I welcome Professor Brendan Drumm on his first appearance before the committee since his appointment as chief executive officer of the Health Service Executive. I also welcome Mr. Pat McLoughlin, director of the National Hospitals Office, Mr. Aidan Browne, director of the primary, community and continuing care directorate, Mr. Alex Connolly, communications unit, and Mr. Dara Purcell, office of the chief officer. I draw witnesses' attention to the fact that while members of the committee have absolute privilege, this privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. I invite Professor Drumm to begin his presentation.
Health Service Executive: Presentation.
Professor Brendan Drumm
I thank the committee for the opportunity to present to it. I have tabled an opening submission. Since my arrival at the HSE some months ago, my priority has been to meet as many people as possible throughout the country who work in or use the service. I have tried to listen to what they have to say, because that is what is important. This process has been useful and has reinforced several points which are worth mentioning.
I do not exaggerate when I say that health service staff are anxious to provide a top class service and they have shown remarkable commitment in that regard. Many areas within the HSE provide and deliver a high quality of health service on a daily basis. The challenge for the HSE is to build on that delivery in order to deliver health services that are relevant across the communities we serve. We need to do this consistently rather than in isolated pockets and we need to do it with equity.
To achieve this, we will need to base all our decisions on what will deliver what is best for patients. The message we have consistently tried to get across is that whatever decisions are made, they must have regard to what will provide the best quality of care for patients. This will challenge us to act differently and to design our services to meet the needs of patients. We must bring services to patients rather than asking patients to navigate what is often a complex system. We need to simplify the way patients access our services. We believe this will also help us, as providers, to simplify the way we deliver services.
One area to which we must pay particular attention is the way we view our acute hospitals. At present, there is a public perception that if one is not treated in a hospital, one will not receive proper care. This is not the case. As with other countries, Ireland must place greater emphasis on primary and community care systems. We must accept that such systems must become more integrated with each other and with the hospital system.
If I discovered one thing, it is that we have a problem with disconnection throughout the system in that it is almost up to the patient or client to make the connections. To this end, we are focusing on a number of key primary and community care initiatives and seek to establish acute community intervention teams. These teams will enable us to manage acute illnesses in the community, particularly those affecting older people who might otherwise require hospitalisation. An example of this would be where we would set up a team in north Dublin that would have 20 to 25 staff providing seven days a week, 18 hours a day intervention and that would include public health nurses, care workers and social workers. This would allow accident and emergency departments that have patients they do not wish to keep in hospital to contact a care team to tell it that a patient could leave hospital if the care team could take over.
Equally, general practitioners, GPs, could make such decisions instead of thinking they are required to access hospital services. GPs could supervise excellent care at home if intervention teams were available to them in the community. Importantly, we are considering how to make it easier for GPs to access diagnostic facilities, such as X-ray and ultrasound, outside the hospital setting to reduce the need for referrals to hospitals and streamline diagnosis and treatment. This is also related to my consistently stated view that GPs are a greatly under-resourced skills base, particularly as they have the broadest skills available to the health service at a clinical level.
Another area of work is in regard to the development, on a wide scale, of community-based primary care teams to try to utilise such skills, as outlined in the primary care strategy. Our community system is not ideally configured at present to provide a service either through GPs or in response to hospital and patient requirements. We want community services to become more focused on the needs of specific population clusters rather than having each discipline spread over different geographic areas, which results in disconnect in the system. An important part of this process is recognition that GPs are the most skilled professionals in the health service at a clinical level. We need to recognise their contribution because they are willing to take up the challenge. Many opportunities now arise for general practice and primary care to play a central role in the development of the health service. The allocation of €16 million in the Estimates allowed last week, which over a full year will be approximately €28 million, is support for this view.
The review of the GP contract has begun. There are great opportunities for GPs to operate in more family-friendly settings by working in groups, as opposed to the current situation whereby 60% of GP practices are single-handed operations. We need to extend opening hours and ally GPs to multidisciplinary teams to encourage them to manage chronic diseases and illnesses such as diabetes, heart disease and asthma in community settings. Many patients currently engage with the hospital services in a manner that is not required. Engagement of GPs in these areas would benefit them as well as the health service in terms of the quality of their work.
With regard to hospitals, there is much work to do at a number of levels. We need to question our processes and deal with the anomalies. For example, the greatest demand for hospital beds is on Mondays, patients are less likely to be discharged on Saturdays and Sundays and the majority of elective procedures are scheduled for Mondays rather than being spread throughout the week, which creates a further bottleneck demand for beds. We must consider why patients from one part of the country must be admitted to a hospital in another part of the country for non-specialist procedures, a practice which is putting unnecessary pressure on our Dublin hospitals. This practice — I refer specifically to non-specialist procedures — is unjustifiable and unsustainable when facilities and the number of clinicians are being comprehensively built up in local areas.
We must carefully consider the matter of discharge planning to achieve the best level of comfort for patients. At the same time, to maximise our resources we need to focus on having patients in hospital for the shortest period.
I firmly believe patients do not want to be in hospitals. I would like to see a move towards formalising the practice where patients admitted for elective procedures know exactly when they will be discharged and where hospitals will know when beds will be available for those patients that are next in line. In summary, this means that, at the time of admission for elective surgery and a significant amount of emergency work, we identify what should be the discharge date, based on knowledge of average length of stay. If this date is not met, it allows us to challenge the system as to where and why the breakdown occurred.
The discharge planning process must obviously be taken into account. Patients who no longer require acute hospital beds may need some alternative type of care, either in the community or at an appropriate step-down facility. The need to provide appropriate facilities outside the acute hospital environment is most obvious in Dublin. At present, many elderly patients are inappropriately placed in acute beds. I emphasise that this is through no fault of the patients. They need appropriate high and medium dependency facilities that will meet their specific physical and psychological needs.
In July, the HSE established a joint National Hospitals Office and a primary, community and continuing care steering group to address the issue of delayed discharges in Dublin hospitals. While the number of delayed discharges stands at 378 — a reduction of over 60 since the initiative began and the lowest figure since January 2005 — as a community, we need to decide on how to properly address a need that, in light of our demographics, will become more challenging in the years ahead. We must take a national view on how we provide for the care of the elderly rather than responding in an ad hoc way when our hospital systems become overloaded by our failure to place people appropriately in facilities.
If we are to concentrate solely on providing more acute beds, we will not address the fundamental problems of the system. We must focus on keeping people out of hospital in the first instance by developing consistently high standards of primary and community care facilities. In the second instance, we must develop appropriate facilities for patients who no longer need acute hospital bed facilities but who require alternative and more appropriate care in suitable settings.
At an operational level, we are making progress on a number of fronts. At present, we are closely examining how our organisational structure is established and how we can put patient care at the core of the HSE structure, fully integrate our service delivery channels and enable clinicians and health professionals to become more directly involved in planning and implementing effective health strategies. This work is ongoing and we will be in a position in the coming months to announce more details. We hope to be in a position to take to the board of the HSE a proposal on the reorganised structure, making clinicians and others more central to our processes, in the first week of December.
In the past week, we appointed Mr. Liam Woods as national director for finance and Mr. Martin McDonald as acting national director for human resources, pending a permanent appointment. A corporate plan has been submitted and the Tánaiste and Minister for Health and Children has approved it for the years 2005-08. The annual service plan, which will set out how the corporate plan will be delivered on an annual basis, will be submitted to the Tánaiste next month. Contract review talks with the IMO and IHCA are commencing today on a new consultants contract and a review of the general practitioner, GP, contract has just commenced. Negotiations on a new NCHD contract are continuing. We have established a pharmacy strategy group to focus on controlling expenditure on medication, which we view as an important area, and negotiate the renewal of our agreements with the pharmacy sector. We have established a review of the provision of tertiary care paediatric services in Dublin or it is at least fair to say that we are hopeful we will identify someone to undertake that process.
Accident and emergency is clearly an important issue and the accident and emergency ten-point plan is being pursued, with good progress being made on its implementation. Process mapping is of significant importance to us in this respect. The National Hospitals Office is undertaking a process mapping exercise across ten hospitals to identify how the application of best practice could improve the pathway of patients from admission in the emergency department to discharge, maximising the appropriate utilisation of existing acute capacity. Seven of these individual hospital reports have been finalised and the others are being finalised. These reports have informed us of significant difficulties in the processes within our system.
The report of the national hygiene audit has been completed and published and the National Hospitals Office will implement all of the key recommendations arising from it. An initial capital grant of €20 million will enable hospitals to implement the recommendations. Nursing workforce planning and recruitment is clearly central because there are approximately 35,000 nurses in our system. The nursing workforce planning and recruitment project has led to 15 back to nursing programmes running nationally. National and regional recruitment has resulted in a net increase of 578 nurses in employment and 670 recruited from overseas will commence duty on a phased basis.
Work on the recruitment of nurses in the mental health sector and midwifery is ongoing but these areas continue to pose a challenge. The work of the HSE's mental health implementation project is ongoing and significant financial investment in mental health services, which will greatly enhance capacity, quality and reach, has been undertaken by the HSE. Major capital investment framework projects have been announced by the Tánaiste for a number of locations across the country. The GP visit cards are being issued, the availability of which has been widely advertised in the national media. A draft contract has been issued to each GP and a circular regarding the implementation of the scheme, confirming the scope of the services available with the card, has been issued to all pharmacists, dentists, optometrists and ophthalmologists.
The National Office for Suicide Prevention has, as recommended by Reach Out, the national strategy for suicide prevention launched by the Tánaiste in September 2005, been established. Additional development money of €500,000, to be utilised to address specific initiatives in the national strategy, has been provided in the current year. An area of accountability on which we have been working in recent months and which will be of interest to the committee is the development of our parliamentary affairs division. The proper management of parliamentary affairs is a key performance indicator and is a priority for the HSE within its 2005 service plan and into the future.
We have established a new parliamentary division in the HSE which reports directly to my office. A key objective is to ensure that timely and quality replies are issued to parliamentary questions. Our aim is to issue replies within 20 working days of replies being issued in the Dáil. Where this cannot be done, we will issue an interim reply. Where it is possible to issue replies in a shorter timeframe, this will be done. The HSE is committed to reducing this timeframe as it develops its organisational and information capacity. However, it must be remembered that parliamentary questions can differ substantially in the complexity of the subject matters or the extent of the details sought.
Another central task of the division will be to initiate and develop channels of communication with Oireachtas Members to inform them about HSE activities and plans at national, regional and local levels. Using facilities such as a dedicated telephone and, hopefully, e-mail service, the division will ensure that Members of the Oireachtas can access timely and accurate information on health issues. Work is ongoing with the Department of Health and Children on developing the function of the division and finalising these new arrangements in the near future. I thank the committee for this opportunity to present a statement.
I welcome our guests from the HSE. This could turn out to be a long morning for Professor Drumm and his staff because, as far as members on this side are concerned, this is the only form of accountability the health services have to the general public. With the abolition of the health boards, this committee is the only place where former health board officials and elected representatives come together to discuss matters in an open manner that would have been familiar to those familiar with the old health boards. Many questions will be asked this morning and I hope our guests will bear with us.
A great fear is that the HSE will metamorphosise into something such as the NRA, which is almost totally unaccountable to the taxpayer in all respects. In this case, it would be to the patient. It is not that we are fussy about the parliamentary affairs division but it is the only source of information on what is currently happening in the health service. If committee members are unable to get good answers from the HSE, we will be unable to monitor developments in the health service. In that event, there will be speculation and leaked information will be the only form of information on developments within the health service, which would suit no one.
Professor Drumm should elaborate on how he sees his own role developing. He made two comments recently which were political in nature as they did not pertain to the administration of the HSE. First, he stated more acute beds were not required. I want him to explain this comment. Second, he discussed future policy on care of the elderly. This is an extremely political issue which Opposition members have raised persistently. A policy on the care of the elderly formed part of the health strategy of 2001. However, this was not delivered and the issue is political.
I have a question on the establishment of the HSE's structures but which also pertains to Professor Drumm's role in some respects. I understand approximately 40 senior positions in the HSE were advertised and that while a number of outsiders applied for these posts, few were successful. Most of the successful applicants came from within the old health board structure. The HSE's job is to run the health service on a day-to-day basis. Civil servants within the Department of Health and Children are expected to provide policy advice, while Professor Drumm's job is to implement it. Did any of the advisers hired by him apply for any of the HSE posts? On what basis did he decide to hire his own special advisers? What is their role within the HSE? The issue of their accountability is especially important. I understand the professor's advisers work from an office in Dublin, while his senior HSE management team works from its headquarters in Naas. How do his advisers link up with senior members of the HSE?
I want Professor Drumm to clarify some of his comments. He mentioned the need for greater integration between the primary care and acute hospital sectors. He will be obliged to make strong proposals in this respect, because in my recent experience as a practising doctor, integration between the acute hospital sector and the primary care sector has broken down completely. While GPs were once able to admit patients to hospitals, that is no longer the case. All patients are now admitted through accident and emergency units. This is even true for pre-booked admissions and, consequently, patients experience unnecessary delays which should not be acceptable. What changes will Professor Drumm introduce to revert to a patient-friendly system whereby GPs can admit patients directly to hospital wards? That would be more acceptable to patients. I am not referring to the medical assessment units which are unique and work well but to halting the practice whereby everyone is admitted through accident and emergency units.
Professor Drumm referred to community care teams which are to be made up of 15 to 20 individuals. In this respect, the focus appears to be on north Dublin. Why is this initiative limited to that area? While the professor spoke about providing for equality of access across the country, this appears to be another example of a small-scale pilot scheme. Like the Tánaiste's ten point plan, this appears to be about giving the impression that something is being done, rather than actually doing it.
In the past six months one of my major criticisms of the Tánaiste has been that the budget for home help hours was cut by at least €2 million in 2005, which I discovered by reading the HSE's corporate plan. However, when I sought further information, it took six months to get anything resembling an answer which only arrived yesterday. In respect of community care, I do not wish to see a situation develop where Peter is robbed to pay Paul, that is, where services are removed only for the HSE to turn them into home care packages which it then undertakes to deliver. What will the availability of the proposed home care packages be and to whom will they be available? If Professor Drumm is considering such an option, this must be clarified.
On diagnostic access, Professor Drumm has proposed greater access for GPs. Given that one of his first statements was to the effect that we had too many hospitals, laboratories and diagnostic facilities, proposing to make diagnostic facilities available in the community for GPs seems contradictory. Should we consider the quality of GPs' access to existing diagnostic facilities in hospitals, rather than establishing another range of such facilities in the community? The professor's arguments are contradictory in that he wants to establish a new level of services while simultaneously rationalising them at acute hospital level. If the facilities are already available, it might be better to consider how they are currently being used.
A recent report in the media concerned the cancellation of 10,000 elective operations. The Tánaiste stated this constituted only 2% of all procedures carried out in hospitals during the first six months of this year. However, given that so many procedures are now carried out on an emergency basis, if the figure is considered as a proportion of the number of elective procedures, it suggests between 15% and 20% of elective procedures are being cancelled. I am glad to see the HSE has taken this issue on board and that patients are not being called in to undergo a procedure — regardless of whether it is for a hernia repair operation or an endoscopy — only to find out on the morning in question that it has been cancelled. I experienced this in October in respect of one patient who had arrived at the hospital in question at 8 a.m., having fasted for an endoscopy procedure. Seven other prospective patients had accompanied her. All the procedures were cancelled at 8 a.m. because the patients' beds had been taken by an overflow from the accident and emergency unit. Subsequently, however, the patients were all given rescheduled dates between February and March 2006. If the procedure was important enough to carry out in October, a wait of six months sounds ridiculous. The handling of elective procedures in hospitals is a serious management issue.
Professor Drumm will probably not wish to comment on the specific case of the gentleman who unfortunately died in Monaghan General Hospital. However, the Dáil was informed that procedures should have been in place whereby such patients were not to be treated in Monaghan General Hospital but were to be moved directly to Cavan General Hospital to have an operation carried out. However, there appears to be an impression among senior management in Cavan General Hospital that such procedures should not be carried out there either. Why was this so-called process in place at Monaghan General Hospital if at the time senior management at Cavan General Hospital did not believe it was appropriate to treat such patients there? What did Professor Drumm know about surgical services in Cavan General Hospital at the time?
This is like a Second Stage speech.
Unfortunately, this is the only opportunity committee members will have to meet Professor Drumm. He discussed the review of paediatric services which amounts to building a new hospital in Crumlin. Has he given any consideration to building a new tertiary hospital to include adult services as well as paediatric services? Has he considered the possibility of establishing a proper hospital to deal with the delivery of all tertiary services?
The HSE is examining the issue of nurses' workforce planning and the introduction of nurses from abroad. Recently I encountered a case where part-time nurses working in Wexford General Hospital were being overlooked in favour of non-national nurses who had been brought into this country to work shifts. The non-national nurses are asked to work specific shifts, while the Irish nurses who live in the area are given work to do on a piecemeal basis. They are dependent on others being on holidays or sick. Why are such nurses, having worked in hospitals for years, not being given the same opportunities as non-national nurses? Any crisis in nursing is due to the manner in which nurses are frequently treated in the system. I gather this is still happening.
Could the heads of each directorate come before this committee to discuss individual directorates? It would be slightly awkward if Professor Drumm tried to answer every question about some of the current difficulties within the HSE. One of the issues in question concerns the HSE's ICT unit and the development of the PPARS and FISP systems. The Committee of Public Accounts will examine this issue but this committee should also examine it. Could the financial director of the HSE come before this committee because the executive is chiefly responsible for €12 billion of taxpayers' money? What procedures are in place with regard to accountability and transparency? We do not want to see a situation where funding is not spent where it should be.
I welcome Professor Drumm to this committee. We are all conscious of the challenging nature of his position. He has assumed a very difficult post and I wish him the best of luck with it. He has not been helped by the manner in which the HSE was established because the preparation required for its establishment was not in place and the transition did not happen. A political decision that the HSE would be established on 1 January 2005 — regardless of what would happen — was made. When Professor Brennan examined the health service, she did not argue for the creation of one authority and the abolition of health boards. She argued for the reform of the health boards and the retention of locally-accountable people to oversee and scrutinise what happened at local level.
What is the extent of the bureaucratic problems still being encountered because of the lack of preparation? It is evident to any member of this committee who contacts the HSE that the ghost of the old system and the baby of the new system do not always gel. There is still extensive bureaucracy and people do not know their role in this system. An assistant CEO told me that he has held six different job titles since the establishment of the HSE.
My second point concerns accountability, an issue which cannot be overstressed. A closed system has effectively developed, about which I am very concerned. Little tyrants tend to breed in such a system. This is no criticism of any individual in the HSE; it merely acknowledges human nature. The lack of scrutiny now evident in the system is deeply disturbing and does not solely concern the fact that local public representatives no longer sit on health boards. It also concerns the role of the media and the fact that parliamentary questions do not come back to Members within a specified timeframe and, most importantly, on the Dáil record. The process of asking parliamentary questions has now become a private transaction where the HSE writes to Members as individuals. This process is not open to scrutiny because there is no longer any record for the media and public to access. We must deal with this but could Professor Drumm comment on it and take note of it as a very important safeguard that has now vanished?
Could Professor Drumm comment on data collection because it is relates to accountability but is currently very limited? When one asks very obvious questions, such as the number of people who have died from MRSA or where MRSA levels are in different hospitals, nobody knows the answer. We also need to know how many hospital visits are repeat visits. What are Professor Drumm's views on this matter?
I fully support Professor Drumm with regard to shifting care to primary level as far as possible. However, it is impossible to do this without resources. Is Professor Drumm talking about taking resources from the acute hospital sector to put into primary care? He mentioned a figure allowed for in the Estimates but could he tell us the cost of the deal struck with the GPs to take on GP-only medical cards? This money will presumably come out of the item in the Estimates for primary care.
I agree with the point made by Deputy Twomey with regard to pilot schemes. There has been a pilot cervical cancer screening scheme for approximately ten years but there is still no national cervical cancer screening programme. Where does a pilot scheme that begins in north Dublin with multidisciplinary teams, which is a very good idea, go? Is it simply a case of paying lip-service?
How much funding in total was not spent this year and why was it not spent? How did the problems with the PPARS system come about? People were claiming benchmarking pay awards through the verification process on the basis that they were involved in implementing PPARS, which was a massive and extraordinary waste of public money in an area that desperately needs investment. What will now happen with regard to this system? It seems the idea of having a national computer system is not necessarily correct. It was unrealistic to expect a system to deliver that and somebody made mistakes. Will a number of systems be introduced or will the HSE attempt the gargantuan task of rectifying the problems associated with PPARS?
There appears to be a difference of opinion between Professor Drumm and the Tánaiste and Minister for Health and Children regarding the delivery of health services. Her ideological viewpoint is that provision through the private health service is the way forward, while Professor Drumm has stated that it would be disastrous if we relied on the private health sector.
I support Professor Drumm in this debate but could he address it in his reply? Building up the public service and making it efficient does not deal with the inherent inequality in our system. We are unique in Europe in that private and public patients have completely different experiences of treatment. Even a private patient coming into the public system will be treated differently compared with a public patient. GPs are not setting up in areas of disadvantage, the provision of medical cards to people over 70 is deeply discriminatory and geographical inequalities also exist. People's health and lives can be determined by their addresses. Could Professor Drumm comment on these issues?
I understand that VHI is establishing a private accident and emergency facility. What is the reasoning behind this? It makes no sense. What is Professor Drumm's opinion regarding the fact that private developers are being encouraged by the Tánaiste and Minister for Health and Children to develop general practice centres. A private developer involved with the pharmaceutical industry and having such influence in general practice is almost unethical and could be detrimental to primary care. Perhaps Professor Drumm could comment on this also.
Professor Drumm startled a few people in respect of acute hospital beds. He said that we needed more high dependency beds in the community, which is correct. I do not know whether he could put a figure on it but I support him fully. However, even allowing for this and no matter how efficient we become, we will need more capacity in our acute hospital sector due to our population's growth and age. Perhaps it is unfair to ask Professor Drumm but could he speak on this matter?
I understood that, when the HSE was to be established, the HIQA would be established alongside it. As a result, there would be a certain amount of healthy tension between them. The HIQA was to concentrate on standards in excellence and information, which would help our concerns about the health service in terms of standards of care, problems arising and a lack of information. However, the HIQA does not exist. Does Professor Drumm believe this is a serious problem in respect of how the system was devised during the reform?
Does Professor Drumm believe the new consultant contract will deal with the basic inequality in our health service? Would it be a better arrangement to have the money follow the patient regardless of his or her income in order that he or she would be treated equally? Will the issue of urban areas of disadvantage and rural areas that no longer have GPs be addressed in the GP contract? From reading the leaked document about the GP negotiations, much concentration is given to what GPs must do. In the context of those negotiations, will the HSE be able to tell GPs that it will provide the community infrastructure required if they are to develop further? There will be a shift.
The greatest problem I have with the Hanly report is the idea of taking accident and emergency services away from local communities. How will the HSE address this issue when we are in a country with a large rural population, poor road network, poor public transport and difficulties in terms of accessing current services? I appreciate the issues surrounding excellence, working time directives and so forth but how will the HSE answer the concerns of local communities about losing their accident and emergency services?
I know many questions have been asked but we will allow another speaker.
I join the other two speakers in welcoming the team, in particular Professor Drumm. As a fellow Sligo man, I am happy to see him in such a prestigious position.
I wish to develop part of a point raised by the other two speakers, namely, when the HSE was established it was envisaged that one area of public accountability would be this committee. Without going into the matter in too great a depth, as these are still early days in the life of the HSE, the reality is that this is our first meeting. I would welcome a definitive arrangement coming from today's meeting whereby various sections could come in on a regular basis. We all have issues with the health service raised by our constituents. Since this is the only forum available to public representatives of any hue, I would like to see a situation where we could meet on a regular basis, express our concerns and the HSE could likewise have a free flow of information with us. In light of this I welcome the establishment of the parliamentary affairs division. I will go a step further and ask whether it would be possible to furnish the committee with the names and, possibly, telephone numbers of the people in key positions in order that, if any Members have an issue, they can contact someone.
I will not go on at length as the issue is too broad but I will allude to three points raised by Professor Drumm's presentation. I welcome the HSE's view of general practice's central and important role. As a former GP, I concur with Professor Drumm. It is an area of the health service that has been underfunded in the past and its true worth has not been recognised. This is a positive development.
A number of changes have been brought about in respect of nursing, particularly in midwifery, but a point raised by nurses with me concerns the two courses of intellectual disability and general nursing. There was a facility whereby if one studied intellectual disability, one could do an extra year and get a general nursing qualification but I understand that this is now gone. Many people do one or the other and want to get the extra qualification without doing another three years in a different discipline.
What is the current position of the proposal to build private hospitals on public hospital grounds? Has it reached the stage of approval? I will confine myself to these matters as I know others are waiting.
Professor Drumm
I will deal with Deputy Twomey's questions and work my way through as best I can. I will ask for help as I go. A central point that keeps arising is that of the distancing of the health system from the political system. I will be perfectly honest with the committee and say that I had no involvement in or any significant knowledge of the reorganisation of the health services. Perhaps this reflects the fact that many people in Dublin's voluntary hospitals tend to live in a cocoon, which may be an indictment of what we are doing.
Professor Drumm came out of his cocoon.
Professor Drumm
That is correct. We have reached a certain point. Everyone present on this side of the table comes from a rural environment. Our group, which is at the head of the organisation, does not wish to see it disconnect from the political system. We grew up in environments that were quite closely connected with the political system and we understand its importance. I am not patronising the committee when I say that we must communicate properly with the political system, if only from a self-interested point of view as much as anything else. If there is no communication, politicians will be unhappy, which will not do our public relations any good. We must get it right. Mr. Dara Purcell will explain what we are doing.
At the broader level, consumer affairs responsiveness will be a large focus of the organisation. Taking on board how the consumer views the service will be a major development in coming years and our responsiveness will call for the parliamentary affairs division to be central. We have attached a new office that interacts with the CEO's office to try to show this sincerity and there will be regional health forums. Everyone is somewhat uncertain as to how the forums will operate and, to be honest, none of us really knows how they will work at a practical level. We presume they will work efficiently in terms of local public representatives. We should be able to give politicians a good service, which I hope is the committee's perspective at the central level.
Deputy Twomey's next issue was that of political versus organisational statements from me in terms of acute beds and care of the elderly. One cannot ask the senior management team or me to drive efficiency into the health service and then tell us we cannot comment on the basic tenets of that provision. I suspect to do so is impossible. One cannot ask somebody to run Aer Lingus and then tell them exactly how many aeroplanes they must buy to start with. The process would not work. A system cannot be managed on that basis. This organisation and I must become involved in policy development, not in a conflict role but to advise. We are new and we must comment on how all policies that have been there to date will impact on us. I will return to the specific issues of acute beds and care of the elderly when I deal with some of the other issues. Efficiency in the management of the structure is critical to what we do and will demand that we are centrally involved in planning.
Many aspects of the issue of outside applicants for HSE senior management positions predated my taking office. The directorates amounted to ten posts. Every other position was subject to an agreement with the IMPACT trade union, and in the first instance internal people had to be offered opportunities to apply for the posts. Combining so many organisations into one clearly involved major industrial relations issues. In an ideal world, everybody in every new organisation would like to start with a greenfield site. That was not the case here.
Equally, I must state that my experience of the people within the system and at administrative level has been positive in terms of commitment and wanting to progress. All of the directorate posts were advertised publicly. I was involved in only two, one in HR and the other in the directorate of finance. We did not make a HR appointment, despite the fact we had internal and many external applicants. The directorate of finance had in the region of 20 to 25 applicants, which were shortlisted. We appointed what could be seen as an internal candidate but the appointment followed a robust procedure with input from two individuals in the finance area completely independent of the health sector. They were the driving force in determining that appointment, as I was determined they would be.
The issue of my advisers was in the newspapers from early on. We considered six people initially, and five of them were appointed. Two are internal to the health service. Tommie Martin who was chief executive of Comhairle which is part of the health service transferred to run the office of the CEO. That was an internal transfer within the system. John O'Brien, the chief executive officer at St. James's Hospital, will transfer although that must be in line with the needs of St. James's Hospital and his eventual replacement. He will provide strategic advice on how the health service evolves at hospital level, specifically focusing on experience at developing directorates within the St. James's model. KarlAnderson, my adviser on communications, comes from outside the health service. Seán Maguire is a GP from Carlow who is recognised not only in this country but also in the UK as one of the most innovative people in the development of new approaches to primary care. Maureen Lynott has been brought in to examine improving the efficiency of our delivery systems in terms of performance management.
Seán Maguire happened to be a student in Galway at the same time as me but I had not set eyes on him in the 25 years since we both left. I never met Maureen Lynott until I entered this process but from my general knowledge of the system I identified her as someone with a great deal of experience of examining how our systems operate and I felt she would bring a great deal to it. I knew Karl Anderson in recent times through his involvement in lobbying for patients in the system. I knew John O'Brien from my time in Comhairle but I had no personal relationship with him. The same is true about Tommie Martin, the person whom I knew best. I did not choose these people as a cabal of my friends. They were picked because of the talent I thought they would bring to the system.
We went through an extensive process to ensure conflict was not created within the system. We have a process in place that clearly establishes these people do not have a line management role. Everyone in the system is free to speak for themselves, but I believe the working environment between line management and the people working in an advisory capacity has been extremely positive and has been seen as adding value to the system.
The people in line management in the Health Service Executive, including me, are overrun at senior management level because of the enormity of the task of bringing it together. If we were not able to deal strategically with issues in a rapid way and allowed ourselves to be buried in line management demands each day, in a couple of years this organisation would find itself being highly criticised for its failure to change. I believe allying these two resources was critical.
Regarding the primary care sector's interaction with acute hospitals, I agree that if one looks back one will see that historically a much closer relationship existed between GPs and the local physician and surgeon and therefore access to the system. We will take up the issue of GPs admitting directly and why a person with a letter from a GP must go through such a convoluted system.
The Tribal Secta study has been extremely useful. We identified situations where patients arrive at an accident and emergency unit with letters from their GPs. They are seen by an advanced nurse practitioner and then a junior hospital doctor in the accident and emergency department. They are then seen by a consultant who works certain hours in the accident and emergency unit. A call then goes out to a junior hospital doctor, the surgical or medical house officer on the ward, who may be six weeks qualified.
Our data suggest that doctor may not show up for four or five hours because of other demands. That is five contacts with the health service and the patient is still on a trolley. If 200 beds were available in the hospital, the likelihood of a patient getting off of the trolley inside ten hours would be surprising. Using our primary care deliverers to access and take on board their decision a patient needs to be admitted and cutting out this process of jumping through many loops, is a priority for us. Tribal Secta is the name of the company that carried out the review of efficiencies in the system and it identified that as a major issue.
A question was asked on why the acute intervention team was based in north Dublin. I should have stated there will be one in north Dublin and one in Cork. It leads to the obvious question as to why we do not have such a team everywhere. We must justify whether they will be effective, which can be done quickly. Recruitment will be a major problem because it is a new form of working. We must also determine whether they will impact on how primary care operates, how accident and emergency units return people to the community, and how hospitals discharge people early. We can determine that quickly and if they work we are committed to resourcing them because our focus is on keeping people out of hospital. We will not consider it as a Dublin system but we believe they may operate differently outside large cities. We may be able to drive it nationally through the GP co-op system. It may be more important in rural environments to link them to the GP co-op system. The situation must be evaluated.
To ensure the questions are followed in order I will ask Mr. Aidan Browne to comment on home help hours and home help packages.
Mr. Aidan Browne
I do not know what information Deputy Twomey has on home help services. I can state definitively we spent more money on home help services in 2005 than in any previous year. That should result in additional home help services.
I will correct that point. When I inquired of the Department of Health and Children, I was told more money was spent. I also was told the number of people working in home help services. It has yet to correct the figure of the reduction of home help hours from 8.9 million to 6.9 million, as was outlined in the HSE annual plan. Where did the 2 million home help hours go?
Mr. Browne
Deputy McManus highlighted one of the critical current failings within the HSE, that is our capacity to collect data accurately and to be able to stand over the data we sometimes present, particularly in this transition period when we are collating data from ten different administrative units into one unified system. My understanding is that the figure which appeared last year was for home help and home support hours assigned to both disability and elderly care, whereas I think Deputy McManus is specifically referring to elderly care.
I issued an explicit directive that home help hours should not be cut. We have assigned additional moneys to home help in all the HSE areas. Therefore, there is no reason there should be a reduction in home help hours. However, I understand the Deputy's question, which relates back to the initial figure that was given in the 2005 service plan.
If a home help is on holidays, are people entitled to a locum?
Mr. Browne
Yes, if such a person is available.
People are entitled to a locum if such a person is available, but I have been told that they are not.
Mr. Browne
Home help is not about the person who provides the home help, it is about the need of the individual who receives the help. If a provider goes on holidays, the need does not diminish. Clearly, it is an issue of delivery.
That is very useful information.
Professor Drumm
If there is a disparity between the figures perhaps we will be able to clarify the situation and revert to Deputy Twomey at a later date.
Mr. Browne
I think we will have to ask for some degree of forbearance from members. The figures, from our perspective, will almost have to start from now because our data collection system is only coming together at this point. I would have major difficulty standing over figures because of the way data have been collected. The primary, community and continuing care sector in particular, unlike the hospital system, has no minimum data set or universal data collection system. The hospital system at least has the hospital inpatient inquiry system, which has been in place for a number of years. It has some fairly reliable data in terms of output, although the inputs are sometimes questionable in terms of people's understanding when filling forms.
We will be devoting a great deal of energy to this area. We have done some work this year and will do more next year on developing data systems that will allow me to assure the Deputy and others of the correctness of the figures.
Professor Drumm
I ask my colleague, Mr. McLoughlin, to comment on the issue of elective operation cancellations and how to protect acute beds.
Mr. Pat McLoughlin
We have been examining this issue nationally since the executive was established and we have identified that having beds is no guarantee of access for patients. There are large variations in the number of beds per 1,000 of the population in the different areas. However, some of the former health board areas that have the lowest number of beds are also the areas that have no trolley waits. The actual number of beds does not seem to relate to the level of activity.
The cancellation of any operations is unacceptable to us. We have been examining the degree to which these are known quantities. When one examines the data for accident and emergency departments for each day, as we have done, patterns emerge and there is a fair degree of predictability in terms of how many patients will present on Mondays, Tuesdays and so on. It is dependent on practices in the community and in the hospitals. That is why, as Professor Drumm has said, we have been examining how patients are admitted into hospital and are asking if it is sensible to admit patients on a Sunday night for procedures that will take place on Mondays, given that Mondays are generally the busiest day in the accident and emergency department. We are now discussing this problem with the ten busiest hospitals and are asking if we can examine how they are doing their work internally as well as looking at how we can get patients discharged more quickly.
If hospitals have 20 or 30 patients every Monday or Tuesday, for which they do not have beds, then they will have to change the way their elective operations are managed. Elective processes will have to be carried out in a different manner. That has been a very useful exercise because up to now the hospitals were saying that the problem lay in the community and that they could not get patients discharged. The maximum number of patients whose urgent phase of treatment is over and who could be managed elsewhere is in the order of 400 but we have 13,500 beds. Therefore, the issue is really about managing resources in the hospitals and in the community. The management of the other 12,500 beds in the hospital system is critical to efficiency.
As Professor Drumm has said, we must examine how patients get into acute and elective beds and receive treatment in hospitals. We are recommending a system of "see and treat" patients rather than the current system of putting patients through numerous doctors before they get to a specialty when the doctor who may be in that specialty is less experienced than the general practitioner who referred the patient in the first place. This will mean a wholesale change in how hospitals do business but the hospitals are working very closely with the executive on this issue. They are co-operating well and it is very helpful for us to be able to analyse the data nationally. This is the first opportunity to do that because previously we had ten health boards and the Eastern Regional Health Authority.
We see major potential for the National Hospitals Office to be able to compare and contrast data. From January next, all the information we receive on hospitals will be pooled centrally and fed back to the managers so that they can see the performance of their hospital as well as every other hospital. This will enable them to see how they can become more efficient.
As of now, there are major differences in lengths of stay which are not explained by the level of acuity of the patient.
Can that data be published?
Mr. McLoughlin
Absolutely. That data will be available, as will case-mix data. There is no difficulty with publishing this type of information. The private sector report is at final draft stage. We will be publishing that once it is signed off by the steering committee. As with the hygiene audit, whatever work we are doing that involves public money will be published.
Professor Drumm
That will be hugely informative. We must be honest about this and wash our own dirty linen on where we have systems problems.
On the issue of diagnostic facilities and access to services, I have been to places like Wexford and Kilkenny recently, where access to services in hospitals for GPs is much better than it is in other areas. If we can get access to hospital services, that is great, but what we do not want to do is to continue with a hospital delivered facility for GPs that involves multiple loops before patients get tests done. We are determined that will not happen and that may mean looking at the efficiency of carrying out diagnostic tests on other sites rather than in hospitals.
There are elements of that issue that are relatively straightforward. For instance, if a GP wants to get an ultrasound scan done on a patient with gall bladder problems, which is a fairly simple procedure, he or she must send the patient to the outpatient clinic first in order that the hospital intern can sign the form and then send the patient to the X-ray department. It is not that we need to radically change the X-ray departments but rather that GPs should be considered reasonably competent and capable of signing the forms.
Professor Drumm
I could not agree more. However, we face resistance in our own systems to that type of change, and the easiest way to drive it is to say that we must and will get the service. In any event, we will be seeking that service and we believe that it must be achieved. The situation that Deputy Twomey has just described does not stand up to any scrutiny.
The Monaghan Hospital death is something that has saddened many people. It is subject to a review and it is difficult for me to comment while that review is under way. However, it has been stated in the media that the surgeons or the medical board of Cavan Hospital wanted Monaghan Hospital reopened and put on acute call but I have a letter from the medical board in Cavan Hospital which states the opposite. That letter states that there is justification for the safe provision of only one on-call unit. The college of surgeons, in the report it just issued with regard to the way services should be structured, focused on providing day surgery in Monaghan and 24-hour surgery in Cavan.
As an organisation, we must address the wider issue of ensuring the quality of the services we provide throughout the country, specifically in terms of services provided by junior hospital doctors in areas where the population is not sufficient to allow for a large number of consultants. In coming weeks, this issue will be addressed on many different fronts by the surgeons who have been appointed to review it. While the college of surgeons made proposals a while ago concerning how services should be provided, this is not only a surgical issue but concerns the wider provision of health care across population bases.
Issues in terms of tertiary care paediatric services arose because plans have been made for the redevelopment on the Mater site of Temple Street Hospital, which as anybody who has been in the latter hospital would agree, is not before time. The conditions under which children are cared for in Temple Street are clearly unacceptable. Although the facilities in Crumlin are not as old, everybody accepts that they too are not close to the standards by which we should provide care for children. Proposals for a new development there have been well advanced.
We are concerned with establishing what is in the best interests of children because the developments will cost €700 million to €800 million between them and taxpayers are entitled to know whether a full assessment has been carried out of the development of paediatric services in this country. The provision of tertiary care paediatric services is an issue that affects not only Dublin but the entire country, from Falcarragh to Caherciveen, although I suspect that point is sometimes lost. We would not be operating proper governance if we did not determine international best practice for the provision of tertiary care services.
Obviously, the provision of tertiary care services will influence the location of secondary care services. The decision on whether a new national tertiary care centre is built on the Mater site, close to Crumlin hospital or in the city centre will have huge ramifications in terms of secondary care. In such a situation, secondary services may be developed in the most southern part of Dublin or north County Wicklow. Equally, if a site in the city centre or at the Mater is chosen, it would not be ideal to provide secondary care services 500 yards distant. The issue arises of what is best for children and taxpayers.
The prospect of establishing a national centre of excellence for tertiary adult services has not yet been investigated. Deputy Twomey raised that matter with me on a previous occasion and I have started to discuss it with people because there appears to be an interest in it. It should be looked at in terms of efficiencies in our system.
With regard to what is being said about the Mater and Temple Street hospitals, Professor Drumm appears to be indicating a preference for a redevelopment which would turn Temple Street into a paediatric unit within the Mater rather than it continuing to provide the specialised services it offers at present. More specialised services would be transferred to a national tertiary unit.
Professor Drumm
There is the possibility that the national tertiary unit would be on the Mater site. The contending arguments involved have not yet been fully thought through. It must be determined whether a single national tertiary centre is the correct option, although I suspect that most people agree that it is appropriate with regard to our workload and the needs of the country in general. People also have different opinions on the location of such a unit. The rail network will be an important consideration in any decision because up to 40% of children attending the centre will come from outside Dublin. While I cannot make a determination in advance of a detailed planning process, the centre should ideally be in the city centre or close to the Mater site.
The implications will be more significant for people on the Crumlin site than for those in the Mater or Temple Street Hospitals.
Could we move on as I want to give others opportunities to ask questions?
Professor Drumm has not answered my question.
Members of the committees have other meetings to attend and I am trying to accommodate as many questions as possible.
This will not work if we ask questions that hang in the air. There is no other way to resolve the matter.
Now that the air is clear on that issue, members must realise that we are doing our best to include them. I am receiving notes from them on a regular basis and I hope I can move the meeting on.
Professor Drumm
This is the democratic system in action and, in the interest of providing new information, we will comply with whatever is decided in terms of getting people to meet the committee. With regard to the employment of nurses locally and whether there are unfair practices with regard to overseas staff, that issue should be dealt with at a specific level. I do not know the details but I suspect that, by law, preference must be given to EU candidates.
The bureaucratic problems arising from collapsing several health boards into one system are enormous. Significant industrial relations issues must be carefully addressed. The most challenging problem for us is how to finalise our structure, which we hope will be done by early December. An immediate concern involves taking on a large number of former health board employees who are uncertain of their roles within the new system. That will be a significant undertaking at the human resources level but it must be done. By early December, after our central structure becomes clear, we will begin to offer people the opportunity to transfer the most appropriate positions within that structure. We would also like a number of staff to move to positions which support the development of directorates in the acute hospitals sector where they will be involved in driving patient care provision. I cannot under-estimate the enormous challenge of this process, which is one of the largest management changes ever undertaken in Europe. People will have to be made more happy about working in the system because many are uncertain at present.
We are committed to accountability. As it is relevant to everybody here, I will ask Mr. Dara Purcell to comment on the parliamentary affairs division and the method of response to questions. We will have to take instruction on whether these responses will be put on the record.
Mr. Dara Purcell
As Professor Drumm has stated, the HSE has set up a parliamentary affairs division. The division, which has been building its capacity since its establishment in April, is the central point for all parliamentary questions referred to the HSE for direct replies. We have developed a protocol with a timeline of 20 days, which is similar to the practices of the former health boards. However, we are attempting to reduce those times progressively.
In response to a suggestion made in a previous committee meeting, we are developing an initiative which follows the social welfare model by looking at parliamentary questions in advance. If they concern, for example, direct information on a particular case, we try to bring the information to the Deputy concerned before the question is due for reply. That is one area where we can improve performance.
We can also improve the quality of replies. Previously a Deputy who asked a question on a national issue could have received replies from 11 different health boards, each with a different interpretation of the question. With a central unit we can now provide a single reply. Professor Drumm mentioned direct access for Oireachtas Members to the parliamentary affairs division. As Deputy Devins said, we are preparing, and will soon issue, a briefing note with contact details of all the people working in the parliamentary affairs division.
Since the parliamentary affairs division was established it has processed over 2,000 parliamentary questions for direct reply. One of the key issues in setting up the division was to ensure it had the authority of the office of the CEO when it sought information in the system to reply to a question. It is centralised as a key part of the office of the CEO. The protocol to which I referred authorises parliamentary affairs division staff to contact any of the national directors to get information to provide a reply. The division is in its infancy and we have worked closely with officials in the Department of Health and Children on our new function.
I welcome Mr. Purcell's helpful statement. It would also be useful to have a flow chart to illustrate where the divisions and people fit in. On Deputy McManus's point about the parliamentary record, my colleagues have no access to the replies I receive to my questions. If a question relates to a constituent, that is fine, but some questions are of broader import and relevant to everybody. I do not know what the solution is, but perhaps those questions could be put on the parliamentary record and be made accessible to all Members.
I agree and in the meantime they should be published on the HSE's website.
Mr. Purcell
We plan to prepare a website for Oireachtas Members, and perhaps the public, to access the replies we issue to parliamentary questions. The only way we can make them available in a public forum is via the referral mechanism from the Oireachtas to the HSE, which replicates how it was previously dealt with when non-policy questions were referred to the CEOs of the health boards.
Professor Drumm
I will continue with the issue of data collection. We need more advanced patient information systems. One of the strengths of this centralised authority is the potential to create a tremendous information bank of 4 million people. This could be used at a research level to inform good practice internationally and we must achieve this. One of the current problems is that two thirds of our patients are unidentifiable at a general practice level. We are working on this and people are working on establishing the PPS number as an identifier. It would be wonderful to get an identifier to carry through from our general practice to our hospital system.
As Mr. McLoughlin described, it is difficult to trace what is happening, and Deputy McManus highlighted this issue on MRSA. The lack of a proper patient information system is crippling the HSE's ability to provide service and is a missed opportunity. We must get it running. These are controversial times for the HSE in terms of information systems but this one would play a critical role. The national identifier is a bigger issue for the members than for the HSE in terms of the principles behind it and whether the Data Protection Commissioner can be convinced that it is the way to go. It would be of enormous advantage to us.
Primary care resourcing will be an ongoing focus. Even Mr. McLoughlin, who is committed to the hospital system, will agree that this is a necessity. This year €16 million has been added to the primary care budget. For some reason it is based on how much we can spend next year by the time we have the team set up. It is €28.5 million over the year. This is not the money for the GP-only cards, it is new and separate money. The GP-only medical cards are funded separately.
That is not the question I asked. A deal was struck with the GPs for back money. How much was that? Will it come from the primary care budget?
Professor Drumm
No.
Is Professor Drumm sure?
Professor Drumm
The primary care budget has been provided for new developments.
New developments.
Professor Drumm
New revenue developments in terms of the primary care strategy, in terms of new staffing.
Mr. Browne
We received an allocation last year to deal with all the GP retrospective payments and any money currently in the system is for new developments. There is €60 million in the system for the 30,000 additional medical cards and the GP-only medical cards in 2005 and that rolls over with that process into next year.Professor Drumm refers to the €16 million that is dedicated to primary care for next year.
Where does the money to buy the GP's goodwill towards the cards come from?
Mr. Browne
It was not a case of buying goodwill. The performance verification was part of the benchmarking process. That money was allocated for the pay deals in our 2005 allocation.
Therefore, the HSE had that money but withheld it.
Professor Drumm
We are carrying that money.
Mr. Browne
Part of the performance verification group process is about achieving improvement.
Is there a breakdown of the 300 frontline staff for primary care to be funded by that €16 million?
Professor Drumm
No, and there must be flexibility in how that figure is broken down. We will not just throw people in on the basis of a central plan. We intend to ask local health officers and people with a focus on developing primary care strategy locally to come to us with submissions on specific inputs of this money. This money will be best spent by planning from the ground up. That applies to much of the health service. How we spend the money will depend on local requirements, provided it complies with the overall strategy of enhancing primary and community care services.
Mr. Browne
Different parts of the country are at different stages of readiness and some need investment in capacity building before they are ready to take on additional staff. Therefore, we intend to use the money as widely and as wisely as possible and not to prescribe to people how the money should be used.
I do not want to delay the meeting, but how will that be done? Will the HSE ask people for submissions, and, if so, whom will it ask?
Mr. Browne
As part of our new structure we have appointed local health office managers in each of our 32 local health office areas. We will work through those local health offices.
Are these new positions?
Mr. Browne
They were developed in the context of the primary community and continuing care directorate. There are 32 local health officers whose primary role is the implementation of the reform process, of which the development of primary care is a significant component. They will have a significant role in bringing forward those proposals. As Professor Drumm has pointed out numerous times, we are open to hearing the views of the GPs and primary care providers.
Is it possible for a formal structure to be set up whereby local managers meet, say, three times a year with Members of the Oireachtas to keep them fully informed of events at local level?
Mr. Browne
I am positively disposed to developing a process where local health office managers meet Members of the Oireachtas. It should not, however, overlap with other structures emerging for local and public involvement in the system.
Professor Drumm
As I cannot comment on reports of the Comptroller and Auditor General before they are published, I cannot comment on PPARS. A detailed report is due within weeks and will be presented to the Committee of Public Accounts on 13 or 15 December. I have been shown the preliminary report to check it for factual errors and it will contain answers to most of the questions asked, although it will also raise questions.
What happens now?
Professor Drumm
Pending that report we have paused all spending on PPARS and have done so for the past month, if not two, on the basis that we must review the entire project and determine whether it can be made fit for purpose in the health services. It is parked but must continue to run as a pay system in a few health areas where it has run for a number of years. The major expenditure to develop it nationally is suspended until the results of a major internal review are known. Government now has an overview body crossing over a number of Departments but driven by the Centre for Management Organisation and Development, CMOD, in the Department of Finance, which we must consult before we re-enter the process. No money is being spent at present.
Deputy McManus asked if there were differences between me and the Tánaiste and Minister for Health and Children on whether the private or public sector should provide health care services. I am on record as saying I will support the provision of care from any source provided it is assessed on what is best for patients. I and the Tánaiste believe the majority of health care services should ideally be provided through a public system. We must guard against the inequalities highlighted by the Deputy if services are provided through a private system. The system is unusual by any western European standard, a hybrid between a highly subsidised private system and a public system. It is unique apart from, possibly, Australia. I argue that in some respects it has worked much better than, for example, the National Health Service, NHS, in Great Britain because we underestimate the problems faced there in terms of service provision.
A challenge is involved in getting general practitioners to set up in disadvantaged areas. We hear much about this topic but a young GP has difficulty getting access to a GMS bidding number to set up in these areas. There is something self-fulfilling about the situation. A GP would be brave to set up in an area where 60% or 70% of people have medical cards but he or she is told they cannot have access to them. That is not directly under the control of the HSE but is part of an industrial relations agreement with the primary care providers. We must look at disadvantaged areas more broadly. Is everybody open to having as many GPs as possible in those areas? Does everybody support open access to GMS bidding numbers in those areas? That does not exist at present. Many young GPs are willing to set up in these areas but it would not be a wise business decision based on present structures.
The private accident and emergency development has started up in Dundrum.
This morning.
Professor Drumm
Right on time. What the private sector does is its business. The HSE provides optimal health care for the public at large——
It is not the private sector but VHI.
Professor Drumm
It is an amalgamation of VHI and significant private sector input. In my understanding, VHI is a partner, although I may be wrong. I have no problem with paying for public patients to use that service provided they receive an optimal quality of care. The risks of running such a service are not the concern of the HSE but we can envisage contracting with anybody if it reduces the bottlenecks in the system.
Access for GPs to diagnostics could be provided if it reduced a bottleneck and was properly costed. If it provided a quality service, it would not be a problem for the HSE.
What about where private developers with links to the pharmaceutical industry establish primary care centres?
Professor Drumm
Pharmacy is a broad issue. The taxpayer spends more than €1 billion on pharmacy supplies and drugs. We must look for better value for money. If we achieve that it may impact on pharmacies and general practice setting up alongside each other. General practitioners and private developers have set up alongside each other on many occasions. I do not know if the HSE can have any effect on that or whether ethical issues might arise. They would need to be evaluated by the Medical Council. From the taxpayer's point of view it is important that we exercise greater scrutiny of our total pharmaceutical bill. It is a priority issue and one we are addressing.
The need for beds has caused controversy since I assumed my position, not that I have courted it in any way. I had to look at the resources available to the organisation and how to maximise its potential. The need for private sector beds is a separate issue but must be taken into account.
OECD evaluations of beds per thousand people are often unreliable because in some countries chronic beds are locked onto acute beds. The only useful figure is based on the average length of stay for a particular condition and a direct comparison with a system which counts beds in exactly the same way as we do, such as the NHS in Britain. Our average per thousand people is three while in Britain it is 3.5. Considering the very low number of private beds per head of population in Britain and including the 52% under VHI, there are 20% more beds in our system than the OECD counts. Our acute private beds in the Mater Misericordiae, Blackrock Clinic and St. Joseph's in Sligo are not counted. It would not be sensible for us to develop a system without including these in terms of what should be provided. This would drive the average up to 3.5 or 3.6 per 1,000 population.
These figures are not adjusted for age, but the population base of this country is dramatically lower than the UK population base. Between 50% and 60% of the acute care beds are taken by those over 65 years of age. Between 17% and 18% of the population in the UK is over 65, as opposed to 11% of the Irish population. We do not have to delve deeply into these figures to realise that the reason we need so many acute beds should be addressed. Our average length of stay may provide that answer, as average stays are higher than those in the UK.
Why does this happen? Are we not able to discharge people from the system as quickly as we should or is it a breakdown in primary and community care? To be fair, the Tánaiste and Minister for Health and Children, Deputy Harney, has been open to us bringing a fresh perspective on this issue. We have contended that if money is provided for primary and community care, we may be able to take the emphasis off the need to put money into the acute sector or 3,000 extra beds. The Department of Health and Children needs proof of this impact and it is up to us to do so as an organisation. By placing money into primary and community care, we can take away the requirement to provide beds. Clearly, other countries have succeeded in providing care elsewhere.
This does not take from previous comments that we need long-term and intermediate care beds in the community. As the population gets older, there is no doubt more beds will be required.
Does the witness know how many will be required?
Professor Drumm
If it were possible, we could immediately put in place 1,000 to 1,500, but this number should be made more precise. We will conduct a study on bed capacity which will not only take in acute bed capacity, but will inform on what changes in primary and community care services are likely to lead to, based on other experiences, mainly from the NHS. A prediction of requirements for the intermediate level will then follow. We are estimating from figures we already have for long-term stay patients. From such figures, we can state that if we had between 1,000 and 1,500 beds, it would prevent a blockage for three or four years. We should be careful and we need a more exact calculation, which we are looking to procure.
On the HIQA issue, the Deputy is probably as well informed as I am on the issue. The board has been established and it has advertised for a chief executive officer. I do not know if an appointment has been made. We would see the authority as having a very positive role if it is set up in a way to achieve what has been planned. Anything which drives excellence in assessment of standards and provides more information is to be welcomed. The authority will be very dependent on our patient information system and until this is established, the authority's actions will suffer. We view HIQA as policing, in effect, what we do, which is a positive development. However, we must get information systems to a point where HIQA can function adequately.
The negotiations for the new consultant contract begin this morning. This will focus on removing inequality from the system. The issue of money following patients is interesting, but this organisation is focused on measuring performance across the system. We will from next year onwards apply significantly more of our budget to rewarding enhanced performance in hospitals rather than responding to cases of poor performance, which has historically been the case. The consultant contract issue will be difficult in terms of changes in practice which everybody is looking for but will carry some costs. With this contract and the general practitioner contract we are looking for significant changes in practices, which must occur if reform is to happen in the health service. Without such changes to the practices of these central providers, the reform process cannot take root.
I have not mentioned the Hanly report except when I have been asked about it since I came to this post, as I was not particularly involved in it. I again make the point that services can be provided anywhere that they can be adjudged to be absolutely of safe quality. Discussing the provision of services currently across all our sites without a change in how the service is provided and who does so is not sustainable. It is not sustainable either in terms of the European working time directive and the number of people involved. It is not sustainable at a governance level.
The current system has worked historically on the basis of junior doctors, and the public has accepted junior doctors as frontline providers in hospital service, many of whom have very little experience, for long periods of the day, night and weekend. We are reaching a position where it is clear that a large number of these positions will not be accredited posts for training for colleges. Where do we stand from a governance point of view in terms of providing top quality care if we have junior hospital doctors who have not been part of any accredited training programme but are being placed in positions of immediate patient care, often with little direct supervision because the required number of consultants cannot be in the system on a small population basis?
This is a significant challenge. We must bring about a change in mindsets of hospitals being the ideal place to go to receive good care. I use the example of Virginia in Cavan, and Mr. Browne has experience of this service. There is a community care provider service in that location. In a beautiful building there is care for the elderly, with male and female wards off to one side of an atrium where everybody can meet. The GP service, consisting of four or five doctors, is off another side, and public health nurses are located off another side. Minor injuries can be dealt with by the service. This exemplifies a comprehensive service for the community provided by trained personnel with much experience at a primary care and nursing level. This is opposed to a system that falls apart every six months because new junior doctors arrive in hospitals, some of whom have very little care experience, and none of the comprehensive links required across the community. I will plead with people to stop seeing a hospital as the ideal provision of care as it is far from it.
I am conscious of the passing time. With regard to Deputy Devins's comments, we would support in any way communication between the joint committee and various sections of the HSE. If we get such communication right it will be beneficial. As Mr. Purcell has stated, we will disseminate names and local contacts relating to the parliamentary affairs divisions soon. We must address the issue as it would benefit everyone, ourselves included, if we had flow sheets regarding the functioning of this system. Mr. Purcell, who has much experience in this area, has worked on this and it will have a significant impact. We would be happy to take on board any questions.
I am clear on the issue of nursing issues relating to children's care, but I will defer to Mr. Browne on the matter of nursing for intellectual disability. If he cannot clarify it, I will attempt to do so.
Mr. Browne
I may have to defer further. In the old apprenticeship system, nurses could move on to a year and a half of additional training. Since the training has moved to university, my understanding is that there would be a common basic training followed by a specialisation. I do not know what the problem is but we can examine it.
Professor Drumm
I can comment on the issue to some extent, as the issue is probably similar to children's nursing. It used to be that a student nurse had to train for a further year and a half after the initial three years, and the additional training may even have been an additional two years. They have now brought in a four-year programme so that a successful student will be a general nurse and a specialty nurse. It was an attempt to contract the amount of training time, at least in the case of children's nursing.
It may be possible to go directly into intellectual disability nursing, although I am not aware of this possibility. This may be a problem as there is now an insistence on doing the general nursing training and the disability training.
There is an anomaly and it was brought to my attention by people who are training. Perhaps the issue could be examined.
Professor Drumm
Although it is not a direct concern of the HSE, it would have an effect on it in terms of service delivery and we will consider the matter.
Mr. Browne
We have a significant need for intellectual disability nursing which has dissipated to a degree in recent years.
Professor Drumm
We should follow up the issue, but I do not know the amount of control we will have. The educational authorities tend to operate quite independently of us.
The Government's policy regarding private hospitals on public grounds has never been an issue for us. It is up to the Government to decide if it wants to develop the grounds. We were asked to carry out a needs assessment, etc., in regard to local areas. It is currently being undertaken in terms of where they are required and where they would bring most benefit.
There is another issue with which I must deal. It relates to consultants working in private hospitals on public grounds. Private developments are private developments. I must be 100% clear that consultants work within the system.
Will two streams of consultants, including private consultants and public consultants, be part of the contract?
Professor Drumm
I do not think anyone, including the Minister, sees my role in the HSE as running private hospitals. I met representatives of the Independent Hospitals Association, which is very keen on the proposals. Given the new consultant contract, we will strive to achieve maximum efficiency and accountability in terms of how our workforce operates through our consultants.
I am aware that the needs assessment has been carried out in certain places. However, I believe the issue is now with the HSE. Should it be with the Department of Health and Children?
Professor Drumm
I will defer to Mr. McLoughlin on that.
Mr. McLoughlin
We have had much interest in the proposals from both developers and hospitals. However, I have not seen a business plan with which I would be happy or which comes within the framework within which the Government advised us to progress. If they involve manpower from the public site going into the private wing, it will involve a considerable change in consultants' practices and contracts. As these plans have not been forthcoming to date, a number of issues and hurdles must be dealt with. First, we must establish if there is a need for the beds in the particular area and, second, how will it work to the benefit of patients and is there a sustainable business plan. To date, no sustainable business plan has arrived on my desk in this regard.
A small sub-group is involved with the management team established by Professor Drumm. We are working with the Department on these issues. We are also examining how the plan works at present in some hospitals where private and public hospitals are on the same site or, as is the case with the private and public Mater hospitals and St. Vincent's Hospital, are very close together. We are examining how the plan works and whether we can deal with issues such as the movement of labour in particular.
How many proposals are there?
Mr. McLoughlin
There have been two serious proposals up to now. There is much of interest but the proposals will involve some ceding of land, whether on a lease or licence basis. This would have to go through a strict business case assessment. There is a framework established by the Department on how the plans would be assessed. While there has been much interest in the plan, proposals have not been put on my desk that would satisfy those criteria.
On that issue——
I will allow the Deputy——
This is ridiculous.
The Deputy should not be shouting about this because her Minister is introducing this plan. We are supposed to be responsible for scrutinising these plans.
There are people here since 9.30 a.m. who want to ask a few questions.
We will get just one opportunity to deal with this issue.
I recognise that and I want to be fair. I ask Deputy Twomey to refrain and to allow the next four people to speak.
Could Mr. McLoughlin explain at some stage how he scrutinises these documents and proposals?
Mr. McLoughlin
The framework within which they will be scrutinised is laid out in the Department's guidelines to us. I can identify the criteria within which the plan will be examined. It will be treated in the same way as any business case. The primary issue is to establish need. When a public hospital says it wants to examine the issue, one of the crucial aspects is that if 80 to 100 beds that currently come under private practice are to be transferred to another unit, for what would the vacated beds be used? We do not want a number of medical admissions being admitted inefficiently to the hospital. A hospital would have to do a great deal of work before it could put a case to us. The plan must be of strategic benefit in the public system. The crucial issue which has been outlined is that of manpower. We have no difficulty with private hospitals recruiting private consultants. However, if private wings are necessary to rely on manpower that is employed by us, we must be very clear on the conditions within which it might happen. These proposals will be subject to negotiation.
I welcome the representatives and wish them, both personally and professionally, long and successful careers in delivering reform and putting patients at the centre of the health service.
It is clear that Professor Drumm has been examining the problems that are inherent in the system. One such problem with which he dealt today is hospital management. He said that the discharge practices are extraordinary and that the greatest demand for hospital beds occurs on Mondays. However, many procedures are scheduled for Mondays. What can Professor Drumm or the HSE do to organise how hospitals are run and managed? I presume there is a certain autonomy within a hospital. As it is clear that the delivery of service is very bad, what can be done to provide a 24-hour, seven days a week service which is required of a functioning health service?
He referred to the difficulties of multidisciplinary teams in managing chronic illnesses such as heart disease and asthma. He said these services should be delivered in a community setting. He gave a good example of Virginia, County Cavan, where the hospital deals more with emergency cases. He did not refer to the National Treatment Purchase Fund. I would like to hear what his attitude is to this fund, if it is a growing element and whether it is a successful feature of the health service?
In terms of patient records, is the IT aspect a priority? I would think it would be an efficient way of ensuring that the disconnect feature in the system is eliminated. Is this a priority for the HSE?
On the pharmaceutical strategy group, I am sure the increase is of concern. Many pharmacists would say that this is caused by the high percentage mark-up the Government has allowed. Could Professor Drumm indicate how he is trying to contain the pharmaceutical bills?
I welcome Professor Drumm and his team. Perhaps he will recall that I wrote to him when he was appointed to the job and pointed out that I realised things were bad in Crumlin. However, I did not realise they were so bad that he would take this job. He faces a huge challenge.
Since I qualified, which is decades ago, I have heard GPs being praised for all they do. People say they should have better access to diagnostic, physical and occupational therapy treatment facilities. During those decades, the situation has grown worse for them. I do not know how Professor Drumm will turn that around. Like Deputy Twomey, I would be alarmed about the establishment of other institutions rather than trying to use the hospital services that are in place. Some of our smaller hospitals could be well organised and would be quite adequate to serve general practitioners in this regard.
On the acute bed situation, Professor Drumm is quite right in saying that it is very important to arrange step-down units to which people can be discharged. I am on the board of Peamount Hospital, which has begun doing rehabilitation work of which the Health Service Executive is extremely supportive. We are already doing a great deal to help Tallaght Hospital and St. James's Hospital. There must be other units in the country where the same sort of initiative could take place.
Professor Drumm did not mention the retention of nurses. This is more of a problem than training and recruitment. I had dealings with Mallow General Hospital where an elderly relative of mine was looked after extraordinarily well. That hospital appears to be able to retain its nurses. Could we look at places doing well in retaining nurses and try and apply their protocols to areas that are not doing so well? We cannot continue relying on recruiting foreign nurses. The West is acquiring an appalling name in the developing world for taking their health workers.
We also have a problem with regard to midwifery nurses. I am on the board of the Rotunda Hospital, which has a shortage of midwives. I hope the direct entry to midwifery training will be promoted as quickly as possible.
If people take their relations home and try to care for them with the assistance of agency nurses, the VAT on that care is 21%. There is something wrong in that when VAT on hairdressing is only 13%. People do not complain about the cost of agency nurses but they should not have to pay that level of VAT. Perhaps Professor Drumm could ask the Minister for Finance about that because I have had no success on it.
My final question relates to my own interest. I am a public hospital person. While our public hospitals have their faults, they are not the worst in the world. I have been in and out of them as Mrs. McEntagart on several occasions and have come out in one piece. I have VHI insurance and I am extremely alarmed about the development of private hospitals in public hospital car parks because I am not sure the Health Service Executive will supervise them. Will the consultants who work in these hospitals be private consultants or will they be the same consultants as in the public hospitals? Will they have separate intensive care units and operating theatres or will they leech on to the public hospitals and use their facilities? If so, public patients may end up in a worse situation.
People such as me, who have private health insurance and who like to stay in public hospitals, will lose most because we will have to go to the private hospital in the car park. The latter may not have its own intensive care unit or if one's health becomes poor enough, one might be transferred over to the public hospital and thereby take someone else's bed. Will we be operated on in the private hospital, where, perhaps, facilities will not be as good as those available in the public hospital? There is much confusion in this area. I feel even gloomier about the situation having heard Mr. McLoughlin speak. I hope this matter is resolved before further developments take place.
I welcome the delegation. As I see it, Professor Drumm's approach is to go back to the root causes of poor health. I agree that is what primary care ought to be about. Would he agree that one of the main problems in society is alcohol? We only have to look at the number of intoxicated people attending accident and emergency units to see this. The professor spoke about a disconnection. Does he agree that a blind eye is turned to the problem? Task forces have advised the Government on the best way to approach the problem and consultants were hired and paid well for their advice. They all advised that we should proceed with the alcohol products Bill but the Government has dropped it. The executive is not directly involved in policy making but is it possible for Professor Drumm to have a word in the ear of the Tánaiste and talk a bit of sense to her on the issue? We must return to the root causes.
Senator Henry hit the nail on the head with regard to the introduction of more private hospitals. Dr. Risteard Mulcahy spoke about his concerns to my party and possibly other parties. He said that if we look at the American model, we see that the private patient is sometimes over-treated because of the money involved. Last week I raised a question about general practitioners and antibiotic prescription. I was told that if general practitioners do not prescribe antibiotics, people will vote with their feet and go elsewhere. Therefore, general practitioners look at retaining their customers. This is a serious problem. The professor referred to measuring performance. How are general practitioners regulated in this regard? It is an issue we must consider seriously.
Will Professor Drumm gaze into the crystal ball and tell us about the future? We have a problem in all health services because we have an aging population. We have better technology and medication and, as a result, people are living longer and using up more resources. We will, therefore, be obliged to pay more for our health services and health insurance premia will rise. How does Professor Drumm see this panning out? Will there be a huge drain on the resources of the State? If, for example, we improve primary care and people remain healthier for longer, they will eventually become ill. We know more money is spent on people in the last years of their lives than at any other stage. Many people will live longer but this issue has not been debated. It is one of the most crucial challenges we face.
I welcome Professor Drumm and his team, in particular, Mr. McLoughlin, whom I have known for years. I get the feeling that Professor Drumm is of the view that there will be a quantum movement of the general practitioner or primary care sector. If we need the primary care sector to get more involved, it must have better access to diagnostic facilities. This access must be standardised across the board.
In my other life, I am a general practitioner and I have access to two public hospitals. In one, I have direct access to endoscopy and ultrasound facilities but, in the other, only the consultant in the specialty has access. As a general practitioner, I could take much of the load off the consultant by doing the work-up and thereby ensuring that his or her expertise is used in a more practical manner. What are Professor Drumm's views in this regard?
My next query is more political. The professor alluded, but did not refer in detail, to the issue of tertiary paediatric services, particularly in Dublin. Will he comment further on that? He also alluded to the subject of mental health but he did not develop it very much. In my opinion as a GP, psychiatric services are the Cinderella of the health profession. They are underfunded. Psychiatric consultants are not dealt with as evenly as are consultants in other specialties. This may be an historical problem but the psychiatric services must be brought more into the front line. All GPs, particularly those working in a north inner city environment, rely to a significant extent on the psychiatric services for backup and help.
Professor Drumm
Deputy Fiona O'Malley raised the issue of hospital management. We will make the tribal sector reports available to everybody. These will show that we have difficulties but they are ones we are glad to identify. Straightforward issues such as seven-day discharging and whether it is possible to have evenness of discharge across seven days is an issue. We clearly do not have this in our system at present and we must try to achieve it. We must be able to spread elective work more evenly across the week. We must use our hospitals as much on Friday afternoons as on Monday afternoons but we are not doing so. We do not have discharge lounges on a consistent basis so patients fit for discharge must wait in a bed for an ambulance to come to take them rather than having a place to sit and watch television for a few hours. This situation can block up a bed for the day.
Discharge planning in its more detailed level could be achieved by including a date for discharge at the time of admission and then reviewing where the delay occurred, whether with X-ray or ultrasound or the failure of the surgery to take place because a bed or a slot was taken up by an emergency patient. Some of our systems are very good but we are not reaching the type of day case activity figures we should be reaching in parts of our system. Mr. McLoughlin might have some comments.
Mr. McLoughlin
Some of the problems are contractual, some are due to capacity and some are a mixture. The diagnostic one is a good example. We have labs and radiology departments that could be operated for longer hours with our outpatients departments. To do that, we will need contractual changes that would free up a lot of space and activity within the system. We have a menu of ideas and good practice with which we need to move forward.
A point was made about the attitude of two hospitals. I know that some hospitals are afraid to open up their facilities to automatic GP access. We tell them that it has been proven to be effective, such as in the AMU — acute medical unit — model, which is a good example of where a hospital that links properly with general practice will work effectively. We had a general practitioner on the steering committee for the tribal sector report. I have indicated to ICGP that GPs will be part of every review we carry out on hospitals. They are fundamental to the operation of the hospital.
Professor Drumm
On chronic disease management, it does not make any sense to have diabetic patients coming along to a hospital in huge numbers to have assessments carried out. There are many others like that. They are being seen in hospitals by individuals with far less experience and far less knowledge of their overall health in a holistic sense. We believe it should be provided but we must provide the resources to allow that to happen. We believe chronic disease management at the primary care community level is something in which we must invest significantly. It is difficult to do this unless the general practitioners are given the support of community teams with paramedical expertise rather than having them write to hospitals seeking appointments with dieticians.
From our point of view, the NTPF has taken the pressure off the system. It has taken patients and moved them very efficiently. Another positive aspect of the NTPF is that it has exposed us to the rigours of some competition. We clearly would prefer it if the NTPF was to disappear because that would prove that we were doing our job correctly. One of the measures of how well we do our job will be less need for the NTPF. It is a resource that can be used but we would like to see the point being reached where it will no longer be necessary.
Unless the IT and patient information systems are developed further, we will be very limited as a unified system. We must get a nationwide patient information system. We are working on the famous iSoft project. Everybody is afraid it will grow into a PPARS project. We are clearly well informed by the experience of the health sector before us and PPARS. We hope to learn greatly from that experience in terms of developing the iSoft project. Its importance to the system is probably much more than that of PPARS. It is fundamental to running a system that can answer some of the questions raised earlier by members.
I ask for the committee's forgiveness in respect of providing an answer to the pharmacy issue. We are just entering into the realm of negotiations. I would prefer to say that we are determined to get better value for money within the system. We have some very clear ideas on what we want to achieve but it would be unfair of me to bring this into the public domain at this point as I have set up a team of people to deal with it. It would be considered commercially sensitive information.
Senator Henry raised the issue of GP access over the decades. I agree with her and other people have stated this many times. There is a changing way of practice for general practitioners and a sea change is occurring in the way general practitioners view their role. Historically, general practitioners saw their role as independent practitioners. To be honest, they were somewhat like hospital consultants in that they could do everything for everybody. The people who entered general practice in the past ten or 15 years wish to move towards a different form of service provision. I acknowledge that there were good earlier examples of group practices. We have the opportunity to tap into this movement and to build on some excellent examples that are already there. Without us doing anything the demand would still come to make these changes.
Deputy Fitzpatrick made the point that GPs cannot obtain access to diagnostic facilities.
Professor Drumm
We absolutely accepted that as a number one issue. I know of some examples, such as in Kilkenny, where there is superb access. I have visited places where we are close to having ultrasound being beamed in from way out on a peninsula into a central hospital for interpretation. I acknowledge there are issues to do with ultrasound technicians. The issues in the cities are more challenging than those in rural Ireland because the personal interaction is still there between the radiologist and the general practitioner, even if they only meet in the supermarket. This is a dimension that is driving a different form of practice. It is that personal interaction as much as anything else that we want to see working.
In terms of diagnostic services, we will no longer be placing radiologists in a hospital service but rather looking to community services. We will be asking whether they will be employed on a contract that is 50% or 60% funded from the community side, in circumstances where their commitment will be to the general practitioners. When that person goes into work each day, he or she knows that his or her job is more allied to the primary care general practice system than to the hospital. The perspective on how people in hospitals view themselves must be changed, as must the view that applies in terms of how we contract with them from the outset. We must not state "You are now in this hospital and by the way, we expect you to do a little bit out there in the community."
On acute beds, Peamount is a somewhat unique example in that it is sitting in the middle of three or four hundred acres of lush land and is quite attractive for people who want to be placed there on a long-term basis. There is also a history of quite an acute service operating on site. I am not sure that there are very many examples in the country of that level of acute care provision in such a massive and well placed facility. We are on the look out for similar facilities. We have asked the individual hospitals to identify sites. For example, Tallaght is linked into Peamount more so than St. James's, which has a link to Cherry Orchard. It is no secret that patients will transfer much more easily to Peamount than to the long-stay facilities in Cherry Orchard. Rather than us arranging for all their patients to be transferred, we have advised the individual Dublin academic teaching hospitals to connect into a service so that their geriatricians are cross-appointed. They should link with the local primary care providers. This would mean patients would not be told they are leaving, for example, Tallaght Hospital and going to another place. They would transfer within the same system and the same geriatrician would continue to connect with the patients' primary care provider in the community through the Peamount setup. This would greatly reduce the challenge to patients and their families. We are asking the hospitals to begin taking responsibility.
In the case of transfers into privately run facilities, the hospitals need to take responsibility for the geriatricians going in there and for their chief nursing officers to apply control over nursing standards. The hospitals have taken up this challenge and are very positive about allowing them to manage their step down rather than us imposing it. We need to operate from the ground up.
Nurse retention is considerably easier in a rural environment. Everywhere I go the issue is whether they must pay to park their cars. Mortgage is clearly a big factor. I do not believe this is unique to the health service and I suspect the same is true of retaining people in any area. I regularly speak to young nurses in Dublin and they emphasise getting back to where they came from. This is a societal matter with which we must deal.
Immediately after this meeting I will go to An Bord Altranais. I will be controversial enough to mention here another question, which needs to be addressed in nursing, namely, the reason we have so many nurses in the system compared with other systems. We have a number which is totally different from every other developed country's system. It is a bit like the hospital bed issue. We need to decide whether we solve a problem by continuing practices that require what will be an unsuppliable number of people, or whether we look for differences in skill mix providing some of that service. It is unreasonable to go forward in planning nursing services without asking ourselves a very fundamental question, namely, why this country, with an age demography that should put us in the opposite direction, has a huge number of nurses in the system. Nurses bring enormous skills to the system. They need to be moved to the front line, which needs to be done in the context of changing skill mix and how people are used.
I ask Mr. McLoughlin to comment on direct entry to midwifery.
Mr. McLoughlin
The programme has been established and resources have been provided for direct entry commencing in 2006.
Professor Drumm
I cannot say I know very much about the issue of VAT at 21%.
Mr. McLoughlin
We cannot comment on the realm of the Minister for Finance.
It is a considerable amount of money for people who are taking patients out of hospital beds.
Professor Drumm
The families who bring people home are paying this amount. We should bring this to our own table and try to push doors to see if the matter can be investigated, as it would act as a disincentive to what we want to achieve.
Discussing public hospitals on private sites brings us back to another issue. What private hospitals develop will be for them to decide and for us to evaluate whether it is a service that is required. The workings within those, if they are to involve our consultants, will demand contractual negotiations on our behalf. This does not preclude independent hospitals, which are determined to bring into the system as many as possible of their own consultants.
Will they use the public intensive care units, theatres etc.? It is very important to work through these issues before a hole is dug or one brick is placed on the ground.
Mr. McLoughlin
If a private wing attached to a public hospital did not have an intensive care unit, clearly the private hospital would need to pay the public hospital for any patient in the private hospital who needed to be transferred. A service level agreement would need to be established. We cannot have any piggybacking in that regard. Any service we provide for a private wing would need to be charged.
They get preferential access.
Mr. McLoughlin
No, it would need to be part of a service level agreement.
It happens at present with private patients.
Mr. McLoughlin
The patients who come in could be public or private. Completely splitting the private activity onto a wing or other part of a public hospital gives a much clearer definition of the service. However, it would be a matter for the private operator to decide whether it is viable to have its own intensive care unit, theatres and other services. Clearly that is an issue of viability and that will arise.
We could end up with an increase in beds with no increase in the facilities. The remaining facilities such as the intensive care unit of the public hospital would be used by an increasing number of private patients.
Mr. McLoughlin
Clearly we would not allow any business case to proceed——
It is promised.
Mr. McLoughlin
It would be absolutely part of a business case. We will not develop——
While it would be appalling I can see it happening.
Mr. McLoughlin
—— further capacity that would reduce access by public patients to existing facilities.
I can see it happening.
It is happening already, as Mr. McLoughlin knows.
A Member
From our point of view the public sector would be subsidising the private sector.
Mr. McLoughlin
Clearly such a proposal involving subsidisation would not be approved by the HSE.
Some services in public hospitals are easily accessed by private hospitals that pay for them and they get preferential access to these services. The problem could be exacerbated.
Mr. McLoughlin
The decision on who to admit to a hospital is made by the clinician. There are varying degrees to which patients are public or private. In excess of 70% of patients come to hospital through accident and emergency departments. Subsequently they will make a decision. Their need to be in hospital is demonstrated by the need for them to be admitted as decided by the clinician. They may then opt for private care in a designated ward or area. That is the present situation. We have a mix of public and private practice on our sites.
Unless the HSE reforms how this operates, it will simply make it worse.
Mr. McLoughlin
The HSE would not accept any proposal that would make the situation worse for public patients.
In that case these private hospitals are unlikely to materialise. These people will make their money by essentially building on the inequality.
I understood this was to go ahead at the James Connolly Memorial Hospital. Has that been cleared?
Mr. McLoughlin
No.
That cheers me up.
Mr. McLoughlin
No proposal on the James Connolly Memorial Hospital has reached my desk. I am aware of contact in this regard.
We can get Mr. McLoughlin plenty of people to consult if he needs to.
What about Waterford?
Mr. McLoughlin
I have received a very tentative proposal regarding Waterford and I have indicated we need a proper business plan outlining how the existing 85 beds would be used if they were put into a private wing. I am awaiting a response. I have received a further proposal regarding Limerick. They are the only proposals that have materialised at this stage.
Are these proposals made on the basis that the specialists in the public hospital can access the private hospital?
Mr. McLoughlin
The proposal did not even address that matter, with which we would clearly have an issue. A very rigorous assessment procedure is followed before any proposal like this would be approved by the HSE.
Orthopaedics is an interesting example of what is being discussed. There is an elective hospital for orthopaedics where up to 50% of the patients were private patients. Half of all National Treatment Purchase Fund orthopaedic procedures were carried out in the hospital at which the patient was on the waiting list for that procedure. Public patients can wait for three to four years to get access to an outpatient appointment for orthopaedics in the same area. The slant is clear. I believe the HSE understands this comes from within the public hospitals. In the Dublin region we have seen that all the patients who were inappropriately placed, in other words, those patients who were taking up beds when they should have been in a step-down facility, were all taking up public beds and not private beds. The turnover through the private beds was much faster and private patients got faster access to treatment. It was not that anybody was setting out deliberately to give faster access to private patients, it just happened that way because those beds were turning over faster, giving patients access to diagnostics faster.
Mr. McLoughlin
The Deputy referred to orthopaedic procedures carried out under the National Treatment Purchase Fund. This fund has been using more public capacity and we have debated the matter at the Committee of Public Accounts in recent weeks. However, this takes place in hospitals that are traditionally elective hospitals such as orthopaedic, and ear, nose and throat hospitals etc. It is important to put the work of the National Treatment Purchase Fund in context. There are 1 million discharges every year on foot of inpatient and day procedures. Some 13,627 patients were treated under the fund in 2004. That is the extent of the fund's workload, compared to the overall workload of all our public hospitals. The fund has concentrated on patients on long waiting lists and those who were being pushed to the bottom of such lists by patients with a greater medical need. The National Hospitals Office and the National Treatment Purchase Fund have been tackling the critical issue of overall length of waiting time for treatment. If one is waiting two years for an appointment as an outpatient, one has to wait for a critical period of time. Under an extremely successful initiative launched in the south east, consultants are funded to tackle the problems in the outpatient sector in order that patients who can be brought onto the National Treatment Purchase Fund waiting list can be freed.
In what sectors is the initiative being pursued in the south east?
Mr. McLoughlin
It is being pursued in the ear and throat and dermatology sectors, in particular.
Is the lesson we should learn from the initiative not that if one incentivises the system to care for patients, it will do so? There is no incentive to care for public patients, but there is one to care for private patients. That is why private patients can access care quickly. Is that not an issue that has to be dealt with?
Mr. McLoughlin
The National Hospitals Office believes it can do a great deal about incentivisation within the existing allocation of €3.5 billion to hospitals. It can encourage hospitals to examine their practices by incentivising certain forms of behaviour. As I said, the release of time and beds which could be used more efficiently in public hospitals is a way of incentivising certain behaviour. That is something we want to start to do in 2006. As Professor Drumm has said, a certain degree of competition has been good for hospitals. For example, they can talk about the cost of providing outpatient and theatre facilities out of hours. A great deal of the National Treatment Purchase Fund's work in public hospitals is done outside normal working hours. A policy decision needs to be made on whether resources should be invested in the public system for the 14,000 people in question — it is obvious that more will be involved in 2005 and 2006 — or allocated to an agency which has a degree of competition.
We will conclude shortly.
I would like to ask about primary care.
I hope we will not conclude until all members have received replies to their questions.
Deputy Twomey has said he would like the delegation to speak about a certain matter before it leaves.
That is fine.
Professor Drumm
I will respond to Deputy Gormley's questions. Alcohol abuse, a societal issue, exerts great pressure on parts of the health system such as accident and emergency departments. It is a challenge in the widest sense. If the HSE is to deal with it, it needs to decide whether accident and emergency doctors should be responsible for dealing with inebriation as a social problem. Should their dealings with people who are inebriated be strictly medical in nature until they are no longer inebriated? Fortunately, a medico-legal approach has been taken, that doctors are responsible for inebriated persons who arrive in accident and emergency units until it is shown that they are sober and capable of operating independently. This medico-legal and societal issue creates tremendous problems in the health service, not only because it leads to a direct increase in the workload of accident and emergency departments but also because the arrival of inebriated persons in such departments can have catastrophic effects on their ability to provide services for other patients. An improvement in the syndrome of acute alcohol intoxication would take a great deal of pressure from the health service. The problems caused by chronic alcoholism do not have such immediate effects on the service. I am not sure what the HSE can do to alleviate the problem of late-night and weekend inebriation.
The representatives of the HSE have given their views on the issue of publicly owned sites being used for private hospitals. The question of antibiotic control is central. Everyone is aware of MRSA which is by no means a uniquely Irish problem. It is having a huge impact in the United Kingdom and central and southern Europe. Most countries in northern Europe had managed to keep MRSA levels quite low but it looks like such levels are starting to increase significantly from a small base. I agree education is central to this issue. Those involved in the health provision system cannot legislate for how doctors prescribe. It is helpful for everyone — general practitioners, consultants and everyone who prescribes — that the MRSA issue has become part of the public agenda. It is the first time in my professional career that I have felt a certain level of awareness of the effect of prescriptions of antibiotics on MRSA. I was not aware of the problem to the extent I should have been. We all knew there was a problem but none of us was accepting responsibility for it. It is almost as if we are lobbying on behalf of the public in order that the message is transmitted. As medical practitioners, we feel we should be responsible for dealing with the matter. The concerns in this regard have to be taken on board, in conjunction with a major education programme. The HSE is heavily involved in trying to increase the level of education on the use of antibiotics.
I was asked whether future demographics would lead to increased costs in the health sector. Perhaps what was being described is not clear to everyone. This country has enjoyed the most advantageous demographics in the developed world in recent years. Our youthful population has enjoyed tremendously high standards of education. We have done many things well, for example, by keeping down taxes. We will have to face some challenges such as providing for more long-term stay facilities as the system has to deal with increased costs. We will have to take what this means on board. I accept that health costs will rise. I am challenging many of our present calculations on the basis of our advantageous demographics. We will face a tremendous shock if we do not face the challenge. If we are unable to meet the current challenges in an efficient manner, how will we cope when we face a real challenge in 20 or 30 years when there will have been an increase in the percentage of the population that is older?
I will respond to a point made by Deputy Fitzpatrick about primary care centres. I alluded to the tertiary paediatric service in response to an earlier question. The HSE is focusing on trying to ascertain how to provide the best tertiary care. We need to consider the impact of this and what it means. I hope there will be a focus on the provision of optimal care. Most believe there will be a single tertiary care centre and that it should be located close to the city in order that it can be accessed by people from around the country. Such a centre would have a substantial impact on the current major providers of tertiary care, Temple Street Children's University Hospital and Our Lady's Hospital for Sick Children in Crumlin. It would also have a subsequent effect on the hospital in Tallaght. If Crumlin Hospital is moved from its current site, the workload at Tallaght will increase significantly. I think the structure in Tallaght could cope with this.
Mr. Browne
I would like to discuss the mental health issue raised by Deputy Fitzpatrick. I agree there has been a significant under-investment in mental health services in recent years but I am happy to say this has been corrected in 2005 and 2006. An additional €15 million has been invested this year. Some €25 million has been assigned for specific service development in 2006, in the context of implementation of the mental health legislation which will radically change how mental health services are delivered. I agree with the Deputy about mental health consultants. There has been a silo approach to mental health — people think it is "over there". Such services are not well integrated into the primary care system. Yesterday I met some mental health clinical directors who are very enthusiastic about moving towards a population-based approach that is more supportive of primary care and the introduction of psychological therapies into primary care teams. I am confident the HSE is making good strides in that regard.
I thank the members of the delegation. I assure them that the joint committee will not keep them here for three hours on the next occasion they visit.
The joint committee adjourned at 12.20 p.m. until 9.30 a.m. on Wednesday, 7 December 2005.