one before. This problem must be progressed more stridently and I am interested in any observations the Minister of State or his officials might have in that regard.
In regard to sections 38 and 39 organisations, many of the relevant issues have already been ventilated this morning. Last June, I asked whether the Department would adequately, and in a timely fashion, deal with the negative impact of pay increases on the delivery of services by organisations funded under section 39. I am amazed to read in the response I received today that under the provisions of the section 39 grant, there is no stipulation as to what proportion is to be allocated to pay and what proportion to the funding of other aspects of the service provision. This avoids the fact, which was acknowledged in the answer given the last day, that it is up to section 39 organisations to negotiate salaries with their staff as part of their employment relationships and within the overall funding available for the delivery of agreed services. A service level agreement, SLA, is not about handing over some money and asking that an organisation does the best it can with it, and rightly so. Rather, it is a case of allocating X funding and setting out the outputs and outcomes that are required in return. Whether or not we are talking about a public service organisation in the sense of its coming under the FEMPI legislation, those organisations are funded under the section 39 provisions because they provide a public service.
The crunch issue is the impact on the delivery of quality services, and that has been acknowledged by the Director General and the Secretary General. Mr. O'Brien noted earlier that while there were concurrent cuts to the section 39 organisations going back to the early days of the recession, as pay levels have been restored, the HSE has not had its funding increased to reflect that reality. The Secretary General made the same point today that was made the last day, namely, that the resolution is not likely to be a unified or one-size-fits-all model, which is how, traditionally, the matter was dealt with on the other side. I see no evidence, even though it was invited, of any engagement having taken place with these organisations. I do not contradict who the employer is, but there is a contract between the State and those employers to deliver a quantum of service. That arrangement is in jeopardy, to a greater or lesser extent, because of the migration of staff and, in certain organisations, the churning of staff. In some cases, the organisation is effectively a training place for people who will go on to work elsewhere. That is fine for the individuals involved but not for the delivery of services. We must grab this issue by the scruff of the neck and make sure it is addressed in a practical way. We can no longer tolerate this type of roundabout process where the organisations are saying they do not have the money and the unions know that is the case, but still they all trot down to engage in discussions. The one person who is not in the room in that scenario is the person who can give account for the making available or not making available of the funding. The whole process is becoming a circus that does not lead to anything. The Department must take a strong hand in the matter if the problem is to be resolved.
The other issue I raised was in regard to personal assistance, PA, provision. I see now that some of the detailed information I sought in this regard was available all along within the HSE. According to the executive's key performance indicators for service planning, there are just under 1,000 people in receipt of one to five PA hours per week; just over 500 availing of six to ten hours per week; 400 getting 11 to 20 hours; 240 receiving between 21 and 40 hours; and 67 persons in receipt of 60 plus PA hours per week. It seems there is an absolute reticence on the part of the HSE and the Department to set that situation out clearly. The figures show that only a handful of people are getting what amounts to one whole-time equivalent worth of PA hours. If we average the whole lot, only a tiny number are receiving seven hours of care per day. What is the problem with saying clearly that the service is providing five or six hours per week to X number of people? Of course, such a provision is not within the spirit or meaning of what a personal assistance service should be.
Mr. O'Brien noted that the Sláinte Care report provides the diagnosis and the prescription for the delivery of health care, but that does not really solve our problem. Will the resources and the steel necessary to dispense the prescription be in place? Saying we know what the problem is and what the answer should be does not mean we actually have a solution. The answer is that, as a State, we must front up to the problems we face in the delivery of health care by acknowledging the resources that are needed and the commitment and steel that are required to deliver those resources in a context where hard decisions must be made.
Mr. O'Brien spoke very well about general practice, which should rightly be regarded as a critical specialism in its own right. We often think of the GP as the handyman or handywoman, offering patients a bit of everything before sending them on somewhere else. In fact, general practice functions as the linchpin of care for people.
It is important to talk it up as a core specialty in the health service.
I thank the Senator. Perhaps the Minister might bank the questions, as I will now bring in Deputies Louise O'Reilly and Kate O'Connell. As they are sitting beside each other, they can keep an eye on each other in order that they do not drag on too long.
I will ask a number of brief questions, to which I hope I will receive long, detailed answers. I am seeking a breakdown of the funding in the mental health division that will be used to cover the cost of agency staff and external placements - people who are not being looked after in the service but for whom care costs are being paid.
Key performance indicators have been set for the cancer programme, as have targets for early detection, but already, according to the mid-term review figures, the HSE is falling short. In the light of the fact that the fund is not quite €7 million next year, will it be sufficient to hit the key performance indicators and catch up next year on those missed this year? In my estimation, it will not and I sincerely hope I will not hear that the targets have been revised downwards. We will only want to hear how the HSE has been able to meet its targets.
We have discussed at length the GP contract. I have some knowledge of negotiating in a multi-union environment and understand how challenging it can be. I can see wry smiles on the faces of the representatives from the HSE who will be more than familiar with this issue. Can they give us an idea of how many hours have been spent in the meetings that have taken place to date and do they have a work plan? I fully appreciate that negotiations can be extended, but it seems that the Minister and the Government have hung a great deal on the conclusion of the talks on the GP contract which might, if one were cynical, lead someone to think they have just established who to blame if the targets set for next year are not met. I sincerely hope, however, that is not the case. I would also like to know the grades of the staff involved in the negotiations. I have had experience of turning up at negotiations with people who did not necessarily have the authority to negotiate, which was not very helpful.
In the light of the committee's report, the compassionate access programme to medicinal cannabis will be considered next week. When will the programme be available and will legislation be required to give it effect? If so, is preparation of the legislation near completion?
The average cost of home care is €23.20 per hour, the figure provided by the Department of Public Expenditure and Reform. Clearly, a home help and a home care worker are not paid anything near that rate, in either the private or the public sector. Will the officials explain the reason for having an hourly rate of €23.20 because, as I remember from a few years ago, the rate ranged from €13.95 and €16.35 per hour. The figure provided is a considerable percentage above that rate. My feeling is that this rate of pay is in the for-profit sector and that the headroom is, in fact, their profit because we know that they have big cars and offices and all the rest. There is an emphasis on home care and treating people at home, but it strikes me that we will not be able to afford to fund many hours of home care if we keep increasing the average spend.
I will follow on from Deputy Louise Reilly's point on home care and the fair deal scheme. My colleague, Deputy Durkan, asked about the reasons for overcrowding. I know that it seems obvious, but is there evidence that the delay in discharging patients, due to be discharged to a nursing home, as in normal circumstances they would not be able to return home, is due to families delaying the start of the fair deal scheme arrangement? It is my understanding the fair deal scheme arrangement only kicks in once a person enters the nursing home system. I have heard that families do not expedite the move to a nursing home because the family assets have not been transferred to a place where the HSE cannot access them. I have also heard stories of how to work the five-year clawback period to move assets out of the State's reach. A person is left in hospital for a year and then something is cobbled together to meet requirements. If there is evidence that this practice is widespread, has there been a move to extend the clawback period to seven years? Seven years would be a long time to cobble something together to try to avoid the clawback. Are these just a couple of instances I have heard of and is the practice not widespread?
I spoke to the Minister earlier about the expansion of the number of primary care centres from 43 to more than 100. He mentioned that there was no point in providing facilities that closed at 5 p.m. Senator John Dolan quoted Mr. O'Brien as saying, "As I stated, much of the diagnosis and prescription is contained in the Sláintecare report." One of the key aspects of the report is a reorientation to provide health services in a primary care setting. One can have all of the diagnoses and prescriptions one wants, but unless one does what one is told to do and swallows the tablets, one will not get better. We can have the prescription, but we need to implement it. A key part is the expansion of the number of primary care centres, to which Mr. O'Brien referred as primary care hubs. That is the direction taken in the Sláintecare report. We discussed diagnostic centres in the community being aligned with primary care centres in order that people would be able to find out what was wrong with them. As we are six months into the 20-month Sláintecare process, what progress has been made? Does the HSE have specific actions to expand the number of primary care centres in light of the Sláintecare report, which recommends expanded opening hours and access to diagnostics, to assess the impact on the level of hospital overcrowding?
With regard to the Meath Hospital community care unit, the process has been delayed by more than 18 months in the move to Mount Carmel hospital because, as I understand it, Belvilla nursing home had to be refurbished and the residents moved to the Mount Carmel hospital step-down unit. They were told they would be there for nine months, but they are still there two years later. Deputy Durkan spoke about blockages in the system. This is a prime example, unless, again, I am reading it incorrectly. I would be happy to receive a comprehensive response after the meeting, if the information is not to hand.
There appears to be a fee being applied to venesections by hospital management in certain hospitals. As many know, this is used as a treatment for haemochromatosis. We have quite a heavy disease burden of haemochromatosis in Ireland. I understand medical card patients are exempt from the €80 fee and people with private health insurance have their fees covered by health insurance. There is a cohort in between who do not qualify for a medical card and do not have private health insurance.
Venesection is an important part of people's treatment. I have heard from the Irish Haemochromatosis Association and various patients that people are spreading out the interval between their venesections because they cannot afford the €80 fee. Obviously, there are negative health impacts following a failure to attend for venesection when due.
Why is this policy being implemented? Is it on a hospital by hospital basis? Is it something the HSE is doing? If it is being implemented by the HSE, are there any figures on the net financial gain? I would imagine that the processing of an €80 fee costs the HSE a lot of money, based on information I have seen. Are we imposing a fee on people who require treatment? Does that have any other effect, aside from poor patient outcomes? Is there any financial benefit? Is the HSE doing anything about it?
I thank Deputy O'Connell. We have been here for over two hours. If the witnesses want to take a five minute break we are happy to accommodate that. Are they happy to continue? The witnesses have a large number of questions. Senator Dolan's questions were first. Who wants to take them?
Mr. Jim Breslin
I will take the question on section 39. I will not commit to resolving it. Mr. O'Brien could talk about the GP contract process and the compassionate access scheme for cannabis.
There are two issues in respect of section 39 agencies. We could concentrate on one or the other. One is the question of public service and parity with the public service. As Mr. O'Brien said, that has quite wide implications. Although section 39 agencies are a very significant component of the health service, there are other sectors across government whereby voluntary agencies are funded from the public purse. It is not possible to unilaterally take a view on that. The matter will have to be addressed centrally.
The second issue the Senator flagged concerned whether cost increases within a section 39 agency affect funding. Without answering the first question, Mr. O'Brien said the HSE and Department of Health had not received funding for restoration. The mechanism for the funding relationship is the service level agreement which involves individual discussions rather than sector wide discussions. That is very much predicated on individual discussions not being able to set public service-wide pay policy. They can only deal with the realities of costs as they present themselves.
On compassionate access-----
Without getting into the answer Mr. Breslin has given, I am concerned as to when and how this will be addressed. Mr. Breslin's statement can be made again in three months' time. What will happen next week and the week after?
Mr. Jim Breslin
Deputy O'Reilly could give more insight on this. This will play its way through the industrial relations mechanisms. Some employers are already involved with the Workplace Relations Committee, WRC. The consequence of that will have to be one which is the subject of discussion. People will have to establish whether they had pay taken from them. Not all employees in section 39 agencies had pay taken from them. The implications of that for their current relationship with their employer will have to be determined.
Respectfully, my focus has not been the issues for staff. Rather, I have focused solely on where this impacts on service provision. I have avoided talking about pay restoration. There is a plethora of legislation to support staff and employees, including trade unions and other bodies. I am considering this solely in terms of the impact of the delivery of the service. We had section 38 and 39 agencies before the recession. Some staff working in them were not public servants and this was not an issue.
Mr. Jim Breslin
It was not as sharp an issue.
That is fair enough.
Mr. Tony O'Brien
The question of pay and conditions, and the equivalence of pay and conditions between section 39 agencies and the rest of the public service, is an issue which employees and their representatives have organised around for a considerable period of time. Pensions, holiday leave and other issues have been regularly ventilated over the years. Some progress has been made.
I keep coming back to the person who is or is not receiving a service. The default is to talk exclusively about employees. I am not unsympathetic, but we have to treat people fairly. My bottom line is that this is having an impact on organisations which are delivering services which they are contracted to deliver through SLAs. That is where we need to keep the focus.
Mr. Tony O'Brien
The SLAs still specify the quantum of service and the standards to which it should be provided. They also provide for mechanisms to enable discussion about the consequences of any mediated judgments which might be made about this pay issue. The Senator's question is, fundamentally, about pay, which is to be addressed within the established machinery of the State. The service level arrangement provides mechanisms which enable us to engage in those discussions with section 39 bodies, a number of which are exercising those mechanisms.
Obviously, we are concerned, in general terms, if, for any reason, the financial viability of a key service provider becomes jeopardised. That would be true not just of this but any other situation. From time to time this does happen. Where necessary, we engage with our colleagues in the Department of Health.
We cannot make decisions which have the effect of turning voluntary bodies into State bodies. We do not have the authority to do so and I am not sure it would be a good idea.
I do not agree that this is essentially a pay issue. I have set this out as an issue which impacts on the delivery of services. The impact would be different in agencies where there is easier mobility or whatever. The impact will be more intense across certain grades of staff. I have only framed this issue in the context of the difficulty in recruiting and retaining staff to provide the service.
Mr. Tony O'Brien
With respect, while the Senator's concern is the consequence, the root cause of the issue he has identified is differential pay. We are not talking about two different problems; rather, we are focusing on different components of the consequence of that problem. We have a shared understanding of the underlying concern of the section 39 bodies and their staff and service users. The only way to fundamentally change that dynamic to one which creates greater mobility or the greater desire for mobility is if we can resolve the causative factor which is a differential in pay which has now emerged.
I thank Mr. O'Brien. Mr. Breslin was going to address some other issues.
Mr. Jim Breslin
I do not have a running total for the GP contracts. I could try to draw up an estimate based on the hours. I have a sense of how much diligent engagement is taking place in this regard. On the HSE side, the engagement is led by an assistant national director who has years of experience in contract negotiations. On the Department of Health side, it is being led by a senior official. There have been weekly meetings over the relevant period. At one stage, I had a running total of the number of meetings. I can get that for the Deputy and share it. There is extensive engagement and further extensive engagement is planned over the coming weeks. There are regular contacts as part of the working process that is under way.
After the Health Products Regulatory Authority published its report on compassionate access to cannabis in February, the Minister established an expert group chaired by Dr. Máirín Ryan of the Health Information and Quality Authority. There is significant clinical involvement in the group, which has been developing operational, clinical and practice guidelines to guide access to the programme. The group has conducted a targeted consultation on its draft guidelines and is due to finalise those guidelines shortly. In parallel with that, officials from the Department of Health are working on secondary legislation to underpin the programme. We do not believe primary legislation will be required. We are also working on the logistics of sorting suitable supplies of cannabis-based products. If the programme is to work, we will need to have a proper supply chain for cannabis-based products. All of those initiatives are under way at the moment.
Is there an estimated timeframe for their completion?
Mr. Jim Breslin
I think it will be some months before they are all concluded. We are certainly working on these issues in parallel, rather than in a sequential way.
Mr. Tony O'Brien
Deputy O'Reilly sought long and detailed answers to three questions. She will get those answers in writing, if that is okay.
Senator Dolan raised the specific issue of the current way in which highly intensive clinical care needs are being addressed. It is evident that there is a difficulty in providing for such needs in environments which are designed around the needs of older people. The Senator described eloquently the nature of the establishments in question. The answer that was given to the Senator sought to make it clear that certain patients, or people who need care, have clinically assessed complex medical and social care needs which mean they cannot be cared for in their own homes and require care in other settings. The answer in question referred to such cases. The numbers involved are relatively small. The challenge we face is to determine how we can provide care in settings that are more specific to the needs of this particular subset of patients. Factors like geographic distribution have to be considered in this context. By and large, this is currently done on an undifferentiated basis in mixed use facilities, the primary purpose of which is to provide for the care of the elderly. Clearly, we need to find a different solution. The particular needs of these people unfortunately mean that the solution in question cannot involve providing care to individuals located in their own homes. The nature of the resources that are required mean that a number of patients need to be in receipt of this care. I acknowledge that we do not yet have the right answer. Our social care division is focusing on this issue.
I do not doubt that in a small number of cases, decisions on participation in and co-operation with the fair deal application process are influenced by particular family dynamics and issues of long-term economic interest. No evidence is currently available to us to suggest that this is a widespread issue. It is reported in very few cases that those experiencing delayed discharges are not co-operating with the fair deal application process. I do not suggest that such cases are not important because any case in which a hospital bed is delayed or inappropriately used for a number of days denies more appropriate care to a patient who is probably on a trolley in the accident and emergency department of the hospital in question. I do not think this is a very widespread issue. The number of cases is quite small, but it often seems that it is much greater because these stories grow legs in the telling. The evidence does not appear to exist to support the idea that there are many such cases.
Would there be any logic to the equivalent of the fair deal in the home setting kicking in at the point where the medical people say the person in question can now go home? Rather than kicking in when the person walks out the door, maybe it should kick in when he or she is fit to go elsewhere. I wonder whether that is a possible way of trying to address this issue. Mr. O'Brien has said that it probably accounts for a small number of cases, but I would say there are varying degrees of it as well.
The issue raised by the Deputy has been brought to our attention on numerous occasions by people who are frustrated because they feel they could care for their family members at home, thereby sparing the State the cost of a nursing home bed or a fair deal bed. They want to know why they cannot get an equivalent amount of financial support in cash. Such financial supports are available in other countries. We cannot have both schemes running together. The fair deal exclusively covers the cost of nursing home support. As the Deputy will be aware, it is set out in legislation and so on. It does not address the question of keeping people well in the community. We cannot risk tearing down the existing scheme or starting to interfere with it. We are going to create a separate independent scheme that will mirror the fair deal scheme. The exclusive intention of this scheme will be to support people to live well in their own homes. To answer the Deputy's question, at present there is no facility for the fair deal to kick in when a person is assessed as being in need of nursing home care - it can only kick in when the person avails of nursing home care.
Has the possibility of the new scheme kicking in before discharge - before the person walks out the door - been explored? I understand that it would seem ridiculous to start tearing down the legislative underpinning of the existing fair deal scheme. Now that a new scheme is being proposed, which I think is a great idea, the Government has an opportunity to provide for it to kick in at the point of discharge. If the family home is going to be used to fund it, perhaps that money could start being used up at the point of discharge from hospital. This would avoid delays. The only purpose of this is to expedite people getting into the appropriate setting.
As the Deputy will appreciate, the new scheme is in its very early stages. It is in its infancy. We have just completed the public consultation process and we are starting to design the scheme. All of those issues will be considered. We cannot pre-empt that consideration by jumping ahead and saying we will discourage people from trying to avoid being discharged by providing a financial incentive to stay at home rather than going to a nursing home. We cannot do that under the current arrangement.
I understand that. Will the Minister of State give me an assurance that he will consider what I have proposed?
Absolutely. I assure the Deputy that it will be considered very closely in the design of the new scheme. I would like to respond to a couple of other questions while I have the floor. I do not have an answer to Deputy O'Reilly's very specific question about the €23.20 average cost of home care. Mr. O'Brien has already said that the Deputy will get a detailed answer to that question in writing. Obviously, the hourly payment is one part of the cost of a home care hour. Travel, management and associated costs are also paid out. I will let Mr. O'Brien follow up on that with a more detailed breakdown of the costs. I do not have that information to hand. Deputy O'Connell asked about other anomalies within the fair deal scheme. I want to confirm that there are no plans to extend the current five-year arrangement to seven years. I agree with Mr. O'Brien that because there are over 23,000 people availing of the scheme, of course there will be isolated incidents. We are not aware of any pattern emerging in this sphere.
Mr. Tony O'Brien
We will provide Deputy O'Connell with a detailed written reply in respect of Meath community care centre. I do not have the information she is seeking to hand. I will ask my colleague, Mr. Woods, to address the question of hospital-based venesection charges in a moment. The Deputy also asked about movement in the direction of the recommendations in the Sláintecare report. Budget day was last week. The Department will shortly issue us with a letter of determination - I think that is the correct terminology - which will allow us to bring to a conclusion our service planning process, which we submit for ministerial approval. It is through that vehicle that we will be able to express what we will do in 2018 to move us in the direction of some of the Sláintecare recommendations. Until that process has been completed, I will be unable to say exactly what we will be doing. We have not yet reached the point at which we can know that.
Clearly, increased utilisation of primary care would have been a priority, even without the Sláintecare report, but the report adds greater focus to that.
Mr. Liam Woods
I will address the question on venesection. First, it is an interesting area to consider because it is something that could be carried out in a primary care setting. The review of the model of care for haemochromatosis clearly points that out and there has been some interaction on it. The charge of €80 that the Deputy mentioned would be the public charge for a day case or overnight case. It would not be charged to, or paid by, a medical card holder and may be covered by insurance. I do not have data with me on the practice on venesection across all hospitals but I will get it and refer back to the Deputy on the practice.
I understand it is something that has started recently. I was first informed about it in June or July. It appears to be something that is emerging in certain hospitals and is driven by the management of those hospitals. I agree that venesection can be carried out in the primary care setting. That will be great in the future but currently patients are being charged for it in certain hospitals and they were not charged for it in the past. I hear that the patients are lengthening the time between their treatments and, as a result, will potentially cost the health service more in the long run because of complications. It is something that should be urgently addressed. It is a little late if it results in admissions.
Mr. Liam Woods
I will be happy to refer back to the Deputy with a report on it.
I had a question about personal assistant hours.
Perhaps the Minister of State, Deputy Finian McGrath, will respond on that.
What was the question?
You were not present when Senator Dolan asked the question so perhaps Senator Dolan will ask it again.
My concern about personal assistants is that the information I was given in the response is shy of the information I sought. I know that the information I sought is available in the HSE. It relates to the HSE's key performance indicators for service planning for 2017. I will not go through the litany again, but it concludes with a figure of more than 2,000 for people receiving personal assistance. However, almost 1,000 of them are receiving between one and five hours per week. A small number, 67, are in receipt of more than 60 hours per week. I asked how many people have one whole-time equivalent or more. It is curious that I was not given that precise information in the reply. Is there a reticence to say what is happening with that PA budget? It is hard to believe that 1,000 of the just over 2,000 people who receive support are getting less than six hours per week. That is clearly not, by any measure, a personal assistance service that would seek to do what is set out in the reply with regard to self determination and the ability to be out and about. That is an issue.
I thank the Senator. To give the broader picture, in 2017 some 1.4 million personal assistant hours were provided for 2,400 people. With regard to the data question on the assignment of PAs, which is important, it is collated on an aggregate basis at present. The HSE can provide gross figures for the number of PA hours and the number of persons in receipt of personal assistance. The HSE is currently developing a national system that will facilitate better management information reporting in the disability sector, which will then resolve the problem posed. In the context of the agreed 2017 national service plan, the HSE expects there will be a total of 1.4 million PA hours provided for more than 2,000 people with disability, representing an increase of 100,000 hours over the 2016 target of 1.3 million hours.
Second, in respect of the expected delivery of service for 2018, service planning processes are currently under way given that the budget for 2018 has just been presented to the Oireachtas. It is not possible, therefore, to give the number of PA hours that will be provided at present. However, PA supports will continue to be a core aspect of the service provision funded and provided by the HSE. It is important to clarify that a key principle underpinning the provision of PA services relates to service user self-direction, in terms of the locus of control being with the person accessing the support. I feel strongly about this. The overarching aim of the PA service is to facilitate individuals to maximise their capacity to live full and independent lives. The service aims to provide for this by way of supporting people to live in community based settings and to access facilities and services, including engagement with community based education, training and employment service providers.
The HSE and I accept the value of further developing the role so there is a consistency of approach and to ensure that the principle of self-direction is universally understood and applied. The social care disability operations team at national level will lead a process to achieve this in consultation with the service users and service providers.
The Minister of State has read out the written response I was given. I asked supplementary questions on the basis of that response. As I said, there is information from the management information system in the HSE that answers the first part of my question, but it was not provided here. With regard to self-direction, the service aims to facilitate individuals to maximise their capacity to live full and independent lives and to achieve this by supporting people to live in community based settings and access facilities and services, including engagement with community based education, training and employment. Will somebody tell me how a person getting between one and five hours of support a week can do that? There are 996 such people, almost half the cohort concerned. How can five hours per week provide something that ambitious? It cannot.
Mr. Tony O'Brien
I will ask the social care division to look at the answer again and see if the question could be answered in a slightly different way. However, I understand that the fundamental requirement to answer the question as fully as possible is the implementation of the new management information reporting tool. Notwithstanding that, I will ask the division to take another look at the question.
I wish to follow up on a question put by Deputy Kelleher relating to approved posts filled on a temporary basis. There are ten approved posts in obstetrics-gynaecology which are occupied on a temporary basis. A report produced in 2003 set a target of 180 consultants in this area by 2012. I understand the number was 130 at the last count. At that time we spoke about increasing the number by ten per year thereafter. I am aware that four vacancies were advertised recently. There were three applicants for the four vacancies. I understand that one of the applicants was already in an existing permanent post so in real terms there were only two applicants for the four vacancies. Are we facing difficulty in obstetrics-gynaecology with sourcing people for permanent posts?
Are we looking at how we can deal with this issue? It is an area that will face major challenges in the next few years. Is there a long-term plan to deal with it?
Mr. Liam Woods
There is a plan when it comes to overall numbers, yes. The model of care for obstetrics, undertaken by the obstetrics programme and now in the possession of the women and infants programme to implement the national maternity strategy, identifies the need for increased consultant numbers of up to 100 over a period of time. That is clear. Some recruitment took place this year and a small number of posts were filled. The service plan for 2018 makes some provision in the area of the maternity office and maternity services. As the director general has said, we will assess this piece of work further when we see it. In response to the question on workforce planning, the women and infants programme itself is examining workforce planning across all grades for the provision of these specific services. This office was founded relatively recently, at the beginning of this year. There is also a wider agenda for workforce planning which Ms Mannion may perhaps discuss later.
I have no difficulty with the planning but I do have a problem with the numbers applying for the posts. This will pose a major challenge. When four posts were advertised only two new people in real terms came in to apply for them. That is a difficulty for us this year.
Mr. Liam Woods
I apologise to Senator Burke as I had meant to address that issue. We have certainly had problems with the numbers of applicants, and not just in obstetrics. In recent months, however, the numbers of applicants across the system has improved somewhat. This is clearly something that we are going to have to work on. As the Secretary General mentioned, part of the central challenge here is to create attractive posts in care settings. Getting and retaining staff in that area is critical for us and our workforce planning, both on the women and infants programme and on a wider level, will have to focus on that. Our number of consultants has gone up by 88 overall since the start of this year so we are making some headway in recruitment.
What about obstetrics and gynaecology?
Mr. Liam Woods
I do not have the numbers for that here but I will happily come back to the Senator on that.
We need to set clear targets on this because we have been making very little progress over the past ten years. I am concerned that we now face major challenges here particularly because it is an area in which there is major litigation. Our chances of reducing the problem are poor unless we have the consultants in place.
Mr. Liam Woods
I will happily come back with the details on the specialist areas.
I have two questions that either Mr. Breslin or Mr. O'Brien might address. One concerns the funding mechanisms for primary care centres as I understand that there are several different mechanisms to bring these centres into being. Could the witnesses address how these mechanisms function and which is the most successful or commonly used to bring a primary care centre to completion?
My second question concerns private care in public hospitals. We had a discussion about how patients have the right to decide whether or not to trigger their private health insurance upon arriving in a public hospital. I would also like to hear the witnesses' views on the Sláintecare report, which proposes that there should be a separation of private care from public hospitals. How do they see this proposal panning out? This feeds into the issue of elective-only hospitals, another proposal in the Sláintecare report, which could serve to take the pressure off acute hospitals trying to supply both acute and elective services with the former encroaching on the elective beds.
Mr. Jim Breslin
There are three main funding mechanisms for primary care centres. The traditional pattern for both primary care centres and health centres was that the HSE would build the centre and then, on occasions in the past, invite GPs in. The HSE stilll retains this model and it is an important string to the bow of the executive, particularly in areas where the private sector may not want to get involved. In poorer or in rural areas, then, it remains an option for the HSE to deliver a primary care centre through its capital programme. The second mechanism is to lease primary care centres, which involves the HSE going to the market with requirements for specific square footage in a specific town or urban area and seeking a rental agreement from the private sector to make that primary care centre available over 20 or 25 years. This generally also includes a specification for what other components might also be provided in the building, particularly GP participation. This approach has been broadly successful and there has been much interest in it in many areas. There have also been parts of the country, however, where the HSE has sought to move ahead with this but has not got the kind of response from the private sector that it might have hoped for. The final mechanism has not yet come on stream but will do so shortly. This involves developing primary care centres as public private partnerships, PPPs. Instead of a lease, the HSE pays back the cost of capital to the developer over an extended period.
The distinctions between the three mechanisms are probably of more interest as financial instruments. In every case we get a building built for purpose which we have to pay back over an extended period of time. All three options have to pass the same tests. They have to pass a cost-benefit analysis, for example, establishing that it is an economic way to deliver the infrastructure, and they all do so. Having a combination of mechanisms is helpful because if we were to put all of our eggs into one basket we might find that it might not deliver in the certain parts of the country where we need it to. While we have not yet had any delivery of primary care centres through the PPPs, we feel that using a range of mechanisms is a good way to proceed.
In response to the Chairman's question on private and public practice, I am aware that my own boss has just arrived and he sets policy in this particular area. From a personal point of view all I can say is that this is an issue I have had to grapple with right across my career. When I sit down with colleagues from other jurisdictions I find that they do not face the same complexities as those facing the Department of Health in Ireland, particularly with regard to the presence of private practice in public hospitals and to the differential incentives for different actors in our system. In an ideal world, then, we would not start from here. Everybody's life, my own included, would be a little simpler if we had a more straightforward system. Private practice is embedded in our heath service: 50% of our population has health insurance and we have about 20% private practice in our public facilities, which is the limit. Private health care is a significant feature of the healthcare landscape in Ireland and we cannot wish that away. We have to find the means of moving from where we currently are to the kind of vision set out in the Sláintecare report of single-tier universal access. The Minister's initiative last Friday to set up an independent group to examine this is, I think, the right way forward. Even if we can agree on the destination there are many different ways of getting there, some of which might have more unintended consequences than others. It is an important first step, then, that we undertake this piece of work between now and next summer so that we can fully understand this matter before starting to change anything.
The Department broadly agrees with the principle of elective-only hospitals and it is something that we would like to see brought forward in terms of our bed capacity assessment and our ten-year capital planning. On the question as to how this might work when it comes to new builds, the experience internationally seems to be that while one can certainly build an elective-only hospital on a stand-alone site, others have been established on the site of an existing hospital. In these cases, however, they have been opened as dedicated, completely self-sufficient buildings that are in no way dependent on the rest of the hospital for diagnostics or beds. They can be run very well on that basis. This also allows for the possibility of cross-cover, meaning that if a patient deteriorates, for example, they could be brought over into an ICU. Broadly, then, that would be the preferable model. This is not a wholly new idea, of course. We have single-speciality hospitals that have operated on an elective-only model over the years - I mentioned Cappagh and the Eye and Ear hospital earlier. This has brought a predictability and productivity to their work.
If we were able to develop that more widely, it could give us a very strong basis on which to tackle waiting lists. I, too, am broadly supportive of that and hope to see progress made on it in the planning work one will see over the next few months on capital, bed capacity and the implementation plan for Sláintecare.
Does Mr. O'Brien wish to add any comment to that?
Mr. Tony O'Brien
I have just one. I fundamentally agree with everything the Secretary General said regarding elective hospitals. In fact, I would perhaps go a touch further and say we will not meet our current challenges without them. The answer on primary care centres and their funding models is absolutely complete. We do need to retain all three tracks if we are to achieve our objectives. I have to declare an interest in that, as a child of the NHS, I bring a certain philosophical approach to the nature of public-private health care that colours my opinions to some extent. I have no hesitation in fully grasping and attaching myself to the notion that public hospitals should exist for public patients. The challenge is that the journey from where we are, which is not a great place, to where we need to be is quite a crunchy one that will require the making of a number of difficult choices, not least of which is on the extent to which the funding of the current public health system is intertwined with €600 million or €700 million in income from privately insured patients. It could not withstand the simple loss of that income. The reality is that the income comes at a price of considerable subsidy in many instances to private health insurers. The per diem rates paid to a public hospital, by comparison with the rates that would be paid to a private hospital on a fully absorbed cost basis for the same treatment, leave a big delta in the sense of the public system picking up the price of the private health care in many instances.
The third reality is that the private health care system is simply not big enough to absorb, or capable enough right now of absorbing, all the private work in the public system. One must ask whether it would be desirable to create conditions in which the private system would grow to the required extent and how that might act as a competitive magnet for the key staff we need to provide for the large acute hospital system. These are just some of the questions that need to be thought through as we decide which route we take to get from here to there.
I thank the Minister, Deputy Harris, for coming back from the Cabinet meeting. He was not indispensable in that we kept going but I thank him for coming back. He probably picked up on the question I was asking on primary care centres. To be parochial, over several years there have been several runs at trying to develop primary care centres in Ennis, and each has failed to date. Perhaps Mr. Breslin could give me an update on that whenever he gets a chance.
I now call on the Minister to comment.
Again, I apologise for the way in which today worked out with the Cabinet meeting. I see, however, that the health service is very ably represented by the director general, the Secretary General, the two Ministers of State - Deputies Jim Daly and Finian McGrath - and the other officials from the HSE.
I wish to comment on the conversation on public and private services. From a policy direction point of view, I fully support the direction that Sláintecare wishes to take in this regard. I have heard the Taoiseach talk publicly about wishing to see public and private care decoupled. For all the reasons the director general outlined, however, Sláintecare is a ten-year plan. It is because there is a significant amount of disentanglement that would need to be considered.
The second point, on which the director general is again entirely correct, is that the proportion of Irish people who have private health insurance is extraordinarily large, amounting to nearly half our population. One should compare the figure with those for other jurisdictions, including the United Kingdom. There is a very different culture. I am very conscious that there are very many people in this country who take out private health insurance not because they can comfortably afford to do so - far from it - but because of their genuine concern about being able to gain access, in a time-efficient manner, to the public health service. One would hope that as we move on the Sláintecare journey and towards investing in driving down waiting times and improving access, as we are now, the knock-on effect will be that the private market will shrink in size. That is ultimately where Sláintecare wants us to get to, and it is where I want to get to. In that sense, there are a number of different tracks on which we have to move.
Dr. Donal de Buitléir, the new chairman of the group examining the public-private relationship, brings experience in terms of the development of public sector policy and experience of the health service here, which will be very important. His work will not go on and on but will conclude around next summer, and should provide us with an evidence-based analysis of the situation that will help inform the next steps.
In our Estimates discussion a number of weeks ago, we noted the take from private health insurance coming into the public system was declining. Therefore, the public system is dependent on fairly volatile private insurance income to support public services. That is not a model that can continue.
I do not believe it is desirable, when emergency departments are overcrowded, that space in public hospitals is being used in such a way that private practice can continue unquestioned, although we are generating a very significant income from it, as the Chairman stated entirely correctly. From an equity point of view, that is an issue all of us wish to grapple with but there is recognition, including in the comments of the Chairman, that this is a very complex issue. That is why it should be seen through the prism of a ten-year plan rather than a knee-jerk ideological response. We have got to get this right. To get from start to finish is a journey of years rather than an overnight journey.
I thank the Minister for coming back for such a short part of the meeting. On behalf of the committee, I thank Mr. Jim Breslin, the Minister, Deputy Harris, the two Ministers of State, Deputy Jim Daly and Deputy Finian McGrath, and Mr. O'Brien, Mr. Woods and Ms Mannion for attending.
The joint committee adjourned at 12.05 p.m. until 9 a.m. on Wednesday, 25 October 2017.