I welcome the Tánaiste and Minister for Health and Children and her officials and Professor Drumm and his officials. We will hear the presentations before dealing with the business of the committee. Members are reminded of longstanding 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 the Tánaiste to make her opening remarks.
Health Services: Ministerial Presentation.
I thank the Chairman. It is always a pleasure to attend a meeting of the Joint Committee on Health and Children to discuss issues of concern to this committee and the public. I propose to make a short preliminary statement before taking questions.
This year we will spend €15 billion on health care in Ireland. This money comes from taxation, the health levy, private insurance and direct payments. A total of 25% of all Government spending is on health, which is a considerable resource of public and private money. In our successful economy, the public rightly expects to obtain a top-class service for that spending. If I came before this committee as Minister for Health and Children in 1997 and informed it that during the next nine years we would increase health spending almost four-fold and recruit an additional 40,000 health care professionals, most people would have left the room feeling we would have a top-class health service. That is what we did.
Public expectations in Ireland have changed and that is good. People are not interested in queuing without end and accepting second best, as they may have done in the past. The core of this Government's message on health is that we can achieve a world-class health system but not simply by maintaining the status quo or accepting failure. We will only get the service we merit for the money we invest if we invest with reform. That is the process now under way. Whether the services are provided by the public service, voluntary organisations or the private health care system, the job of Government is to ensure we provide the highest possible quality of service, regulate, legislate, budget for today and plan for tomorrow.
Much of the debate on health care in Ireland centres on the problems. Before I deal with some of them I will speak about the successes, which are considerable. A few months ago, the Irish Society for Quality and Safety in Healthcare published the outcome of a patient survey involving 5,000 patients. It is interesting to note the response of patients, 93% of whom stated they were satisfied with the service they received. A total of 80% of accident and emergency patients stated they were seen by a doctor within three hours of attending, and 75% responded they were admitted to a ward within six hours of the decision to admit. By any standards that is a high level of satisfaction. If any of us had satisfaction ratings at that level we would be extremely happy as we head towards an event next year.
The issue for us in health care is to ensure that as we provide more resources, we target them to improve patient outcomes. Over the past eight years, an additional 110 new consultants and 329 new clinical nurse specialists were appointed in cancer care, making a significant impact on cancer services throughout the country. The outcome is even better in coronary care. Yesterday, I met the advisory group and members of the Irish Heart Foundation. They stated that what happened in coronary care in Ireland is incredible and we must hear more about the good news. Mortality rates have decreased by a significant 50%, because of the huge increase in interventions.
We now have the capability in Ireland of transplant surgery. I met six patients at the Mater Hospital who recently had lung transplants. In two cases, they had double lung transplants. The impact on their quality of life is incredible. I state all of that because it is important to acknowledge successes if we are to have the capacity to deal with problems.
In recent years we extended GP cover and I am happy to state that 24,000 more people have medical cards than at this time last year. We extended the doctor-only cards and, although the take-up is slow, the recent HSE advertisement campaign is having an impact. That was done because I feel strongly about the need to have graduated benefits and that one does not have all or nothing. The doctor-only card is an opportunity to give some people, particularly those with children, an opportunity to be able to go to their doctors without having to worry about the cost.
We had the first-ever multi-annual disability plan and the first-ever hospital hygiene audit. We recently published a mental illness strategy which effectively commits us to closing all stand-alone mental hospitals between now and 2010 and dealing with mental illness on a multi-disciplinary basis within the community. Where people require in-hospital treatment, it will be provided in modern state-of-the-art facilities attached to general hospitals. Those measures are not taken without reason. They happen because planning, policy and resources are put in place to make them happen and because of the hard work of health care professionals. Those successes give us the platform for further improvements.
Health and its reform is a complex area. In recent years we increased the training opportunities and pay scales of health care workers. We opened up and expanded many new services. The reform is in its early days. Although disparaging remarks are made about the HSE from time to time, I ask committee members to reflect. Do they seriously believe we would do better on accident and emergency departments or standards in nursing homes if we had 11 CEOs and a couple of hundred people sitting on health boards? Does anyone seriously suggest that would be preferable to what we have?
Although the HSE is in its early days, and we were criticised for rushing the legislation through, it was important to begin that journey of reform. The signs are encouraging. The HSE has a management team on board to address issues. With every reform programme, we must have short, medium and long term successes. We will not wake up one morning having arrived at a position where the health care system has been completely reformed. We will always be in a process of reform because it should never end. We will not wake up one morning to realise that many of the imperfections, as we see them, have been put right. It will be a process. Hopefully, we will be able to see step by step progress.
Accident and emergency departments are the focus of major public attention because people are not satisfied with being on a trolley overnight or for a couple of days. That is not acceptable to anybody, and certainly not from the perspective of older people. The HSE established a task force comprising experienced experts from the health care system. I met that task force a few days ago to inject a sense of urgency and show them they have my full support to do whatever is necessary to ensure nobody, particularly an older person, is on a trolley overnight.
Sorting out accident and emergency departments will only happen when we sort out wider hospital issues. What happens in accident and emergency units is a symptom of the wider problems. In many cases, particularly in Dublin, people end up in accident and emergency departments because there are no primary care facilities in the evenings or at weekends, and there is no alternative. Sometimes, people end up in accident and emergency units because they cannot get access to out-patient appointments. Only when we solve the wider problems through reform will we solve the difficulties in accident and emergency units. That is not to state we cannot make significant progress in the short term in addressing the deficiencies recently identified.
Reaching a figure of 495 people on trolleys, as we did three weeks ago, represented an urgent situation that needed to be addressed. As the Taoiseach stated in the Dáil yesterday, approximately 411 older people are still in Dublin hospitals even though they have been medically discharged from Dublin hospitals and doctors believe they are fit to leave the acute hospital system. The challenge for us is to find appropriate accommodation, either through home care packages for people who can return home or in alternative accommodation within the community.
Addressing the accident and emergency difficulties will not sap our energy or disable us. On the contrary, it will mobilise people to address other reforms. Many of the reforms under way are of work practices. We are in negotiations with the consultants, on which there is much focus. We are also in negotiations with non-consultant hospital doctors, general practitioners, nurses and others. Reform of health care is for everybody and not just for a few. If we do not reform across the board we will not reach the potential that people expect. Guiding this reform are patients, who are paramount.
As Minister for Health and Children, my focus must be on patients. That means if things which should not happen do, we must have the courage to stop them and defend the changes that will take place. They will be matters for the Health Service Executive. However, as I stated previously in the Dáil, I will not use any policy instrument to stand in the way of putting in place anywhere in the country appropriate procedures in the interests of patient safety. Any Minister for Heath and Children that would do so does not merit having the job. That means we must face up to certain realities in areas such as breast surgery. We cannot have a situation where breast surgery is performed in up to 30 locations in the country. We all know that outcomes for patients are not good unless there is a high volume of activity in a particular unit. That is just one example.
These are the kinds of decisions the health reform programme is all about but guiding our reform is the need to ensure that we have top quality services for the money we are investing and, thankfully, the economy is in a position to be able to generate enormous resources. There is no country in the world, from our analysis, that has increased spending on health at the rate at which we have done over the past nine years. On a per capita basis we are spending more on health care than France or the United Kingdom. Everywhere in the world there are challenges and difficulties with health because there are new treatments, procedures and therapies coming on stream constantly. If we are to make them available to our patients, we must change the way we do business. That is what the health reform programme is all about and I hope we have the support of members of this committee as we seek to implement the programme over the next few years.
I invite Professor Drumm to make an opening statement.
Professor Brendan Drumm
The letter of invitation asked me to discuss the financial management of the HSE and to give an update on health issues. Given that the accident and emergency issue is so topical at present, I will leave that to the end of my statement.
The health reform programme is the biggest organisational reform programme to be undertaken in the history of the State and that fact must be borne in mind in terms of the challenges the HSE faces in its first year of existence. When launched, the Government said it wanted the health system to provide the best possible standard of care available to all. We have many challenging problems which we are tackling but it would be unfair to staff working in the organisation to overlook the fact that, as the Tánaiste said, thousands of people are delivering and receiving excellent services.
The evidence from the patient survey, which is the only professional survey carried out, is that we provide high quality services, with 93% of patients expressing satisfaction with the service they received during their hospital stay. More than 80% said they had been seen by a doctor in an accident and emergency department within three hours of registering and three out of every four were admitted to a ward within six hours of the decision to admit. It would be very unfair if this level of achievement across many parts of the service by so many people was not acknowledged in a situation where so much criticism of other areas of the service is justifiably expressed.
We must move to integrate our services. Only then can we reach a consistently high standard across the country and this is particularly true with regard to the problems in accident and emergency units. Before dealing with the accident and emergency issue, however, I wish to deal with our primary care services. We are focusing on very high impact primary care initiatives. Since I took up this post, I have continually stressed that the largest deficit by far in our health care system is in the primary and community care structures. Historically, people have tended to look on the hospital system as the health system. As long as that continues to be the case, the health service will not function properly. Such a view excludes the reality that general practitioners are the most skilled providers of care available to us. Until the public realises that and begins to use that service and the service is given all the support it needs to operate at a maximal level, we will continue to struggle.
An additional €60 million is being provided for primary care services on a revenue basis this year. Much of this will go towards the establishment of primary care teams and we hope to reach at least the identification of 100 primary care teams, as well as expanding out-of-hours GP services, this year. All general practitioners have now received a letter from their local health office inviting expressions of interest in becoming involved with the HSE in the further development of primary care services, particularly the formation of primary care teams. The response has been very encouraging. Unfortunately, the representative body, the IMO, is currently advising general practitioners not to engage with this initiative. This is particularly unfortunate in light of the fact that the major criticism we faced when I took up my post was that we were not progressing primary care teams. Now that we are progressing them, we are finding that those who criticised us earlier are now advising people not to engage with the process. It gets confusing.
Each of the four HSE administrative areas is being provided with extra support to further develop GP co-operative services. The process of attempting to improve the quality of our GP services in north Dublin continues. The fact that the procurement process has been discontinued does not indicate that the process of identifying and establishing an out-of-hours service is not continuing apace.
The publication of Children's Health First — A Blueprint for Paediatric Services was a very significant event. The study was carried out by McKinsey and Company on international best practice in tertiary and secondary hospital-based paediatric services. It showed that Ireland, based on its population size, can only support one world-class tertiary centre, with the population demand being 4 million to 5 million. This also has a potential impact on Northern Ireland where, because of its population base, support for some tertiary care paediatric services, such as cardiac surgery, is very difficult to maintain. We should be in a position to hold out a support mechanism for their services.
A joint HSE and Department of Health and Children task group has been established to recommend the most suitable location for a new children's hospital and I hope it will report early next month. The timetable for the development of the new hospital will form part of the group's work, as it is influenced by the proposed location for the new hospital. A suggestion was made that because of my involvement in children's services, I have a vested interest in this matter. However, it would be a most unusual vested interest given that the one institution that will not be considered, based on the report, is my own. A further criticism was that the pace of the development of children's services was too rapid. Again, that is an unusual criticism for the health services but we will take it as a compliment. I guarantee that the process is absolutely above board and rigorous, as it was through the entire McKinsey approach. Any suggestion that my historical involvement in paediatric services is affecting this issue is not borne out by the facts to date.
Discussions on the consultant contract have been suspended to the degree that the IHCA and the IMO are refusing to engage further in the talks, which are chaired by an independent chairperson, Mr. Mark Connaughton. The proposal for a new consultant contract, entitled the new employment contract for consultants working in the public health system, was presented to the unions at a meeting on 26 January. On 9 February, the chairperson suspended the talks, pending the resolution of four issues.
The first related to the fact that the board of the HSE had decided a month earlier that no further category two contracts would be issued. At this point, I will describe the difference between the contracts that are currently available to consultants. Consultants who have a category one contract, accounting for approximately 68% of our consultant body, only work within the public hospital system. However, they have the right to see private patients admitted to that hospital system. Such contracts exist across the country, in towns like Mullingar, Sligo, Kilkenny and so forth, where consultants are based in public hospitals on a full-time basis. Consultants with category two contracts provide a full week's work for the public hospital system but can also work, at any stage, in the private hospital system. The board decided that, moving forward, it was only willing to make appointments of people who were fully committed to working within the public hospital system. The unions decided that this was a breach of faith and were not willing to consider continuing with the negotiations.
The second issue related to the mechanism for arbitration of potential disagreements on the pricing of the new contract. They were unhappy that the price of the contract would not form part of negotiations but would be dealt with, in what I think is now a standard procedure, by the review body on higher remuneration in the public sector. They also had concerns about how we planned to approach disciplinary procedures and that remained a blocking issue. Finally, concerns were expressed about the private fees consultants charged to patients treated in public hospital accident and emergency departments. The Department of Health and Children and the HSE were also unhappy to learn of this practice and are not agreeable to it. These concerns precluded any progress of the negotiations, which remain in abeyance.
The National Hospitals Office, represented here by Mr. John O'Brien, has been working to raise hygiene and infection control standards in hospitals and health settings. The first national hygiene audit in 2005 was successful in terms of creating a focus on the need for hygiene standards and the hospitals office commenced a second audit in February. This second assessment will allow the hospitals office and the hospitals to measure progress in hygiene and infection control standards. Obviously, we expect to see improvements on the results of the first audit.
The total cost of the drugs bill is currently around €2 billion per annum. This includes the co-payment by the public for drugs under the DPS scheme, the cost of reimbursing the various schemes through the primary care reimbursement scheme and the cost of drugs purchased by our hospitals. Other than pay, this expenditure is the single biggest element of our budget.
The State and patients must secure value for money, consistent with patient safety. I am determined to strengthen and streamline the management and administrative arrangement for the procurement and use of drugs across all schemes and hospitals to secure maximum efficiencies. I have established a pharmaceutical unit within the corporate HSE structure. After significant preparations, we recently commenced negotiations, in association with our colleagues in the Department of Health and Children, with the Irish Pharmaceutical Healthcare Association, the manufacturers' representative body. We will next commence negotiations with suppliers and with the Irish Pharmaceutical Union, the representative body of community pharmacists. This issue is of significant importance in terms of value for money for the health services.
At an organisational level, we are making progress on a number of fronts. The national service plan was approved on 22 December 2005. The plan, which represents an agreement between the Tánaiste and the executive on service provision, is the benchmark against which our performance will be measured and outlines the agreed level of health and personal social services to be provided for 2006 within the voted allocation of the Oireachtas and the approved employment levels, as established in government policy.
Work is continuing on organisational design and more than 11 organisations and 100,000 employees remain to be integrated. This is a substantial task on its own and its complexity is compounded by the fact that it must be done while we deliver a service to 4 million people. While the benefits of a unified health system are many, the challenges that face us in implementing this massive and complex change programme are also substantial. However, there is a tremendous will among our staff to do what needs to be done to deliver a consistent modern health service.
To ensure that we are well informed, we are establishing a number of expert advisory groups to advise on the organisation and development of health and personal social services, initially in the areas of older people, children, mental health and diabetes, while other groups will be established in due course. We are inviting people such as members of the public, front line physicians, paramedics and therapists to join a forum that will act as a driving force for the development of policies for the provision of health services and will be responsible for monitoring the implementation of the policies. This the first time for any health organisation in the world that front line service providers and the people who use our services will be made central when deciding policy implementation plans. Expressions of interest have been sought from people who would like to become members of one of the expert advisory groups by means of advertisements placed in newspapers.
The issue of democratic accountability within the HSE will be of interest to committee members. Accountability received much attention on the last occasion that I appeared before this committee and has been high on the agenda whenever I have appeared before the Committee of Public Accounts. As I said at our last meeting, I am keen that the HSE should constantly strive to improve its engagement with Members. We have established a parliamentary affairs division within the office of the CEO so that it will have adequate standing. The division has been extremely busy and since September 2005, it has replied to 1,500 parliamentary questions. This represents more than 25 parliamentary questions for each sitting Dáil day since September 2005. Managing this volume of inquiries is a major task for the division, which is continuing to develop its resource capacity.
I wrote to every Member of the Oireachtas on 1 March 2006 to advise of a number of initiatives that will improve services to Members. Many of these initiatives were recommended by the members of this committee on my last visit. For example, a dedicated e-mail facility has been established so that Members may submit queries to the HSE. The parliamentary affairs division is working with our website manager to arrange for replies to parliamentary questions issued by the HSE to be put on the HSE website. I will keep Members informed of developments in this regard.
Arrangements are also being put in place for Members of the Oireachtas to meet senior managers with responsibility for service delivery within the HSE's four administration areas on a twice yearly basis. Face-to-face contact with HSE officials at the local level will be helpful in terms of allowing Members to identify where to go for quick responses to local issues.
Since my last appearance before this committee, two secondary Bills relevant to democratic accountability have been signed into law by the Tánaiste. One of these provides for regulations that create a framework for the manner in which the HSE co-ordinates its dealings with Members of the Oireachtas. The regulations also specify the documentation that the HSE must make available to Members.
The statutory instrument establishing the regional health fora has also come into operation since my last visit to the committee. During February and March 2006, I attended all four regional health fora and responded to questions from the councillors in attendance. I view the establishment of this fora as a positive development and hope they will strike the right balance between accountability and genuine community engagement. They enable us to hear the views of local representatives, which is important in terms of focusing our attention.
Financial management has become an important issue in the media and elsewhere in recent months. As accounting officer for the HSE with responsibility for the Vote, I am pleased to say that we have balanced our Vote. This is good news and is a reflection of the seriousness with which we take our financial management responsibilities. The HSE is obliged under Government accounting rules to provide an estimated outturn figure on a Vote expenditure basis for the year by the fifth working day of each new year. The estimated outturn figures provided in January 2006 were preliminary, as they have to be at that stage, and reflected the organisation's cautious approach to the management of its finances. When the figures were published, it was indicted that they would be revised pending the full reconciliation of the financial statements on an income and expenditure basis with the appropriation account on a Vote basis. My organisation is in a remarkable position because it runs a Vote accounting system in addition to the income and expenditure accounting system historically assigned to the health boards and it now has to integrate the two systems. That will never be completed easily within five days of year end.
The work has now been completed and the final Vote outturn is as follows. In its first full year of operation to the end of 2005, the HSE has balanced its Vote. The revenue Vote account has been balanced to within €300,000 on the €11 billion or €12 billion Vote for 2005. There is a capital surplus of €51 million. The appropriations-in-aid account has a surplus, which is income that comes to the HSE from various sources, of €39.8 million. In the context of what was for 2005 a budget of €11.4 billion this is an impressive achievement and reflects the commitment of the board of the HSE to operate in accordance with the highest standards of governance and financial management. I owe a great vote of thanks to our financial and service pillars for maintaining that accountability and responsibility.
The issue of accident and emergency services is a significant challenge. We recognise there are infrastructural problems in a number of accident and emergency units around the country and we will address these conditions with both urgent, short-term measures and major capital investment programmes which will be announced once the capital plan for this year is cleared. To ensure we maintain a sharp focus on this issue we have, as the Tánaiste said, established a new task force. The team includes two accident and emergency consultants, a geriatrician, a respiratory physician, a director of nursing, a hospital chief executive and senior full-time representatives from the National Hospitals Office and the Primary, Community and Continuing Care Services, PCCC. The key objectives are to reduce the numbers waiting in accident and emergency departments and the length of time patients stay. There will always be patients on trolleys. That is a fact of a hospital system that has 3,000 accident and emergency attendances per day and several thousand admissions per day. The question is how long people are on trolleys and we must focus on getting our trolley waiting times down to an acceptable level. It is unacceptable that people are kept in circumstances like this for 24 or 48 hours.
I am challenged by the fact that on the radio and everywhere else accident and emergency consultants and others say this is purely a problem of the HSE's management. If so, it is due to our failure to manage the processes within our hospital system. Yesterday morning I was challenged to hear from one of our accident and emergency consultants that we require more capacity. That is an easy statement to make. Let us begin by being fair to the people who make the system work well. If one disregards Tallaght Hospital's children's unit, the biggest accident and emergency department in the country over the past five years has been at Waterford General Hospital. We consistently have from zero to three people waiting on a trolley in Waterford. Limerick Regional Hospital is in the top five in the country but has no significant problem with trolley waits. It may reach an average of four or five on average over a year. That compares to waits of between 20 and 25 across several units in our hospital system, mainly in the Dublin area.
Let us think about capacity. Up to 100 people work in our accident and emergency departments, seeing 100 people per day. There can be 20 to 23 doctors rostered in an accident and emergency structure that sees 100 people per day. I might ask GPs what they think about that. Up to 45 nurses are rostered, seeing up to 100 people per day. In one part of the country we can have one nurse on the accident and emergency rota per two patients who attend, not two patients who are admitted. In another part of the country, where there is no waiting on accident and emergency trolleys, there can be one nurse for eight patients who attend. In general this is not the fault of the people working in the system. It raises significant process issues about what we do. Given these figures, for people to go on radio programmes and tell me all it requires is more capacity, and never mention that they might have a process issue in the structure, is unfair to the taxpayer in terms of what is being put in and what we are producing as an organisation for them.
We have mapped what happens to a person who attends an accident and emergency department. If one comes with a GP's letter one has up to five contacts with medical personnel before getting to the end of the process. One is seen by a highly-trained clinical nurse specialist who should be able to arrange an admission for a person with a GP's letter. One is seen by a junior hospital doctor and possibly by a second junior hospital doctor; there is a registrar in many structures; one is seen by a consultant during daytime hours; and, when a decision is made to admit one, a junior hospital doctor, who may have little experience, is brought from the ward to give an opinion on whether the consultant's decision to admit was right. When people appear on Morning Ireland to discuss accident and emergency problems it is unfair not to examine their own processes and ask why one needs five contacts in the department before one can get across the threshold. If there were 150 empty beds on the other side of the wall one would still be there for six or eight hours seeing people because of the processes.
The next question is how we get to a point where we have senior decision making within our accident and emergency structure. We have up to three consultants per day, but they are there only during the day. We must come to an agreement with our accident and emergency consultants to have them there for longer so that the most junior medical personnel are not involved in a decision making process for which they lack the experience. The system grinds along. Attendance at accident and emergency departments tells its own story. Attendances are two per 1,000 in the north west because there are two accident and emergency departments 70 miles apart. Attendances are 12 per 1,000 in Dublin. They are highest of all in the midlands where there are three accident and emergency departments in close proximity. The people in the north west show no sign of being less ill than those in the midlands. The only difference in variables is the number of accident and emergency departments. Let us examine the provision of primary care services. There is no accident and emergency problem in Athlone — a major town — but there is no accident and emergency department in Athlone. The same applies to Carlow, another large town. Athlone and Carlow were the first towns in Ireland where major, comprehensive primary care structures were put in place. The other significant factor that must be dealt with is the average length of stay for acute conditions after admission. We have long-stay patient problems in Dublin and we must find appropriate places for people who are fit for discharge from hospital.
Admissions of people who are relatively well but have an acute illness are another problem. Admission time in Dublin is in general two days longer than it is in Cork, Galway, Waterford or Limerick. If we could remove those two days from the process we would have no accident and emergency problem. We must examine the processes in our system that are not being dealt with. When people discuss this issue, rather than looking for more money from the taxpayer they should ask why the system does not work.
This comes down to the question, which will arise today, of why Ireland needs this tremendous number of beds that the rest of the world does not. Ireland has 3.1 beds per 1,000 people. The UK has 3.5 beds per 1,000. Historically, Ireland, when it has counted its beds, has not included its private beds. That is unfair to the taxpayer. Are we to recreate the beds that the private system has already created and for which people pay through their private health insurance? When we add the private beds in the Mater Private Hospital, the Blackrock Clinic and across the country we have 3.5 beds per 1,000 people, the same as the UK. Nobody should be allowed to quote hospital bed requirements without dealing with the age of the population. Some 60% of our beds are taken by those aged over 65 years. While 18% of the UK's population is over 65, 11% of ours is over 65. Although we have the same number of beds per 1,000 as the UK, if we had the same age demography we would need 3,000 extra beds this morning to cope with it. Somebody must answer the question about how efficient are our processes. We must take on both issues. We cannot take the soft option of additional beds, which will not provide a long-term solution to health care needs in this country. It will solve only the immediate problem. People have quoted me as saying we do not need beds but we will need them as our population increases and ages. At this point, however, all the evidence is that our processes are not coping nearly as well as they should, by international standards of how to treat people both in hospital, where too many patients are kept in for too long, and outside hospital. It is not fair to patients or the taxpayer.
In-hospital practices must change. Decisions must be made in the hospital, by senior people, daily. When a person visits a general practitioner a decision is made by a senior operative on the day but that is not the case in our hospital system. Accordingly, we must put a huge emphasis on increasing consultant numbers and must have contractual arrangements requiring senior decision making on a daily basis.
We also need an expanded working day. It is clearly unacceptable that people remain on trolleys in accident and emergency departments while somebody upstairs in the hospital lies in a bed simply because they were not able to have an ultrasound that day and must wait until the following day. That occurs because we work between 9.30 a.m. and 5 p.m. in radiology departments, among others. The clear solution is to expand our working day, to send patients home and allow those in accident and emergency to have the beds. It is not to ask the taxpayer to pay for more beds when hospitals only work on a nine to five basis.
Discharges decrease dramatically at weekends, which is a challenge. If any member happens to be in a hospital over the weekend he or she will not have nearly the same chance of being discharged as during the week. Equally, on a Monday or Tuesday the chances of being left on a trolley increase exponentially because so few were sent home over the weekend. We must take that challenge on as well.
The health services are going through major structural reorganisation which is having a huge impact on the people who work in them. The focus is on the medium and long term to ensure the taxpayer and those who use the services have a world class service. That does not mean we are unaware of the difficult circumstances for people in accident and emergency departments at the moment, which we will address with immediate measures.
I thank Professor Drumm. The remainder of the meeting will be devoted to questions. There are 16 Members of the Oireachtas present, of which 13 are members of this joint committee. I propose to prioritise those 13. The first part of the question session will be taken up by the main spokespersons of the Opposition parties, beginning with Deputy Twomey, followed by Deputy McManus, Deputy Gormley, Dr. Devins and Senator Henry. After that part of the meeting we will have a second tier session for members who have indicated they have questions, particularly those who have already submitted them. Members must realise that whether they ask a question first or last the question is just as important and will have the same emphasis.
I will make some brief points. The Tánaiste is correct that we expected more after nine years. Some basic health services are non-existent, such as cervical screening and BreastCheck has not been rolled out as extensively as we would have liked. Another area of concern is the dialysis being provided in the middle of the night in the very hospital in Waterford to which Professor Drumm referred. Radiotherapy and cancer services are not up to international standards despite the money he says has been put into them. We are at least five years behind the doctor training schedule outlined in the recently published reports and for all the talk about waiting lists improving some people are still waiting four years for some specialties.
The Government promised 200,000 medical cards as a priority but that has been watered down to doctor only medical cards. The primary care strategy promised 600 primary care centres but that has been watered down to 100 virtual centres. Professor Drumm said more beds were needed. In January 2002, however, four months before the general election, the then Minister for Health and Children, Deputy Martin, published a report he had commissioned on the need for beds which stated 3,000 were needed before 2011. Up to now only 350 acute beds have been brought into the system so there seems to be a contradiction between both positions as to whether it is still Government policy or has been abandoned.
Has the internal audit of the PPARS consultants been completed? Has the HSE identified the beneficial owners of Blackmore Group Assets Limited? Has the HSE had any contact with the Revenue Commissioners and the HSE north west region over payment of taxes for consultancy fees relating to that company? The issue arose at the last meeting of the joint committee and needs to be cleared up.
The out of hours co-operative in north Dublin has been operating for the past 12 months and there seems to be a deliberate attempt to collapse it. For example, the contract contained a clause imposing €600,000 in penalties on GPs in that area, yet the contract they were shown gave no indication of what would give rise to these penalties. They have not been advised by the HSE what they have to do wrong to incur them. That is a strange way to deal with an out of hours co-operative such as the one in north Dublin, an area that really needs an out of hours GP service, because there is only one GP for every 2,500 patients compared to one for every 1,600 in the south side of the city, as Professor Drumm is well aware.
Much of what Professor Drumm said is very important and gives an accurate insight into how hospitals work but he is inclined to skew facts in his own direction. He mentioned local health officers circulating a letter to GPs to ascertain their interest in becoming involved in the virtual primary care centres. I received one of those letters, as I did four years ago when it came to nothing. Right across the country doctors went to the trouble of drawing up plans and advising the number of doctors who wanted to become involved. General practitioners do not believe it will come to anything this time either.
Professor Drumm misrepresented the IMO because I also received the e-mail to which he referred. The IMO actually suggested we meet the HSE and submit plans but should on no account enter into contractual arrangements until discussing the plans with the IMO, which is standard procedure for a union representing its members. The HSE's behaviour with regard to the contract negotiations for the out of hours co-operative in north Dublin leaves much to be desired, but we do not have time to go into that.
Professor Drumm also had a meeting on 25 September 2005 with the Department of Health and Children to discuss the grounds belonging to private and public hospitals. He has expressed some concerns over that this morning but does that mean he totally opposes private beds in acute hospitals? That would contradict Government policy.
The professor was correct about the way patients move through the system, which has been well known for the past ten years and was an issue when I was an intern in hospitals in this city. Patients were admitted through accident and emergency departments and then subjected to endless rigmarole but nothing constructive has been done about it. In fact the situation has deteriorated in the past ten years, because most patients are now advised to visit casualty to gain admission, it being impossible to organise a bed from outside the hospital. There is no such thing as direct admissions to our major hospitals. It is a well-known problem but nothing has been done about it in the past ten years and we should acknowledge that.
I will not bring up the consultant's contract for the children's hospital now because I wish to give other members an opportunity to ask questions. If there is time I hope to broach the subject later.
This arrangement is very unsatisfactory. Many issues have been raised this morning that deserve proper scrutiny, although we are not in a position to give such scrutiny to all the points. This should be noted. There were systems of accountability, flawed as they were, within the health service that have now been abandoned. This is not a satisfactory substitute. I have a number of questions and I thank the Minister and Professor Drumm for attending today.
The Minister stated well over a year ago that the resolution of the accident and emergency service crisis would be the litmus test for this Government. She established her own measure of performance, which nobody asked her to do. Since then, the problems in the accident and emergency services and units have been exacerbated rather than relieved. I do not know which planet the Minister is living on, but we as public representatives are constantly hearing stories of individuals and their relatives who are put under much stress and are now afraid to go to an accident and emergency unit because of what they might face.
In speaking to a young doctor one will hear about dirt, faeces on the floor, blood on the walls and disoriented patients who are unable to get proper privacy and left without dignity. This is the reality and the reason Mr. Brendan Gleeson struck a chord. That did not happen without a reason. That is the experience, particularly of elderly sick people who find themselves in circumstances where they feel abandoned rather than secure, protected and in the care of good medical practitioners. This is not to show disrespect to those working in accident and emergency services, but this is an ongoing and recurring story which we hear.
It is not good enough to come in here to promote some benign picture. We should get real on the issue and consider what has been happening. Does the Minister accept that concentrating on bureaucratic change has drained the existing Department and system of much capacity to deal with daily issues faced by patients? This not only concerns accident and emergency services, it is also about the patient, for example, who is waiting four years to see an ear, nose and throat specialist in Beaumont Hospital. That is happening and there are similar cases with other specialties.
The Minister issued a ten-point plan to resolve the accident and emergency crisis, but I do not think it was mentioned at all this morning. I thought the first point to be made would be a progress report on that plan. One of the main elements in the plan was that out-of-hours GP cover would be provided in north Dublin. Some days ago that tortured and delayed process collapsed. In 2004, the GPs of north Dublin approached the Department of Health and Children to sort out the matter, but we are probably in a worse position than ever in 2006 with regard to resolving the issue.
How many minor injury units have been established across the country? How far have we progressed on getting GPs in a position where they can directly refer to hospital patients who do not need to be in the accident and emergency department? The impression one gets is that the ten-point plan is a flop, and perhaps the Minister might comment on it.
Professor Drumm has spoken about the issue of acute beds. Perhaps we are people of simple minds, but we work in the political world, where commitments are made, assessments are done and decisions carried out. This commitment resulted from a report carried out on the need for acute beds which stipulated that 4,000 new beds were required. The commitment made by the Government was that 3,000 acute beds would be provided. I could not find out how many community nursing beds we need as step-down for patients who can be moved from hospitals.
As far as I can see, there is no agreement between the Minister and Professor Drumm on the issue of acute beds. Is there an agreement on community care beds? I would like to know what that is. Professor Drumm has spoken of being under pressure when consultants demand more beds. I do not mean any disrespect to Professor Drumm, but he should get used to the criticism. I have heard that doctors in important positions are being told to shut up, which is not acceptable. We must hear from these people, and we can then argue whether they are right or wrong. Any muzzling of a doctor with regard to what is happening in the health service is unacceptable.
Only yesterday the Taoiseach made the point in the Dáil that 411 patients are in the acute hospital service who should be in stepdown facilities. There is a need for beds, and the private nursing home sector will not be able to provide for high-dependency patients. I have no idea what the policy is on the issue and I do not even know if it is the HSE or the Department of Health and Children that is designing policy. What is the capacity requirement for community beds, high-dependency beds and medium-dependency beds?
On 29 November 2005, I asked the Minister — she referred me to Professor Drumm — how many beds in the community have been provided for our elderly, in particular the number in 1997 and 2005. I received an answer the other day, but it is so defective that I still do not know the total. The impression I get from the answer is that we have fewer beds in the community now. That may be wrong as there are gaps throughout the answer and it is impossible to know for sure.
How many acute hospital beds do we need? I am convinced we require 3,000 and will continue to do so until somebody tells me otherwise and explains why. We should not have to wait for yet another review or report, which is what Professor Drumm has stated. We should know the number of acute and community beds, and if we have that we will at least know what is the target. These people are very good at setting targets for other people, and it is a great idea to set a target and leave it to somebody else to achieve. People are waiting for many different periods to get different treatments, be they in accident and emergency departments or trying to get an appointment for a specialist. We do not know the number of people waiting for elective surgery. The Government promised to get rid of waiting lists, which it did because it stopped publishing them. Therefore we do not know the current position on waiting lists.
The small piece of research that the Minister and Professor Drumm keep coming back to is a minor study on patient satisfaction. I have no doubt that the vast majority of patients, when they can actually access care, are grateful for it. That is the impression I get. That does not include the people who cannot get the care and who are waiting, sometimes in appalling circumstances, to get the care they require. I hope the National Treatment Purchase Fund will not be used as an argument, as it only applies to people who already have an appointment. I know a man suffering from an appalling medical condition on his knee who is now waiting a year to see a specialist in order that he can use the fund.
I apologise if I am speaking for a long time but this is the only opportunity we have to air these issues, and it is important that our questions are answered. Professor Drumm is being very honest in his statements, but asking questions and raising issues does not get us very far. We must know the kind of progress being made with regard to managing the hospital service in a better way.
There are good models in the hospital service. I visited the hospital in Nenagh, and there were no trolleys there. There is a fantastic system in St. Luke's Hospital in Kilkenny. The question is why such a system, with good practice and good relationships between GPs and specialists, is not established in other hospitals.
I point out to the Minister and Professor Drumm that the HSE is now in its third year of existence. It started in shadow form but had a chief executive officer and structures in place. It is now in its third year, yet the impression is being constantly given that there are major obstacles in trying to integrate within it and that we must give it time. How long are we expected to give it in lead-in period? It was a disastrous decision. All of the preparatory work should have been done before it was established. It was a stupid move and we are paying the price. Is it carrying all of its responsibilities or are there some with the Department that should be with the HSE? Has the process been developed?
What is the position on progress on the privatisation agenda, which is obviously dear to the Minister's heart? How far have we moved on the project of building private hospitals on public grounds? If consultants cannot work in both, does it make sense to use valuable public lands in this way? Regardless of whether we want private hospitals, surely the way to proceed is to allow them to be built elsewhere and use public lands for other purposes.
Does Professor Drumm believe it is appropriate for the HSE to be spending its time promoting a private health care conference? Its website is promoting Ireland's inaugural private health care conference. Is that a good idea? Does the HSE not have other priorities? The private hospital sector has been assisted enormously by the State. The investors who will put their money into private hospitals cannot believe their luck, given the benefits that will accrue to them from cherry-picking within what they regard as a very lucrative market. Must we engage in this way in the further privatisation of the service?
What is the position on the industrial relations aspect? I am aware there is much frustration about the consultants' contract which has not served the country well. We all want full reform and radical improvements but how far have we progressed because that is the key? Until the issues involved are resolved, we will continue in great difficulties. The Minister said she intended to take certain actions at certain times but how are the negotiations progressing? The impression I get is that they were slow to begin. There is no sense of urgency or concentration in dealing with the hospital consultants and, for want of a better term, sorting out the problem, yet it is probably the most important task that must be concluded if we are to make progress.
I welcome the Tánaiste and Professor Drumm and thank them for their presentations. I will try to be brief.
I want to raise a subject which the Tánaiste is aware I have raised in the past, namely, alcohol. We spend approximately €6.6 billion annually on alcohol products, yet alcohol associated problems cost the country approximately €2.4 billion a year, which is a substantial amount. The problems include absenteeism, anti-social behaviour, street violence and dificulties in our accident and emergency units. I hope the Tánaiste agrees the drugs problem is the most serious we face. That may not be a popular comment, given our drink culture, but it is a problem that must be tackled.
Does the Tánaiste agree that she is not doing enough to address the problems caused by alcohol? She was very quick to drop the alcohol products Bill. She has said that if the voluntary code does not work, she will reintroduce the Bill but how long will she give the code to work? Why was she prepared to allow the alcohol industry to dictate on the issue? How long will it take to implement the recommendations of the task force on alcohol?
The task force report on obesity is another time bomb. Two out of five European children will be overweight in the coming years. If the problem is allowed to continue unaddressed, it will develop and result in an increase in the incidence of heart disease and type 2 diabetes. Like a bad doctor, the Tánaiste appears to be treating the symptoms rather than the root causes of the illness. I understand 0.25% of the total health budget is spent on health promotion. One quarter of 1% of total expenditure is spent on trying to keep people healthy rather than treating those who are ill. Again, we appear to have got our priorities wrong. Is it the Tánaiste's intention to change these priorities? While primary care is the most important issue, a point to which the Tánaiste alluded, it is also about health promotion. I do not see this happening in her tenure as Minister for Health and Children.
To return to the issue of accident and emergency services, Professor Drumm highlighted it well when he indicated there was a huge disparity between the way such services operated in hospitals in Waterford and Limerick compared to other hospitals. He referred to a process issue, in other words, an efficiency issue. What is he doing to address the difficulty? If he believes certain hospitals have an issue in that respect, how is he addressing it? He expressed his displeasure about it but how is he dealing with the hospitals that are dragging their feet? If it is not a capacity issue — Professor Drumm appeared to indicate that capacity was a secondary issue — but an efficiency one, will he tell the committee how he is approaching the problem?
Like other members, I welcome the Tánaiste, Professor Drumm and their officials. I am delighted to have the opportunity to speak on this issue. I will be brief because I am conscious that other members wish to contribute.
Professor Drumm has said a decision will be made early next month on the location of the proposed national children's hospital. By that does he mean in the next week or so as we move into April or will it be May?
With regard to accident and emergency services — on the basis that all politics are parochial or local — I wish to refer specifically to Sligo General Hospital. I note from the figures produced for the trolley count that during the past three days there was a wide variation in the number of patients on trolleys in the hospital. On Tuesday, the number was 23, the highest in the country outside Dublin, but on Monday it had only six patients on trolleys. While I am aware the reasons patients are on trolleys are multi-factorial and that it is only a snapshot, as Professor Drumm eloquently outlined, the reality, unfortunately, is that the number of patients being treated in the accident and emergency department in Sligo General Hospital has gradually become excessive relative to its capacity. I ask the Tánaiste to examine, as a matter of urgency, the submission of the management of the hospital on the provision of an acute medical assessment unit, which would be of enormous help.
I wish to deal with another issue mentioned in the Tánaiste's notes. I congratulate her on the adoption of the Hollywood report on radiation oncology services. I am delighted she has reached agreement with her counterpart in Belfast to allow patients from County Donegal to be treated in the new Belfast cancer centre. Some weeks ago we had a meeting with her on service provision for patients at the lower end of the north west, an area which covers Sligo, Leitrim, north Mayo, south Donegal and Roscommon, patients from which had to travel to Dublin for treatment. They will now travel to Galway.
A public meeting was held recently in Sligo. While the testimony of men and women who, unfortunately, have cancer was very moving, what I found particularly impressive was a statement by a consultant surgeon who had previously worked in Aberdeen in Scotland. He made the point that, as a result of the availability of radiation oncology facilities, 80% of women who had a lump that needed to be removed opted to have a lumpectomy followed by radiotherapy. Unfortunately, since his arrival in the north west his experience has been the complete opposite, with 80% of women opting to have a mastectomy followed, in some cases, by radiotherapy.
There is a petition in the north west with a view to getting people to indicate how strongly they feel about the need for a satellite clinic in Sligo. I agree entirely with the Tánaiste that best international practice must be followed, on which medical and nursing experts are working. I look forward to meeting her again in order that we can drive forward this project.
I welcome Professor Drumm's statement that arrangements are being made to hold meetings twice yearly with Oireachtas Members in each health service area. The number of Members who are not members of this committee who attended the meeting mentioned is indicative of the major level of interest in health issues. I have no doubt the meetings to be held twice yearly will be very productive.
In case the message is sent from this meeting that it is all doom and gloom in the health service, I recently met two consultants from the United Kingdom, one an oncologist and the other a rheumatologist. Both were incredibly envious of the position here on the availability of cutting edge drugs and technology which, apparently, will not be available in the United Kingdom for some time.
I welcome the Tánaiste and Professor Drumm. Specialists treating patients with tuberculosis attended a meeting of the committee recently. "Tuberculosis" is a very emotive word. While I fully support the Government's policy on the treatment of the disease, I was dismayed to hear from the specialists that the incidence of tuberculosis in Northern Ireland was three per 100,000 of population compared to ten in the Republic. In the south of the country the incidence is 27 per 100,000 of population. I was worried about the gaps in the Government's plan. For example, Mr. O'Brien will be well aware that the promised tuberculosis laboratory at St. James's Hospital has not materialised. As a result, we do not have a specialised laboratory in the country. There is also the matter of the promised extra beds to ensure correct treatment of tuberculosis in proper isolation units — positive pressure rooms — of which there are four in Cork and one in Dublin. This is important, given that if there was an outbreak of avian flu, we would find it difficult to isolate people properly.
It seems BCG policy has not been applied nationwide. I do not know what the best policy is, but it is important that we should know what it is for the whole country. It seems there is a great shortage of respiratory physicians in many parts of the country. Addressing these needs would not be expensive. There is a high incidence of respiratory diseases, as well as tuberculosis, on which I would like to hear the views of the Tánaiste and Professor Drumm.
We heard on "Morning Ireland" that a clinic in Cork was, apparently, administering stem cells as a treatment for multiple sclerosis. I am sure patients are being defrauded because there is no evidence that this treatment is useful. Prior to Christmas the Chairman and I went to the Department of Health and Children to ask what was the position on the EU tissue directive, but we did not receive a satisfactory answer. Not only may this treatment not be very useful, it may also be dangerous. What is the position on the tissue directive, on foot of which we are to introduce legislation covering the administration and storage of cells, bone transplants and other such matters?
I support the thesis that the proposed national children's hospital should be located on the site of an adult university hospital, but who will manage it? What will be the ethos of this tertiary hospital? Will it be that of the parent body on the site or will it be inclusive of the whole country?
I thank members for their contributions. It is important to point out that the issue that has occupied our minds for some time is that of accident and emergency services, an issue to which Professor Drumm referred. It is important to get a fix on and establish the number of beds required by members of the public.
I have taken careful notes and will answer as many questions as I can.
I acknowledge what Professor Drumm said about the financial outturn of the HSE for 2005. It was an issue for the committee and one which was discussed in the Dáil, Seanad and publicly. I acknowledge that the HSE balanced its books in year one. That is an incredible achievement, given that in the previous year in the health boards there was an overrun of €120 million. It would be remiss of me not to say I am proud that that is the case. We do not hear as much noise about the good news as we do about possible bad news. The point should be acknowledged.
On cervical screening, BreastCheck and cancer services generally, an issue mentioned by Deputy Twomey, cervical screening should be undertaken at primary care level. It is very high on our agenda in the current negotiations with the IMO on a new contract of employment for general practitioners. We have asked the HSE to put in place an implementation plan. I want to see this done as quickly as possible. There is no doubt that early detection is essential.
The BreastCheck screening programme will be rolled out from the start of next year. As in the case of all population screening programmes, expert staff must be recruited, facilities put in place and so on. The programme will be in place in the regions currently not covered at the start of next year. I was in Canada recently where I learned that the response rate to its programme was approximately 50%. The figure here is more than 70%, which is positive, but up to 20% of those contacted by
BreastCheck do not respond. I encourage women to do so every opportunity I get as it is a fantastic service and the results are great. We all have an obligation to encourage women to respond to it.
On medical education and the training of doctors, the Government has decided to more than double the number of Irish and European students taken into medical schools from 305 to 725 in the next number of years. Beginning this year, we have increased the number by 70. We have provided in the 2006 Estimate for the Department of Education and Science and the Vote for my Department for the roll-out of the increased numbers of clinical placements and academic clinicians. The Government has also decided to provide for graduate entry into medical school, with 240 places in the 2007 academic year. The Higher Education Authority has been asked to arrange a tender to select where this should happen.
There is no question of hospital beds being provided simply for the sake of it. Given what Professor Drumm said and what I know to have been the case in the past year, if we had an extra 5,000 beds, I suggest we would still have problems. We must use our resources effectively. If we have 411 older people in the Dublin hospitals who have been medically discharged by their consultants but 120 of whom are still in the hospital because we do not have an alternative place for them, no amount of beds will solve our problem.
There are a number of care of the elderly issues. Recently, I put proposals before the Cabinet — they are currently before it — on continuing care for older people in Ireland. We have 20,000 older people in institutional care in public and private nursing homes, approximately 4.5% of whom are over 65. All the evidence suggests that approximately 4.5% of people over the age of 65 require institutional care and we are in line with that average. However, in the past, 28% of those who went into institutional care had low levels of dependency but had there been home supports, they could have been supported at home. That is why this year we have provided a package of over €1 million towards home care and community-based supports to help people stay at home; these are currently being rolled out by the HSE.
The beds issue is related to the use of beds. While I do not wish to bore members with statistics, we doubled the number of day cases treated in the hospitals between 1998 and last year, from just over 200,000 a year to 500,000 a year. If more procedures are being done on a day case basis, clearly one must constantly review what one requires.
Dr. Codd's bed capacity report was based on existing practice at the time but we must factor in where we are moving to more community-based services, more resourcing of primary care and more day case activity and where we are providing alternatives for older people. A hospital bed costs the taxpayer approximately €1 million to put in place. A 500 bed hospital costs approximately €500 million even before one looks at staffing issues which are also considerable. Clearly, there is no question of providing beds for the sake of them. Of the 3,000 beds that were promised by 2011, over 800 have been provided and more will be coming on stream later this year.
Deputy Twomey made the point that the process has been well known for years. That is true. On how we managed health services previously, there were ten health boards and the former Eastern Regional Health Authority and they were the organisations responsible for running health services at local level. Having such a large number of bodies responsible did not make sense for a population of 4.3 million. I do not think we would ever have had the capacity to implement the kind of reform needed in this country under the old health board regime. It just was not possible. In my view, it would not have been done because much of this will be extraordinarily tough. It required an integrated unified organisation with a CEO and a team of managers who have direct responsibility nationally for the provision of services.
That was why it was important, taking up the point made by Deputy McManus, to empower that CEO and make him or her the Accounting Officer. I acknowledge that decision is still being criticised in this House. It was not officially welcomed — I know that to be a fact — but one cannot expect somebody to be responsible for the delivery of services if he or she is not accountable for the money.
I did not even raise that point.
Deputy McManus raised the bureaucratic and administrative mess.
Yes.
I do not accept that it is a bureaucratic and administrative mess. The HSE has been operating on a statutory basis for 15 or 16 months. As we have heard, it was the biggest change management process ever undertaken in Ireland, in the public or private sectors. By any standards, it is doing extraordinarily well. We are in the early days of trying to ensure that, first, we get to know what are the problems. Every time I hear suggestions for remedying the deficiencies it is about more of the same — just scale up what we have. We hear it every day in the Dáil — calls for more beds, more nurses, more doctors. There are more nurses in the Irish health care system than in any health care system in the world and more of the same will not solve the problem. The HSE's task, which has the full support of the Government, is about delivering change and getting better services for patients with the considerable resources which, thankfully, the economy is able to generate for the health services and other areas.
Deputy McManus asked on what planet was I living. I stated at the start of my appointment to the Department of Health and Children 18 months ago that there was no magic wand. If there was, reform would have been undertaken a long time ago. Health care is complex and reform is even more complex. I equally stated that we were determined and committed to put in place the changes that would deliver long-term improvements. Just because the marathon runner increases the pace on a lap does not mean he has not been running for the previous 20 laps. The reality is that when the figures hit 495, which was an unprecedented level, it required more thinking outside the box and urgent measures, which, as the committee heard from Professor Drumm, are being put in place at present.
I agree we need more consultants. According to estimates, we have 4,000 non-consultant hospital doctors and approximately 2,000 consultants and we need to switch that ratio around. Appointing consultants is also expensive. We need to do it on the basis of a new contract of employment. Particularly in the regions, there are many areas where we do not have any specialists or we might only have one person. No matter how good such a person is, he or she will not be able to provide a service. To provide a national regionally based service, we need to considerably increase the number of consultants in the Irish health care system. We have done remarkably well in cancer care, where we have appointed an extra 110 consultants in recent years. We appointed several more consultants in coronary care, etc. We need to do that right across the board and on the basis of a new contract of employment, which serves the needs of the Irish health care system in 2006 and which is not inflexible or inappropriate to our current needs. That is what the negotiations are all about.
On the waiting lists, all the waiting list initiatives in the past tended to make the problem worse. At one point we had 27,000 on the waiting list for elective treatment in hospitals. The National Treatment Purchase Fund has been given the job of devising a patient register and it is doing a remarkable job with that. It will have further progress on that later this year. It is estimated that there are probably 10,000 people nationally on waiting lists for treatment. There used be 27,000 or 30,000 people on such lists. In the case of 14 of the top 16 procedures in which the National Treatment Purchase Fund is involved, people are seen within a four to five month period from the time they have been diagnosed by a consultant to be in need of a particular procedure.
There are serious problems in the outpatients area. We have given the National Treatment Purchase Fund some piloting work on outpatients and it has seen approximately 5,000 such people this year. Since its process is all about procedures, it has been involved generally in the area where procedures are required. In areas such as respiratory illness, we are still encountering major problems and that is why we need more staff.
The issues in the Department that have not yet transferred to the HSE include the hospital planning office, the case mix and superannuation. These issues will transfer to the HSE but, obviously, with any new organisation one wants to transfer matters on a phased and gradual basis.
Will the Minister repeat those areas please?
Superannuation, the hospital planning office, the case mix and a number of areas like that.
What are the other areas?
Mr. Michael Scanlan
There will be some national work across any policy issue, across the range of issues in the Department.
Is the Minister stating that right across the board there are still responsibilities that are with her that should be with the HSE?
No. The hospital planning office will transfer to the HSE.
I asked about other areas. I am trying to get an idea of the scale of what still needs to be transferred.
Not a significant amount. There is the hospital planning office, the casemix group and superannuation, and some of the health promotion doctors are moving to the HSE.
On private hospitals and further privatisation, I am often amused by statements that are made about this. We have about 13,200 beds in the public hospital system, 2,500 of which are private beds. Under the Government's proposal we want to convert 1,000 of those private beds to public beds, which is the reverse of privatisation and yet we are accused of more privatisation. I could understand the outcry were we to introduce what Sweden under the socialist government is doing by bringing in private health providers to run all their public hospitals, but we are doing the opposite. The issue for the State is how we can buy services for patients. If buying diagnostic services in the private system makes sense then that is what we should do. It is all about trying to provide treatments for people as quickly as possible.
I share the views expressed by DeputyGormley on alcohol. We have a major problem with alcohol consumption in our society. It is a wider issue than simply banning products or the advertising of products. Recently, the Department funded an officer to be appointed by the GAA, an organisation with 1 million members, to deal with alcohol related issues within that organisation and its supporters, and we are happy to support initiatives of that kind. Clearly health promotion and the management of chronic illness is a major primary care issue and it is very much on the agenda for the discussions with general practitioners. A sum of €3 million has been allocated to the HSE this year for the implementation of the obesity task force report.
The Hollywood report has been embraced by the Government. I agree with Deputy Devins that every patient would like to be treated as close to home as possible when he or she is ill but, equally, he or she would like to receive the best treatment, wherever that may be. If quality assured services could be provided in every region, we would support that. When the Government agreed to the implementation of the Hollywood report, we agreed to satellite centres linked to major centres so that the skilled staff would remain in the satellite centres and staff would rotate between both types of centre. The population base in the north west did not justify such a facility. When the city hospital in Belfast opens next month, it will be the best facility on the island and in Europe. It has capacity which can be made available to patients from the north west. The HSE has been asked what might be required from the hospital and to buy services, which makes sense in the short term.
I am not expert in this area but it has been advocated by the experts that two linear accelerators are needed for safety reasons and so on to function as a centre. I am not certain that is planned for the north west. Our cancer outcomes are not as good as they should be because many of the treatments happen in relatively small places. A report on a particular hospital was published by consultants earlier this week, which compared value for money in a small hospital with a large hospital but one must examine the complexity involved when analysing value for money. A hospital that conducts cardiac surgery, lung transplants and other tertiary procedures cannot be compared with a hospital carrying out secondary procedures. All the international evidence suggests better outcomes are achieved for certain illnesses when patients are treated in larger centres. The Government's policy is to make sure procedures are carried out in the appropriate facilities and this is about using facilities to their full potential to do what is required, not closing them.
Senator Henry referred to tuberculosis; perhaps Professor Drumm or Mr. O'Brien will address that issue.
I refer to the ethos of the children's hospital. This hospital is in place for all the children of Ireland and it not acceptable that ethos issues could prevent certain treatments of a child. We now live in a much more multicultural society and it must be ensured that when the taxpayer is funding a tertiary facility for ill children, every child should have the opportunity, if he or she requires it, to be treated in that facility.
Professor Drumm
Deputy Twomey knows better than I that the waiting lists for specialists present a major challenge and it is the greatest challenge faced by the health service. At the acute level, people on trolleys is a huge human challenge but the person walking around with stiff hips for a year waiting for an appointment is also a major challenge. More specialists must be appointed to the units we have. Mr. O'Brien will confirm there is a major focus on increasing the number of specialists and, in line with that, reducing the number of junior hospital doctors.
We are told by the consultant representatives that there are only 2,000 consultants in the system which, by international standards, is low. Everybody forgets to include the 4,000 junior hospital doctors, which, in international terms, is astronomical and they cost as much as consultants. We have leveraged the system to be run by people who cannot be expected to be decision makers, to be fair to them. We must get to where other countries are at, which is to use junior hospital doctors to replace training doctors and not to provide front-line clinical services. Resources will be freed up to continue to build on the number of specialists. There is a training issue regarding how many are available but I will not avoid the issue other than to accept that waiting lists for specialists is one of the major challenges in the system.
We stated we would try to get the primary care centres to pull together to provide 100 this year. This means getting people together and then putting the entire structure in place. We hope this will be repeated annually in the next few years. Our capacity to do this will improve. The aim was to put in 500 or 600 centres to begin with and, therefore, 100 is not our goal. That is our goal for the next year if enough people sign up.
I did not receive the communication regarding the IMO. I only read about in the press. The outline in the press was that the organisation was advising general practitioners not to enter the negotiations. I am glad to accept that is not the case and if they support the process, that would remove a major challenge, which would be unfortunate if it presented itself. I defer to the clarification provided that the IMO is willing to get involved and its only role is to ensure its members are contractually protected. We want to be extremely flexible to encompass as many working relationships as possible with general practitioners because we realise various general practitioners will approach this from different angles. We will not try a one-size-fits-all policy, which will slow the process.
I refer to the out-of-hours service collapse in north Dublin. This establishment of such a service is still being negotiated in private and I do not want to go into this. While, from the general practitioners' perspective, penalties may have been one issue, as they are across all areas, other more significant issues arose from our perspective and we could not proceed with the service based on what was on offer to us. However, we still hold out the hope that the north Dublin GP service can be provided by north Dublin doctors. That would be the ideal for us.
Deputy Twomey commented on the number of general practitioners in north Dublin. We have a problem in this regard because we hear about how the poorer population in the north inner city does not have access to an adequate number of general practitioners, yet I have received several letters especially from female trained general practitioners complaining that they cannot set up a practice in north Dublin because the numbers are restricted based on GMS billing numbers. I am in the remarkable position of constantly listening to the criticism that this deprived area cannot be served by general practitioners while having these young fully trained doctors who want to work but are precluded from doing so based on agreements between the HSE and the IMO. Does the union representing general practitioners want more GPs in north Dublin? If so, we will support them in every way to become established. From our perspective, a contractual arrangement with the GP representative body precludes us from appointing these people. Many people would love to take up that work.
They are available but the union issue means the HSE cannot appoint them.
Professor Drumm
A general practitioner cannot go in there and bill a patient. One can join a practice as an assistant. One might do that in an area with a low medical card base and high private patient numbers because one would survive but it is not economically viable to ask someone to go into a medical card dominated part of this society when he or she is precluded from billing for those services. There is a problem. I hope we can advance our contractual negotiations with the GPs, the vast majority of whom want a service in these areas. Our experience of engaging with north Dublin GPs has been very positive, which is why I hope many of these issues can be resolved. This is what is preventing us getting more services established.
The internal audit report should be presented at the board meeting next week. I should be able to provide Deputy Twomey with the report within the next ten days because the board meeting will be held next Thursday. I do not want to comment on it in detail, except to say that it is well known from the Comptroller and Auditor General's report that there are significant problems to be addressed in regard to procurement processes in general for consultancies and PPARS which were not adhered to. The details on payment of taxes, etc., by consultancies will be dealt with in the report. I will make it available to the Deputy after the board meeting next Thursday.
In reply to Deputy McManus's point on the Blackmore group, there do not appear to be any Irish residents involved in that British Virgin Island company. As it was pre-HSE, the system fell down because tax clearance certificates were not obtained. This matter will be part of the internal audit review, and the information is available to us.
On the beds review, this is not just another review about another review. The beds review available to us was based on existing policies on the provision of care. If a beds review were carried out today, based on what is done in the hospital system, it would come up with the same answer, namely, that we need 3,000 to 4,000 beds. I intend to totally reorient the system towards primary and community care provision whereby the average length of stay will be reduced to that in the remainder of the western world and we will not keep people in hospital beyond the required time. I need a clear indication of the acute beds capacity based on these changes. However, one can never be 100% accurate because one must depend on the changes working. Given the increasing population numbers and an aging population, I accept that we will need more beds. However, in light of the reform process that is being put in place, it would be totally irresponsible for me to ask for the kind of money I need for primary care teams, community services and long-stay facilities if I did not review the acute bed capacity issue. I hope to make a significant impact on the acute bed capacity issue. I believe the information can be provided quickly because there are model systems in other countries where this has been done.
Muzzling the consultants is unlikely to work. It might be something I would consider but I doubt if it would help. While people should be constructively critical of the structure, they should not say it is all the fault of the consultants and what others do is perfect. It is not acceptable for people to say there are not process problems in other systems. Perhaps others should change as well as the structure, which is the challenge I am putting to people.
We are proud of the quality in health care. The survey was carried out among 4,200 people — members know more about polling than I do — which is a good sample.
I am sorry to cut across Professor Drumm, but I do not want to lose the community nursing beds issue.
Professor Drumm
I will come to that next. Mr. Aidan Browne, who is the primary and community care representative, will comment on the units that have been built and so on.
Mr. Aidan Browne
It is difficult to comment retrospectively. I cannot comment on the numbers involved between 1999 and 2006. The reason for this is that during this time facilities have been modernised and upgraded. Very often a new facility replaced an existing facility. The Tánaiste made the point earlier that many of our facilities over many years were equipped to look after low dependency clients, with beds very close together. There was no capacity for nurses and care staff to work with high dependency people. There is almost a perverse incentive to keep low dependency people in elderly care facilities and not admit high dependency people.
We have been trying to develop new facilities that are equipped for high dependency clients. The public sector is the best location for high dependency clients. It is best equipped and it has the best organisational management and supervisory structures to ensure that people with the greatest need receive the greatest levels of care. We should look to other sectors to provide the more homely-type services where people need less intensive nursing, medical or therapeutic care.
There are proposals in the 2006-10 capital plan, which is yet to be signed off, for an additional 27 new facilities which will have approximately 1,500 beds. There are 12 replacement facilities which will replace some of the older workhouse facilities. Some of the existing buildings will be upgraded to make them more suitable for use. I recently established a project group to identify community bed requirements for the next ten to 20 years, taking into account some of the more recent policy decisions which are primarily about investing in home-based community services. Traditionally, any estimate of bed requirement was based on a very poor community-based service. Following the recently approved home care packages, during the first three months of this year, we have put in place 230 home care packages. These are, effectively, high support beds at home. We are on schedule to provide 2,000 this year. Given the start-up issues involved, we planned for 200 for the first three months of the year, including home help facilities. We are moving in the direction of appropriate facilities for older people in appropriate locations.
Professor Drumm
Deputy McManus referred to the privatisation agenda, namely, private hospitals on public sites and the fact that the Tánaiste and I might have differences of opinion. It would be unhealthy if we did not have them regularly because we are aiming to obtain the best solutions, not necessarily to have an affiliative approach.
Some 52% of the population are with Voluntary Health Insurance. In essence, these people have a right to do what they wish in terms of where they receive their health care. They may come to us for it or they may go to the private sector. The Health Service Executive has been asked to establish a publicly-funded health service that comes up to international standards, which is 100% my focus and the organisation's focus.
If the private sector wishes to engage in building private hospital facilities, and if some people want to get their private health care in a private facility, it takes a certain amount of pressure off us. It could be an advantage if they use our diagnostic services because there will be advanced diagnostics in some of these sites. However, we will seek payment at the full economic cost for the use of these diagnostics. There would be gains for us in that regard. For instance, there will be a need for them to use our intensive care facilities, which will be much more advanced, but we will have to receive full payment for the service. While it would be a constructive relationship, it is something the private sector must work out for itself.
How will the HSE deal with the equity issue? Will there be fast-tracking into diagnostics?
Professor Drumm
The private care sector wants to build private hospitals with their own diagnostic facilities. I presume the sector will use few of our diagnostic facilities. If it does, it will be at a cost and would, I suspect, be for facilities such as PET scanning. There is no way that anybody will be fast-tracked through the HSE system just because somebody has built a private hospital on the other side of the lawn. That will not happen.
One of the issues that will bring clarity to the area — everybody has bought into this — is that the board has confirmed that our consultants, who are category 1 consultants, will work in the public system. The private system will employ its own consultants to work in the private hospitals. There are category 2 consultants who, as I explained, can work anywhere. Where they exist, it is in within their contractual rights to move over and back.
I apologise for delaying on this, but there is another issue. A hospital will be rewarded financially for providing diagnostics for private patients. This will be an incentive for the hospital and because it will make money there will be fast-tracking. It happens already.
Professor Drumm
Perhaps there is a significant reward for consultants within the system for fast-tracking——
And for diagnostics.
Professor Drumm
Unlike in the private system, the payment for diagnostics to the hospital in the public system is relatively small. Public hospitals do not get paid anything like the economic rate. Therefore, payment is not nearly as big an incentive as it might seem. If, however, the structures on which we are all agreed are established — I may be creating a problem for myself here — they will be paid the full economic rate. I agree that then there will be a potential incentive for the hospital. We must have a governance structure within our public hospitals that states that we will not give a private hospital primacy of access over our patients. We are no longer talking about the same patient population in one hospital, but about two separate institutions. It would not be in the HSE's interest to disadvantage its own customer base and that will not be the case.
There will be interaction between the public and private hospital where private hospitals appear. Our goal, however, is to run our service with our staff. If the private sector and people in VHI wish to have their own arrangements, that is something in which I should become involved. It would probably reduce the HSE workload somewhat.
The Deputy has caught me out on the issue of the inaugural private health care conference. I do not know if it is up on our website or whether it suggests we fund it. I would be surprised to discover we were funding it. I had better check it out as I do not know the answer. It is not something the executive would see itself in the business of running.
Deputy Gormley raised the relevant question of what we are going to do about the problems we have identified in the system. That is the challenge. The first objective is to get the primary care teams and community services aligned — we have significant staff at community level. This will only have an effect on numbers coming to hospital if we provide our primary care people with significant access to diagnostic capacity. Large numbers of people are referred on by skilled general practitioners because the only way they can get an ultrasound is to send them to hospital. A junior hospital doctor in the accident and emergency unit will probably have to admit the person before the ultrasound will be carried out. Therefore, we need to increase diagnostic capacity. We are beginning that process and it has already begun in some places, for example in Cork.
We must also enable people to stay at home, even when they are sick. To achieve this, we are putting in place acute intervention teams which can be called on by general practitioners and accident and emergency departments to attend the patient at home. One of these teams is almost ready in Cork and will start work when the remaining IR issues are worked out. The teams consist of public health nurses, a social worker and home care workers. They will look after people in the home such as those who would otherwise have to go to hospital because they need IV antibiotics or special care. The doctors or accident and emergency units will be able to call in these teams when they have a patient who could stay in the home if they had the support. The first of these teams will start in Cork within the next six months and this will be followed by teams in north Dublin, south Dublin and Limerick. These teams will bring a significant change to the system that will allow our primary care structure to deliver. Furthermore, if the primary care structure has a diagnostic capability, it will change capacity and use of our skilled workforce.
We must crack the problem with the out-of-hours system in Dublin. There is a need for 250 contacts with primary care in north Dublin each night between the hours of 6 p.m. and 9 a.m. but there is no capacity to deal with that, apart from 30 to 40 contacts.
Despite the fact that we constantly come up against the IMO on issues that need resolution, I must be fair to it on the matter of the new general practitioner contracts. It has engaged constructively in the idea of a new contract which will reward people for taking on the management of chronic disease in the community.
In talking about efficiency, our system ——
The point I was trying to make had to do with the fact that Professor Drumm mentioned that certain hospitals were out of line. Some hospitals were good and efficient but others were not. How is the executive dealing with those hospitals that are not efficient? Are they called in for a dressing down?
Professor Drumm
I will come to that issue. On the hospital system, chronic disease patients such as diabetics should not have to come in to hospitals. We must get performance related funding running across the hospital system. The people in units in Waterford and Limerick who have produced results in terms of average length of stay must know they will be rewarded for that. There is a limited attempt to do this currently, but the reward system must become targeted on performance indicators.
In the next month or two we will begin pilot projects to put in simple performance indicators. These will have a significant impact in terms of where money goes in the system. Hospitals must realise that they have power. The reward system is not a threat. It lets hospitals know they can significantly improve their structures through a better performance. Identifying the indicators has been a challenge. We have been doing that in the past six months and are now ready to pilot some projects.
Will the HSE publish those lists?
Professor Drumm
Yes, we will publish the performance indicators. The number of consultants must also increase. Consultants get a bad press. In hospitals the majority of consultants provide the cornerstone of the health service, just as general practitioners do in the community. Our experience is that their commitment to the health service is underestimated by the community. However, we need more of them. It is not fair to blame the ills of the health service on them.
Performance related funding will be a significant issue, not as a threat but as an opportunity. If performance picks up, it will be only fair if we come back to the Department seeking further funding. That will be an honest application for funds.
In April the children's hospital report will be issued. John O'Brien may wish to comment on it. He may also wish to comment on the development of a medical assessment unit, AMAU, at the Sligo hospital.
Mr. John O’Brien
We have almost completed the children's hospital report. We have a meeting on Friday at which we are likely to come to some findings and it will take approximately a week to put the report together. We expect to report within the timeframe we had indicated. I would hope that the report will be available by the end of next week or early the following week.
On the issue of the AMAU in Sligo hospital, the HSE has received submissions from a large number of hospitals, particularly those undergoing difficulties with accident and emergency around the establishment of AMAUs. This is a concept with which I am very familiar in that I established the first AMAU in the country at St. James's Hospital. I know what needs to put in place for them and what value they can bring. I refer to what Professor Drumm said that if along with the AMAU one does not introduce the types of changes in practice for processing patients through the accident and emergency department such as in-house consultants admitting patients, one will not reap the full value of an AMAU. As part of the focus and initiative on accident and emergency on which the HSE is currently working, we are looking in detail at these proposals. We are visiting the institutions and hospitals to see the range of issues that are creating difficulties for them. If AMAUs are the solution and resolution, then we will move forward with them very quickly.
Professor Drumm
Deputy Henry——
I am being promoted.
Professor Drumm
I will be in trouble. I will ask Mr. O'Brien to comment on the TB facility in St. James's Hospital.
Mr. O’Brien
St. James's Hospital is proposing a 16-bed TB unit which would be able to take the acute TB transfer from Peamount Hospital which is across the city. This is a priority issue for the HSE estimates for 2007. The hospital has already established a three-bed unit which will go into operation in the course of next week. It is fully constructed and commissioned.
Approval has been given for a consultant post in St. James's Hospital with a special interest in TB and to be predominantly associated with TB. It should not be a worry in terms of consultant proficiency because we already have two of the most eminent TB experts in the world on site at St. James's Hospital, Professor Clancy and Dr. Joe Keane. This aspect of the service is capable of handling what needs to be done. There is a need to proceed to set up the 16-bed unit and create the facility capable of dealing with TB cases.
A sum of €300,000 has been provided for St. James's for the establishment of a TB reference laboratory. There is a distinction between a reference laboratory and the provision of basic TB laboratory services and microbiology. The hospital has an extensive range of TB laboratory capabilities in microbiology. The TB reference laboratory is a separate issue which Senator Henry will understand very well. This has been established at a low level in St. James's at this stage. The intention is to supplement it with relatively small increases in funding to bring it up to a full level of TB reference laboratory status. Provisions are also in position to provide accommodation in which to house the type of equipment and facilities necessary for its function.
Is there any news on the EU tissue directive, which is legislation covering the use and transport of cells? The legislation should be in by next Friday.
Work on this matter is under way in the Department. The directive is due to be implemented by 6 April 2006, next Thursday. I will come back to the Senator on that matter as it is a while since I spoke to my officials about it.
It is quite important.
I agree it is important.
It needs to be dealt with urgently, especially in view of the news about cells from unknown sources being used.
I did not respond to the issue of the stem cell activity in Cork. We will be in touch with the Irish Medicines Board as it is the regulatory body in this area. I understand a Swiss doctor is involved in what is happening in Cork. I only heard about it this morning on the radio and I have not had an opportunity to pursue the matter yet but I will do so later today.
I thank the Minister.
I wish to make the point that nine members and two non-members are presenting.
That is the reason I kept my contribution brief in order that a supplementary question could be asked.
I ask the Deputy to be brief because a third round of questions are being asked and people are becoming annoyed, to say the least.
The initial contributions were brief to allow for this. Most of the speaking time has been used by the Tánaiste and Professor Drumm.
The Deputy should be even-handed as he has been asking for answers to questions for the past three months.
What is the purpose of this meeting?
Deputy Twomey said he would keep his contribution brief and he did so. To be fair to him he said he would speak again at the end.
Members of all parties are signalling to me while the spokespersons are making the point that they want to be heard.
I will give the Chairman my questions and he could ask them at his party meeting.
I will return to the Deputy. I must try to allow people who have not yet spoken. I will move as quickly as possible to allow the Deputy speak again. I cannot be all things to all men.
I will be as brief as possible and I do not intend to go over issues which have already been dealt with.
This committee meeting has still to discuss significant aspects of health care. No reference has been made to the intellectual disability sector which has quite a number of issues to be discussed such as rights. The Minister's script did not make any reference to this sector. Nor was there any reference to mental health and the issue of suicide. I am not surprised that the budget for mental health, a significant sector, has slipped from 11% to 7%. It appears that a blind eye is being turned to this sector.
No reference has yet been made at this meeting to MRSA, despite the fact it is as big a problem as accident and emergency units. Many people are fearful of going into hospital in case they might contract MRSA. Many in rural Ireland are concerned about what will happen if they get sick or if they have an emergency. They are afraid their lives will be at risk. I have heard nothing this morning to reassure me, many people in rural Ireland or those working in rural hospitals that their situation will be considered. Will there be another case like that of Pat Joe Walsh? These are real issues which affect real people.
The meeting has heard about the per capita expenditure and Ireland’s high placing in the expenditure table. It should not be forgotten that this is our own money which we are spending on our health services and it is 25% of national expenditure. I am not sure whether we are getting value for money.
Reference was made to whether it was sensible to have 11 CEOs and 11 health boards and also an array of programme managers and other senior personnel. I am not aware of any redundancies within the health service. I have no doubt these people have been dispersed throughout the areas covered by the HSE. There is considerable confusion and demoralisation. Many people in the service may not know what is expected of them.
These areas need to be addressed as the problems are filtering right down to the lower grades in the service. Many staff members do not know the person to whom they report and are unclear about their roles, which are not yet clearly defined. While the HSE has been operational for some time, we have seen no sign of the issue improving and it needs to be addressed urgently. People regularly tell me that things were better when we had 26 county managers. We are strangling ourselves with managers without knowing what are people's roles.
We have different problems in different accident and emergency units around the country and different hospitals are handling the accident and emergency crisis in different ways. I have heard frequent reference to the hospitals in Kilkenny, Waterford and many of our smaller hospitals. While I do not wish to steal Senator O'Meara's thunder, yesterday saw the publication of the report, Small Hospital, Big Service, which is well worth examining. I am sure the Senator will supply the witnesses with a copy of the report. It is interesting to read about how patients are admitted to Nenagh General Hospital, and the relationship between GPs and consultants. A GP can phone the hospital matron and ask if a bed is available for a patient. The GP may be told that while no bed is available today one may be available tomorrow, which avoids having the patient wait on a trolley. We must examine the system.
Professor Drumm has rightly referred to patients seeing up to five doctors in an accident and emergency unit, which is a ridiculous drain on resources. We see the problem and do nothing about it. Carrying out a daily count of accident and emergency patients, which will vary depending on the time of day it is done, is not a response. With all the expertise we have in the health care system, we should be able to troubleshoot accident and emergency units. I know this matter has been dealt with at length.
A person presenting at an accident and emergency unit with a broken nose will be required to return four or five days later when the swelling has subsided. Why should that patient need to wait for 12 or 14 hours at the accident and emergency unit before being informed that this is the case? We should have a system that streamlines the old, the young and those with minor injuries. Why should we need to wait before tackling this problem?
The Tánaiste referred to the sale of all stand-alone mental hospitals. While I know the numbers of patients in these institutions has dramatically decreased in recent years, we should not sell those mental hospitals now. Those sites are in prime locations in big towns throughout the country and should be kept in public ownership and used for the decentralisation programme. They should be regarded as hubs for the delivery of health care services. Some of our general hospital services could be transferred to the sites of psychiatric hospitals. I am aware of how the delivery of service has changed in that field.
Professor Drumm stated that the parliamentary affairs division had replied to 1,500 parliamentary questions in 2005. The quality of answer is shameful. Deputies do not receive answers to the questions asked. I have an image of people in the division asking how they can frustrate the Deputy asking the question. We are given enormous amounts of irrelevant information that is not pertinent to the question. While reference to 1,500 parliamentary questions gives the impression of openness and transparency in informing us about how the service operates, it is not like that. I am fed up reading the standard reply that indicates it is not an issue for the Department of Health and Children and the Health Service Executive will respond in due course. When the answers are eventually received they can be very frustrating.
Professor Drumm mentioned that we have 100 members of staff for 100 patients in accident and emergency units. To which hospitals does this apply? It certainly does not apply to any hospital of which I am aware. A service operating 24 hours a day requires five people to give cover for one position. However, those types of numbers are not present in most accident and emergency units. It is unfair to many people who are working very hard and are snowed under with work to give the impression that there is a 1:1 ratio of patients to staff in these units. Many staff on the cutting edge in them are suffering considerable abuse with many violent incidents occurring.
Prior to this meeting we were asked to submit issues we wanted to raise with the Tánaiste and Professor Drumm. I raised six other issues. I take it that——
We must move on at this point. They can be taken at the next session.
Given that I have notified the Chairman of six other issues, I ask that I be given some form of meaningful written response.
I accept that the Deputy advised of the issues more than a week ago. However, in fairness to the other eight people, I need to move on. We will look for a written response. The Deputy can report back to the committee next week and if the responses are inadequate he can say so.
I certainly will.
Deputy Connolly has a timeframe at least.
I welcome the Tánaiste, Professor Drumm and their staff. Regarding the hospital hygiene audit, I ask Professor Drumm whether each hospital has an infection control officer. The maintenance of hygiene in hospitals is an operational matter. It becomes a political matter when things go wrong. In my experience it is a matter for hospital staff to ensure that the optimum levels of hygiene obtain. Is the disposal of waste, especially human waste, a nursing duty as was the case when I was training?
I have submitted a number of items on which I can wait for a written response. However, I must again ask the Tánaiste about type 1 and 2 diabetes. These closely related conditions are seriously on the increase. All action thus far has been reactive rather than proactive. What proposals does the Tánaiste have to address this ever-increasing problem? For the past two years I have called for a debate in the Seanad on type 1 and 2 diabetes. Senators Henry, Browne, Feeney and others present will confirm this. Thus far I have failed to achieve such a debate. Has the Tánaiste been asked by the Leader of the House to attend the Seanad for such a debate? Also on the issue of diabetes, the midland region is the only one without a consultant endocrinologist. I would like that issue to be addressed.
I welcome the representational forums. As somebody primarily elected by local authority members, I realise they are regarded as toothless tigers. Will visiting committees be drawn from the representational forums as was the case when we had individual health boards or will there be no ongoing inspection of private and public institutions? Private institutions receive subventions, which are generally provided from the public purse. Therefore, it is my view that visits should be made by people drawn from the representational forums.
It has been established that drugs can be acquired from pharmacies without much difficulty. We all recall the case of a journalist who decided to prove how easy it was to forge a prescription. It is easy to say it is an operational matter for the pharmaceutical profession. Those of us in the Government parties who represent the consuming public need to address this unacceptable situation.
Deputy Connolly spoke about psychiatric hospitals. The Tánaiste has outlined her intention to phase out such hospitals by 2010. I forget the exact term she used. Given that an acute psychiatric unit is being developed under the second part of phase 2 — it is not due until 2011, but it is worth mentioning today — where is the sense in that? The plans for the future of the psychiatric services provide for the devolution of such services from psychiatric institutions to the community. All sides have stated that while the community service is better, it is much more expensive. The mental health budget has decreased significantly, however. The Tánaiste has mentioned some increases, which are very welcome. The psychiatric service, which has been a Cinderella service, generally speaking, needs to be addressed in a realistic manner.
Suicide is ravaging this country. The suicide rate among young males is seven times that of young females. When I had the honour of participating in a recent visit to Scotland, it was proven conclusively to me that the measures taken there have led to a significant reduction in the incidence of suicide. If progress can be made in this regard in Scotland, why can it not be made here?
I agree with Professor Drumm that the deficiencies in our primary care structures are causing many of our difficulties with admission procedures. I hasten to add that when I represented this committee on a recent trip to France, I saw that there were people on trolleys in one of the main hospitals in Paris.
For eight hours.
There were people on trolleys there. Another piece of significant information that I picked up in France was that general practitioner charges there are approximately 70% of GP charges here. I am not slagging anyone when I mention that. I accept that different circumstances obtain in France, but it is something that needs to be looked at. I was sorry to hear about the poor standard of the out-of-hours GP service in a certain part of Dublin. The service in counties Longford and Westmeath, which was put in place by the Tánaiste's predecessor as Minister for Health and Children, Deputy Martin, on foot of lobbying done by me and others, is working very well.
I am glad that we are moving towards an acceptance of the recommendations of the Fottrell report. For the first time in my 27-year political career, I was asked to do something that is not strictly part of my role when I was asked to approach a GP to take on some patients. I do not think that is my job and I should not be asked to do it, but I have been asked to do it at least ten or 11 times in the past 18 months. The need for people to make such requests needs to be brought to an end as a matter of urgency.
The needs of the elderly, the intellectually disabled and mentally ill need to be prioritised. There is some dissatisfaction with the services being provided at present. I am regularly contacted by representatives of disabled people. It has been brought to my attention that certain airlines have decided not to allow disabled people to travel with them. It is outrageous if that is the case.
Will the Tánaiste outline the proposed models for the care of the elderly? Many models are available in Britain and further afield. The Tánaiste also mentioned step-down facilities. I would be interested to hear details of such facilities she envisages. We should not blame people in beds, some of whom have been accused of being bed blockers. The use of such a phrase is grossly unfair to the people in question, many of whom built this State and have been its pillars since its foundation. I would like the Tánaiste to explain her proposals in respect of step-down facilities for such people.
I compliment the Chairman on the manner in which he is handling this meeting.
Top of the class.
I am glad someone noticed.
I have not had to nod or wink at the Chairman. I want to be associated with the welcome that was extended to the Tánaiste and Professor Drumm. Many important issues have already been raised. I will follow the lead of Deputy Devins by thinking local for a few minutes.
I remind Professor Drumm that I submitted a number of questions in advance of this meeting and I hope I will get answers to them. I can say genuinely that I have raised such local issues because I cannot get answers in any other way. I would like to mention some concerns and issues. There is a need for senior citizens to be catered for at the facility in Kilnamanagh. The Tánaiste has supported the calls I have made recently for the provision of a health centre and GP services at Fettercairn in Tallaght. It is a shame that such services are not available to the community in a local authority estate there. I want to know what is going on in that regard. Given that several years have passed since the fire at the Millbrook Lawns health centre, why has the redevelopment of the centre not yet taken place? I would like that question to be answered.
I would also like to ask about the action plan to deal with the crisis in the accident and emergency unit in Tallaght Hospital. My colleagues are aware that I am especially concerned about the image of Tallaght Hospital that is being portrayed at present during the ongoing accident and emergency crisis. I hope Professor Drumm can give me some specific answers in this regard at some time in the future if not today. Other members of the committee have mentioned the accident and emergency crisis in the context of their local hospitals. The committee should consider organising a visit to accident and emergency departments. The case for visiting the department at Tallaght Hospital in that context would be very strong in light of the image of the hospital that is being depicted at present.
The presence of Mr. John O'Brien at this meeting as part of the Health Service Executive delegation reminds me of the issue of the day. I can be found at 8 a.m. most days rambling around Tallaght, taking in the air and checking whether my constituents are happy but this morning, when I happened to listen to "Morning Ireland", I heard the latest part of the continuing debate about the location of the proposed new children's hospital. As a representative of Dublin South-West, I have kept out of the debate because I believed that was the right thing to do. However, now that the debate is taking place in the public domain — anyone who listened to "Morning Ireland" this morning will know it is the talk of the nation — I would like to make the case for locating the new hospital in Tallaght.
I would like Professor Drumm and the Tánaiste to outline the current position in respect of this issue now that people are no longer talking about it behind their hands. It is clear that representations are being made by interested parties. I can genuinely say that even if I did not live in Tallaght or I was not a Deputy representing the Tallaght area, I would believe that the case for locating the new hospital in Tallaght is a strong one. The representatives of Tallaght Hospital have documented and clearly stated that Tallaght is the only choice for the children's hospital. They have pointed out——
I think we are going to put Deputy O'Connor in charge of——
Go ahead, Charlie.
I am entitled to speak for a couple of minutes. I will not speak for as long as anyone else. I am not afraid to speak up for my community. If other parties do not want to support me, that is okay. I will tell people that.
This issue has been debated in the media for the past month. There has been a full report on it.
The McKinsey report set out nine criteria — space, services, co-location, access, efficiency, people, teaching and research, financial stability and full project plan. The case for Tallaght is complete in that regard and I hope this is being done. I wish to hear from Professor Drumm and the Tánaiste about how they are dealing with the fact that this debate is now so much in the open.
I would also like to hear their reactions to the points made by Noel Smith this morning because that is what the public will be asking us about. People will be asking me why the Health Service Executive is not taking up their offer? Why are they not saying it should be built in Newlands Cross which is so close to Tallaght? I could raise many other issues. I will not try to make up for the time I was heckled. This is an important meeting and I hope there will be more of them.
I welcome the delegation. The huge attendance is a reflection of the complete frustration of people——
That is wrong. The Senator should be fair.
(Interruptions).
——who cannot get simple answers. Ultimately this is the only forum in which the health service can be held to account because the regional forums are merely talking shops.
There was no issue at stake in regard to how books were being balanced. Let us be fair on all sides. It is not a matter of——
I would expect the books to be balanced.
This is important. We should take these matters seriously.
Let us try to be fair about it.
Many local issues are being raised and I am sure the media are wondering why. The reason is that we are waiting months to get answers to our questions. I have been waiting six months to get answers to the questions I am about to ask. Unfortunately, I am being forced to ask them again. I have five questions and I will be very brief.
It is not the same story for all of us.
The Government has absolved itself of responsibility in many cases.
We have only three hours.
Can I just ask a quick question about accident and emergency services? I was amazed to learn lately that people who are forced to go on trolleys in accident and emergency units are being charged €60 per day. We should not have any charge for people who are on trolleys in accident and emergency units, or there should at least be a reduced rate. I would favour not making any charge. It is disgraceful that people who end up on trolleys in accident and emergency units with no privacy or dignity pay the same rate as if they had beds. What are the Tánaiste's and Professor Drumm's views on this matter? If I understood Professor Drumm correctly he referred to having made a profit or budget surplus of €39.8 million last year. I make the point in that context.
While Professor Drumm and the Tánaiste have correctly pointed out that patients are seen within three hours of being admitted to an accident and emergency unit by a doctor, that is not really the issue. The issue is the turnaround time in accident and emergency units. There was never a difficulty with patients being seen by a doctor, the problem is being dealt with and being discharged. I tried to find out about the average length of time people spend in accident and emergency units from the time they sign in to when they are discharged, but no information was available on this.
Recently, a friend of mine who is a chef went to an accident and emergency unit when he cut his finger. Even though this was a routine matter, he was kept waiting for 13 or 14 hours. He was seen relatively soon after arriving in the unit, but then he had to wait hours on end for treatment. He could have been discharged after being treated instead of blocking up the accident and emergency unit.
The Tánaiste referred to 495 patients on trolleys as being the magic figure that spurred her into the sudden realisation that there was a crisis in accident and emergency units. Why has she dismissed the consistent figures of 395 and 295 people on trolleys in recent months? Surely once more than one or two people are on trolleys we should be treating the matter as a serious one?
Professor Drumm referred to 100 primary care teams, as opposed to 100 primary care centres. Will he clarify the position because the centres were promised by the Government? Has there been a change to teams rather than centres?
Caredoc in Carlow has worked very well. That said, people in Carlow are very keen to have an accident and emergency unit in the future. We are realistic but we would hope that just because things look perfect in Carlow, we would not be denied an accident and emergency unit. If there is a spare accident and emergency unit, we will take it in Carlow.
We had a very good meeting with the Tánaiste a few months ago about MRSA. A total of €5 million has been allocated towards the treatment of MRSA. Are there specific target areas for where that money will be spent and who will be responsible for it? Is it intended to impose penalties if targets are not reached and will there be any element of accountability?
The Tánaiste was also amazed to learn about the axis of information on patients. Patients should be aware of the rates of MRSA in different hospitals. They should also know how many patients have died, not necessarily from MRSA but who had contracted it, because there can be other complicating factors as well. People are entitled to this information. If a person books into a hotel, he or she will know if it is a grade 1 or a grade 5, and there should be a similar rating for hospitals. Ratings should take into account cleanliness, hygiene, rates of MRSA and so on.
MRSA also affects employees. According to health and safety requirements, people employed in hospitals are entitled to have a safe working environment like any other employee. I understand health care providers are obliged to inform either patients or employees if they are being exposed to risks such as MRSA but this is not happening at present. Have any steps been taken to rectify the situation?
In the case of patients with MRSA being discharged from a hospital into a nursing home or into the community, a letter is meant to follow to the nursing home or to their general practitioner explaining that they have or had MRSA so that appropriate steps can be taken. That is not happening either. People are being put into nursing homes and families are finding out months later that they had MRSA all the time. The key point on MRSA is the right to information. Patients, their families, GPs and the receiving hospital or nursing home should know if people have MRSA.
People who contract MRSA often end up with a long-term disability. Surely they are entitled to compensation for loss of income? Some progress has been made in terms of social welfare payments as it has been acknowledged that MRSA can result in disability. I am aware of people who have lost their livelihoods and income. Somebody in charge of hospital management must be accountable and take responsibility for outbreaks of MRSA, its treatment and the provision of information to patients. The health and safety aspect must also be taken into account.
The group, MRSA and Families has asked to meet Professor Drumm. Will he indicate if he is willing to meet the group?
I welcome the Tánaiste, Professor Drumm and his colleagues. I will try to be brief. Some of my colleagues failed in this regard but some of them succeeded.
I wish to question the Tánaiste about her policy, A Vision for Change, the national policy framework for the mental health services. She was kind enough to reply to my parliamentary question and give me the information on 25 January that 7% of the total health budget goes towards psychiatric services. The funding has not followed through this year in spite of the commitment to implement the policy, A Vision for Change.
In her contribution the Tánaiste referred to Planning for the Future, which was published in 1984. I went through that document very carefully after A Vision for Change was published and discovered that more than 50% of the recommendations in the latter document were also in the 1984 policy document. Obviously the last thing we want is for the same to happen to another report in 20 years' time. What are the Tánaiste's plans for the implementation of this policy? What is going to happen? We hear verbal support for the plan but I would like to hear concrete information on what will happen this year for a start, even though the Tánaiste has not allocated extra funding for it.
The Tánaiste allocated €1.2 million for suicide prevention even though a report with 95 recommendations came out in October of last year. The Minister warmly welcomed that report, as did the Minister of State, Deputy Tim O'Malley. I question the allocation of only €1.2 million to deal with a serious issue of great concern to many communities and families, regardless of its political impact. I gleaned this figure in a reply to a question on 25 January. It is a paltry sum given the needs that have to be met. If one compares it with the moneys allocated to the National Safety Council, which deals with road accidents, the rate pertaining to which is one third lower than that pertaining to suicides, it reflects the existence of neglect and a lack of commitment to introducing the 95 recommendations made last October.
Let us consider the policy direction the Minister issued to Professor Drumm on the building of private hospitals on the grounds of public hospitals. I am aware from information provided by the Department of Health and Children under the Freedom of Information Act that Professor Drumm or other members of the executive met the Minister and senior officials from her Department on a number of occasions to discuss this issue. They met on 7 July 2005, 26 August 2005, 23 September 2005, 22 November 2005 and 22 February 2006. Will the professor outline the nature of the concerns he and his colleagues raised at those meetings regarding the policy to build private hospitals on the grounds of public hospitals?
Will Professor Drumm outline his plans for the development of cystic fibrosis services? The matter was drawn to the attention of this committee recently. The professor pointed out the efficiency of the accident and emergency unit in the Mid-West Regional Hospital. Although there have been difficulties, I accept that the figures, which I examine regularly, are well below average. Will the professor explain why such an efficient hospital was fined €1.2 million last year for inefficiency? The money was transferred to less efficient hospitals. Does this not ensure that there will be a less efficient service for him to praise next year?
I welcome the Minister and Professor Drumm to the meeting. On the roll-out of BreastCheck to the west, planning permission was granted last month by Galway City Council for the building of the facility in Galway. The Minister indicated that if the process could be expedited, it would be possible to bring forward the date for the provision of the breast screening service in the west. Some 58,000 women in the catchment area await the service. It has been available in Northern Ireland for ten years and for three years in the rest of the country. As was acknowledged at this committee previously, the issue is very important in the west.
It was mentioned that the expected date for the provision of the service will be at the end of 2007. I noted this morning that the Tánaiste said it is hoped it will be possible to roll it out at the start of next year. Have we now moved the target date forward by 12 months? If so, it is very welcome news.
A general election is due.
I also welcome the commitment made in regard of the cervical screening service. In the west we do not want to be left behind if the national programme is rolled out. We expect to be included in the very first phase. When is the roll-out of this screening service due?
When the ten-point plan for dealing with the accident and emergency problem was announced last year, I stated it would not work, certainly not in County Mayo. Professor Drumm stated that to evaluate the health service fairly, one must look beyond one's local hospital. I accept that one must consider the service as a whole but if one lives in a county that is 145 miles long and has a population of 110,000 people, and which has one acute hospital with one accident and emergency department, one will regard the local hospital as the centre of the health service for people in the county.
The ten-point plan could not have worked because only five of the 500 home care packages announced were made available in Mayo in spite of the fact that the population of the county is 110,000, 11% of whom are over 65. Why raise expectations that people will be able to avail of the service when none will be able to do so? The home care package is an excellent idea and I would love it to become more widely available. I believe many people would avail of it, especially in rural areas where people want to stay at home and do not want to be in nursing homes or hospitals.
Mayo General Hospital has no budget for contract beds. Last week, it contracted out three beds without a budget, and it contracted out six without a budget the previous week.
I compliment Professor Drumm on his proposal to deal with the accident and emergency problem, of which proposal he has not made much. I understand that of the 35 accident and emergency units throughout the country, 15 have been chosen by the Health Service Executive as part of a pilot group. Is Mayo General Hospital one of the 15? I have been informed locally that it is. I issued a press release last week complimenting the HSE on this initiative. I would like confirmation that what I have outlined is the case because I believe it represents the way to move forward. I understand local management bodies have been asked for local solutions to the problems that exist in local hospitals. This is an excellent idea because I do not believe one solution fits all 35 accident and emergency units.
Some short-term issues arise regarding capacity at Mayo General Hospital. The contract beds problem could definitely be improved. Testing in Galway hospital is such that people are taking up beds for three and four nights when they only need to be in them for one. There are definitely management and efficiency issues that can be resolved. These are problems specific to Mayo General Hospital and do not necessarily apply to others.
Yesterday the Taoiseach stated in the Dáil that 411 people who could have been medically discharged were still occupying hospital beds. There is no capacity problem in private nursing homes in my locality and possibly in many of the regions. Within three to ten miles of my local hospital, there are any number of beds available in private nursing homes. There are five to ten beds free in most of them.
I have raised the issue of subvention rates with the Minister on numerous occasions. The disparity between the rates applying in the west and Dublin amounts to €420 per patient per week. I accept that one could justify a difference in cost for a number of reasons but such a disparity seems extraordinarily high. Many people are queuing up to get into public nursing home beds although they would be more than happy to enter private nursing homes if the subvention rates were better. This could be sorted out overnight.
I asked my local accident and emergency consultant why 17 or 18 people were on trolleys in Mayo General Hospital. This is not the average, which I accept is between eight and 11 throughout the year. If I enter the accident and emergency unit at 2 p.m., there is hardly anybody there, but we all know the problem exists at night-time. Professor Drumm hit the nail on the head when he said that after 5 p.m., junior doctors decide whether to admit persons to the accident and emergency units. The reality is that such a doctor will err on the side of caution and admit a patient rather than discharge him. Consequently, many people end up on trolleys, certainly early in the morning. The problem generally improves throughout the day. It is not fair on junior doctors to have them making such decisions and this is the main problem in accident and emergency units. If consultants are not available after 5 p.m., the problem will continue. The sooner we sort out consultants' contracts, the better.
What is happening to the home help service? It is a great service that allows people to remain in their homes and perhaps we are not paying it enough attention. The committee heard from the Cystic Fibrosis Association of Ireland that an adult cystic fibrosis sufferer is often admitted to an accident and emergency ward for cystic fibrosis treatment. He or she could be lying on a bed next to a person with MRSA. It is a ridiculous way of dealing with that situation.
Performance indicators are an excellent idea. However, my local hospital was one of those clobbered last year and is being penalised as a result of supposed inefficiencies. What is being done to bring inefficient hospitals up to the mark?
The children's hospital is a national one. People are travelling from across the country to access its services into a traffic-clogged Dublin city. There has to be a better location for a children's hospital that would serve everyone on the island.
I hope that one of the delegation has Brendan Gleeson's address. He would certainly benefit from the transcripts of the meeting and Professor Drumm's description of the complexity of the problems with accident and emergency departments. Brendan Gleeson will be relieved to learn there is someone brighter than a baboon in charge.
The delegation indicated about the varying processes in different hospitals. To what extent is the Health Service Executive able to dictate that best practice will be followed in other hospitals? If I were running a hospital, I would want best practice and not to be appearing on the news every day with descriptions of its inefficiencies. Waterford hospital was cited as a good example. We must insist these processes become standard in each hospital.
The delay in replying to parliamentary questions was referred to. I would have thought the Health Service Executive has much of the requested information readily to hand. It is frustrating to hear people being critical of the system. I do not understand why there is this delay. Can we look forward to an improvement in the time taken to reply to parliamentary questions?
The cost of €2 billion for pharmacies is shockingly high. Will this cost continue to rise or can we adopt measures to reduce it? I compliment the HSE on coming in on budget. I was taken aback at the overrun of €120 million by the former health boards. It is a good start and I wish the executive well.
The public will receive much information from the committee, particularly the problem of delivering general practitioner services to north Dublin. There seems to be a problem with the Irish Medical Organisation, IMO. I suggest the committee invites the IMO to give its response to this. The committee needs to know who is causing the block in the delivery of the service.
Has the Tánaiste and Minister for Health and Children succeeded in getting the Minister for Finance to give a zero VAT rating to home care packages? We would get better value if that were achieved.
As I was left at the end of the questioners, I discover all my questions have been asked. I have just told Deputy Fiona O'Malley that I am glad I had written them down so she knows I am not just saying what others said. I welcome the explanation given of the medical practitioners Bill. I am delighted that continuing medical education and CPD will be compulsory. When on the Medical Council, I often said no patient would believe they were not compulsory. I am delighted competence assurance will be put on a statutory basis.
The Tánaiste and Minister for Health and Children is probably sick of me asking her to bear in mind the number of doctors operating outside of the jurisdiction who keep their names on the Irish medical register. Many of them have been struck off in other jurisdictions and return to practice in Ireland. The Medical Council's hands are tied in this matter.
The only way to sort out the crisis at accident and emergency wards is to examine the wider problems with the health service, especially the common contract for consultants. An out-of-hours GP service will have to be introduced. The GPs in particular have a role to play and I am glad to hear there is goodwill on their part. There is also an onus on their unions to play fair. I support Deputy Fiona O'Malley's call for an invitation to the IMO to attend the committee. I suggest we also invite the Irish Hospital Consultants Association. Deputy Twomey claims there are two sides to the argument. There is no point in giving them flak unless we hear them.
Deputy Cooper-Flynn has stolen my thunder on the children's hospital. Last January I was annoyed to hear the Joe Duffy radio show taken up with arguments for locating the hospital in either Tallaght or Temple Street. I know Deputy O'Connor's view on that. It was as if a world did not exist outside Dublin. It must be remembered that it is not a Dublin children's hospital, it is a national one. It must be made accessible to people from Donegal to Kerry. One woman on the radio show asked how she was to get her children from her house in Dublin's north side to Tallaght. How does one get them from the north of Donegal to Dublin? I am delighted that announcement will be made on the hospital next month. It is a long-awaited facility.
I have spoken to the Tánaiste and Minister for Health and Children for a long time about an early date for the roll-out of BreastCheck for the north west. Will she get it for the beginning of the year rather than the end?
I want to bring to the attention of the Tánaiste and Minister for Health and Children and Professor Drumm the report by the Nenagh hospital action group. The compliers comprised two hospital consultants, two GPs, a senior staff nurse, an EMT and representatives of the community. The report contained valuable information for the debate that has been raging on accident and emergency wards and the fundamental problems in the health service. It was drawn up due to the uncertainty and vacuum created by the Hanly report. I would like to know its current status.
We wrote the report because we felt so strongly that the Hanly report had something missing, namely, the work being done by hospitals such as Nenagh Hospital. The mid-west region, of which Nenagh is a part, is the pilot area for implementing the Hanly report, and that is why we had to examine it. I ask Professor Drumm, the Minister for Health and Children, and her officials, especially Mr. O'Brien, who manages the hospital service, to consider what it contains. There are some very important facts, for instance, that 97% of patients presenting at Nenagh are treated successfully there, only 3% needing to go on to the expensive tertiary hospitals that the Minister has mentioned.
It is true that the cost of care in such a hospital must be higher than in a small one. There is no need to send ten patients to a tertiary hospital when nine can be treated more cost-effectively at a local one such as Nenagh. The Hanly recommendations would take those nine people out and force them to attend a tertiary hospital at much higher cost to the taxpayer and patient. I ask that the Minister seriously examine that. Some 90% of patients treated in Nenagh Hospital are emergencies. The starting point is that emergency care must be provided, and that is happening successfully in our network, since Nenagh is part of it.
A review of the network of acute hospitals in the mid west has been initiated under McKinsey. We are a little concerned about hiring international consultants, since we feel that local solutions are contained in the report. The research was compiled by a professional project manager. It has cost us over €40,000, raised locally owing to the commitment to our hospital, to produce the missing part of the equation. I request that it be examined. I would like a specific answer to the question of the Hanly report's current status.
I am glad to have the opportunity to attend and ask questions. I welcome the Tánaiste and Minister for Health and Children, Deputy Harney, Professor Drumm and their officials. The roll-out of BreastCheck will not be completed until 2009, which is when everyone will be screened, so it will not be in place next year.
Rubbish.
That is not rubbish, since only then will everyone have been screened. I asked before regarding BreastCheck and was told that it was an analogue service, while the Galway Clinic's was digital. However, now that the former has also adopted a digital system, surely a great many lives, possibly hundreds, could be saved by screening those people before 2009 through allowing the Galway Clinic, under the National Treatment Purchase Fund, to screen those women in advance of completing the national roll-out of BreastCheck. As someone who started the campaign for a national roll-out, I feel that it has taken far too long.
My second point concerns urology. Since 1998, people have been called from a urology list at Mayo General Hospital. It takes eight years to see a consultant. If I told Professor Drumm that ten new patients and ten review patients were seen every month, he would understand that it will take a very long time to see the 1,000 people waiting or whatever is the figure. That is far too long, and the recent Comhairle report did not recommend that the urology service at Mayo General Hospital get a consultant, which is the only way that change will occur. I hope the professor will address that situation.
I know people who have had cancer and have been waiting for months to be seen. People with probable cancer are referred, and a great deal can happen in eight years. People have died, and I have seen people in the final stages of cancer by the time that they were examined, which is unforgivable. The only answer is a urology unit at Mayo General Hospital.
Eight years is too long, but with rheumatology the waiting time is four to five years for a first appointment. There is a window of opportunity of two years during which one can prescribe the necessary drug to stop people ending up in a wheelchair. I know a young woman who is totally disabled and in a wheelchair.
I ask the Deputy to put a question.
There is a recommendation by Comhairle, which I greatly welcome, that there be a rheumatology consultant at Mayo General Hospital. Perhaps Professor Drumm might state when that might happen.
I must ask the Deputy to put a question.
What will be done about neurosurgery beds? The point was made that we have enough beds, but do we have enough neurosurgical beds? Is it because of inefficiency in Beaumont Hospital that people with brain haemorrhages must wait weeks for one? We must all deal with the situation.
I ask the same question regarding the National Rehabilitation Centre in Dún Laoghaire. It has 120 beds, with 25 being for road traffic accidents.
Deputy Cowley, I cannot allow——
Some 150 to 200 people are waiting for the beds.
Excuse me, Deputy Cowley.
There are only 25.
Here is a man who resigned from the committee but now wishes to take it over.
I did not resign. With respect, the answer that I want is——
The Deputy has mentioned respect, but he should have respect for the Chair.
May I ask the question?
The Deputy has finished asking questions. Deputy Twomey will take over. Deputy Cowley was on the committee but left it months ago.
No, I did not leave the committee.
I must give everyone a chance to speak today. I have asked Deputy Cowley for questions, but he will not give me any.
There are 120 beds in the National Rehabilitation Centre in Dún Laoghaire, some 25 of them being for road traffic accidents. However, 150 to 200 people are waiting to attend.
This is the first time that the gavel has been used. Deputy Cowley has completed his round of questions.
I still have some here.
I am terribly sorry, but the Deputy can forward them later.
Some 200 people are waiting to attend the National Rehabilitation Centre in Dún Laoghaire, but there are only 25 beds.
Dr. Cowley, please.
I will suspend the meeting altogether now. We have been here since 9.30 this morning. The Deputy floats in when it suits him.
I thank the Chair for the opportunity to wrap up. The longer that I am left sitting here, the more questions I have.
I would like to examine one or two things said this morning. The Tánaiste and Minister for Health and Children, Deputy Harney, seems to be performing U-turns on major policies agreed in the programme for Government in 2002. When I asked a question on the issue of the sum of €120 million described as an overdraft, I was told it was related to PRSI and superannuation payments. I believe there has been a change in the HSE's system of financial accountability. The old health boards used to make payments a month after they arose, so that it was not an overdraft but PRSI and superannuation payments. As we know, the old health boards had to work within an agreed programme to deliver services, and overdrafts are now allowed.
I completely agree with Deputy Fiona O'Malley that we must bring together all parties on the out-of-hours service in north County Dublin. Something is seriously amiss, and it should have been sorted out a long time ago. When it comes to addressing the issues raised this morning, there seems to be paralysis. On the consultants' contract, it was agreed that if there were no end to the negotiations with the consultants by the end of April, the Minister would unilaterally implement a new contract. Is that still the case?
Regarding the GPs' contract, on cervical screening we cannot wait for renegotiation, since it covers such issues as chronic care and shared management, vaccinations and out-of-hours services. We can follow the model used in Limerick to get a cervical screening programme up and running. We need an answer on that issue. Can the Minister expand on what is happening in Limerick?
The question of there being too many nurses in accident and emergency departments is beginning to concern me. I get the sense that it is an IR issue. Is it because the nurses have too much time on their hands to count trolleys, or is there a genuine problem in accident and emergency departments regarding the numbers of nurses? Patients do not sense that there are great numbers of people on the front line of health care services, and I wonder whether someone is seeking a scapegoat or trying to pick a row in the health service to get the Minister out of having failed to deliver the service.
I must ask the Minister privately about one or two things about which she has written. The vaccination damage compensation scheme is very important. The HSE has directed that automatic defibrillators be placed in the back of every Garda car, yet it has written to all general practitioners and told them that the primary care unit will not be involved in the procurement of automatic defibrillators for GPs. The least that could have been done was to engage with the GPs to see whether they would put them in their surgeries as well.
I should also like clarification of the press statement as regards the targeted resources whereby improvements will be made available by the HSE to solve the accident and emergency crisis. Some of the material in the press statement was very non-specific as regards dealing with the accident and emergency crisis.
I have just one question for Mr. Scanlan, the Secretary General of the Department. He replied to the committee on the question of cystic fibrosis and I was taken by one line in the reply which said that one of the issues to be examined was the relative low level of donor organ retrieval in hospitals where higher levels might be expected. Has the Department identified a problem as regards organ retrieval for donation? Perhaps he will clarify that.
There are approximately 90 questions. I do not know how we will get through them, but we will make a start.
Deputy Connolly mentioned the issue of intellectual disabilities, to which I referred in my opening remarks and in the script I supplied. There is a multi-annual programme of enormous investment gong into this area now, and in order to shorten the contribution here I can make the figures available. As regards suicide, as also mentioned by Deputy Neville, additional resources of €1.2 million are being made available — not just the €1.2 million position, but an additional——
We have been down that road before.
——and there are additional resources of €25 million for mental health, to begin to implement the strategy. On the issue of funding the mental health strategy, as raised by Deputy Connolly, the Government has indicated this will be done by using the capital base that currently exists in mental hospitals whereby the HSE can realise moneys from buildings. Such moneys should be invested in new state of the art facilities attached to general hospitals. However, the bulk of mental health illness in the future will be dealt with at community level. That means it will be more labour intensive and obviously, more expensive. It represents 6.9% of total health spending at present.
Clearly, if one ramps up more resources to incorporate the disability sector and so on, even though more money is being spent on mental health, it will represent a smaller net percentage. The idea is, however, between now and 2011 to increase the percentage spend on mental health to 8.24% of overall spending, which is the recommendation of the expert group and the Government has agreed to it.
As regards MRSA, I have communicated with the HSE and emphasised the need for this to be a priority. MRSA and hospital acquired infections are iatrogenic health service acquired illnesses. One can never rule out infections altogether. However, the incidence must be brought down to the minimal possible level. This year an additional €5 million is being provided. That will go towards the recruitment of additional personnel such as infectious disease liaison people, pharmacists, infection control nurses, surveillance scientists and other initiatives, including a public awareness campaign.
Of course hygiene has a major impact as regards hospital acquired infections, hand washing and so on. The fundamental reason for an increase in MRSA in many countries has to do with the overprescribing of antibiotics. Yesterday I had a very good meeting with Dr. Kelleher from the HSE and some of our national experts, including Professor Hilary Humphreys, to discuss some of these issues. Ireland is currently participating in a prevalence study with England, Scotland, Wales and Northern Ireland to see how the levels compare. At least we will now have some baseline data. That study commenced in February. The aim is to reach the levels of the northern European countries which have the best performance records. Southern European countries and Ireland and the UK have poor performance profiles.
On the question of telling a nursing home or whatever that a patient on leaving hospital has or did have MRSA, this is an operational matter for the HSE. Perhaps either Mr. John O'Brien or Professor Drumm might deal with that. A number of references were made by Deputy Connolly to the fact that county managers used to run the health service in the past and that matters were better then. I do not believe that a committee running anything is better than a single individual with overall responsibility, line managers and so on. In any organisation there must be clear lines of accountability. Perhaps we need fewer managers and more management of resources and processes. As the committee heard earlier, that is underway.
Everybody in health care must work together. Nobody can be excluded from the reform role. We need work practices that are flexible and dynamic, and which respond to patient requirements. That must be paramount. If the taxpayers invest considerable resources in putting diagnostic facilities in place in our hospitals and the health care system, and if these are not used in the interests of patients, as required, that is neither good value for money nor appropriate. These are among the things we must change and are the challenges facing health care systems worldwide.
Deputy Connolly mentioned the ramping up of performance as regards parliamentary questions. The HSE is a new organisation and the parliamentary affairs division is developing its capacity. It has set targets as regards reform. I look forward to the day when the HSE can respond as effectively to parliamentary questions as the Department of Social and Family Affairs. When I came into this House, 25 years ago, the largest volume of questions every day was for the Department of Social Welfare. The then Minister and Secretary put in place a relevant division within the Department and the technology to support it. One hardly ever sees questions as regards individual requirements being tabled for that Department because the response is quicker than the parliamentary question route. I look forward to that becoming the norm for the health service in time. Clearly, it will take time, however.
Senator Glynn asked whether I was invited to the Seanad to discuss diabetes. I probably was, as the Leader of the House invites me to the Seanad very often to discuss many things. Obviously, I am available to discuss issues. I welcome the fact that among the major advisory groups Professor Drumm has put in place is one relating to diabetes. This is a major challenge for the health care system here, as elsewhere. Managing chronic illness is the major issue that clearly has be dealt with more appropriately, particularly at primary care level. It has a strong focus in the new discussions with the general practitioners.
I am not in favour of councillors inspecting facilities. I do not believe that is the role of the politician. We have made tough decisions here as regards separating the political response from operational and management issues in the health services. We are establishing an organisation, the Health Information Equality Authority. That will have a social services inspectorate attached to it. It will be the job of that inspectorate to inspect public and private facilities where older people are resident — not just private, but public ones, too. As Mr. Aidan Browne has acknowledged, we will probably have to spend a considerable amount of public money for fewer places, because many of our public facilities are grossly over-crowded. We have people in large Florence Nightingale-era wards where there is not even room for a wardrobe between beds, and that is not good enough. I have no doubt that considerable resources must be allocated, as the HSE is continuing to do, to upgrade those facilities so that older people may live with greater privacy and dignity in the last few years of life.
As regards legislation, later this year we will have the pharmacy Bill, dealing mainly with fitness to practise issues and there will be legislation on the Medical Council, which has not been updated since 1978. Clearly the catalyst for many of the reforms will be Judge Harding Clark's report, which is a cause of concern for all of us. We have to learn from that, particularly as regards clinical audit and governance, levels of competence, continuing medical education and ongoing professional training, which have to be the order of the day. The president of the Medical Council, Dr. John Hillery, and I have had very good engagement as regards the Bill. We hope to publish the heads of the Bill by the summer and to have the legislation later this year. The same applies with the HIQA legislation, the pharmacy Bill and a number of other key pieces of legislation that are being rapidly advanced at the Department of Health and Children.
I have written "airline business" and I do not know why. Somebody asked me about that, but I do not have responsibility for the airline business. I realise now what it relates to, disabled passengers, and of course every citizen should be entitled to travel. However, I do not have responsibility in this area, as the committee is aware.
Senator Glynn asked about what we were looking for as regards care of the elderly. We must have flexibility. International research suggests that if somebody can live out their last days at home, they live longer and have a higher quality of life. The aim or our policies must be to support people to stay at home. There are societal and cultural developments, particularly in the Dublin area, which seem to place growing emphasis on institutional care. If we put supports in place for families, the vast majority of older people would wish to be at home.
In response to Deputy Cooper-Flynn, if there were only five home care packages in Mayo last year, I accept that is very few. We are only beginning the process. This year, we will have approximately 3,000 home care packages. The job of Mr. Aidan Browne and his team is to try to allocate them as fairly as possible. We will probably have to move to a situation where we have 7,000 to 10,000 home care packages in a number of years but, given resource priorities and so on, while we will try to ramp the service up as quickly as we can, it will not happen as quickly as we would wish, unfortunately. The home care package is a very attractive option. It is flexible and gives great choice to the person being cared for in the context of what might or might not happen to them.
Deputy O'Connor knows that Tallaght used to be part of my constituency. I know a lot about the area and am disappointed to hear that Fettercairn, which has a population of 6,000, still does not have a general practitioner. There are real issues in disadvantaged areas. The fact remains that it is more lucrative to establish a practice in a middle class area. I understand what Professor Drumm said in this regard and this has been my experience with regard to doctors who want to open practices. We must incentivise doctors to open primary care facilities and services in areas of major disadvantage. I have no doubt that some of the gaps are adding to the accident and emergency problems at Tallaght hospital. I am impressed that the Deputy rambles around Tallaght at 8 a.m. My constituents do not have the benefit of that service from myself.
With regard to the paediatric review, until some months ago the intention was to build a replacement hospital for Temple Street and another for Crumlin. The jury was out as to whether they would be onsite or offsite. The plan was to add 600 or 700 beds at a cost of €600 or €700 million. Before I become Minister for Health and Children, the issue of paediatric services was not one I had ever reflected on or discussed. However, many of the experts with whom I discussed it told me that in a country of 4 million we only need one tertiary facility for the children of the whole country, including Mayo. Therefore, it makes eminent sense to undertake a review and I have asked the HSE to review what is required. McKinsey consultants were also brought on board. I was very impressed with the work they did in a short timeframe. They considered facilities throughout the world and the committee knows the conclusion they reached, namely, co-location.
Following that process, a group has been put in place comprising representatives of the HSE, the Department and the OPW. I will not interfere in the choice of site. I want the best option for sick children, which is what their parents want. I was very taken with the group of parents from Crumlin who told me that they did not care where the hospital was located so long as a modern state-of-the-art facility was built for their sick children.
Mr. John O'Brien said earlier that he hopes to have the report within a week or so. I know the group has put an enormous effort into completing that report quickly, evaluating the applications and considering the sites. I am no wiser than the committee as to what the group will recommend, and I do not want to know. I just want to receive the report when it is completed. I know the report will be robust, fair and objective, which is what everybody wants. We have heard the public debate and it would be wrong of me to comment while the process is underway.
With regard to Senator Browne's question, one point is certain. If we were beginning to establish a hospital system in Ireland, we would not have 53 acute hospitals and 35 accident and emergency units. While it is an operational matter for the HSE to decide where it locates accident and emergency units, we should build up and use what we have to its optimum potential rather than creating duplication of services. That is what serves patients best.
I agree with the Senator that we need more information on the length of time patients spend on trolleys. The HSE is determined to get that information. A person I know had a fall last Sunday and went to a private facility in Dundrum. That person was x-rayed, dealt with and released in one hour, although the service cost €160. I want to reach a situation where people are effectively and efficiently dealt with in the public system, which is what this reform is all about. It is not just about the length of time people spend on trolleys because people will always be treated on trolleys. It is about how quickly we can turn patients around in accident and emergency units. If one does not measure something, one cannot manage it, as I noted in regard to the hygiene audit. The HSE intends to measure response times and so on, which is part of the target setting that is underway.
I dealt with Deputy Neville's questions. On the issue of private facilities on public grounds, a growing number of people have private health insurance — the proportion has gone from just under 38% seven years ago to 53% today. There are three reasons for this increase, namely, the growing wealth of our society, the perception that one will have quicker access to services and the perception that if one does not have private health insurance, one will not get a speedy response. There is no doubt that if a person can afford to visit a consultant in a private clinic, that person will have quicker access for elective procedures. That is the reality, which is unfair and unacceptable.
To take the case of one hospital, Tallaght Hospital, last year, 46% of its elective work was on private patients. The hospital only gets paid for approximately 20% of those procedures through insurance and does not receive the full commercial cost. It is heavily subsidised. In addition, the consultants get paid for all of their work on private patients. That is an unfair and unacceptable situation. The Government wants to reduce the number of private beds in public hospitals by at least 1,000 through the initiative we announced and communicated to the HSE. At present, we heavily subsidise private activity in public hospitals.
It is Government policy to move to a situation where the full commercial cost, whether for drugs or other diagnostic procedures, is charged to the insurers. I accept this will undoubtedly have a knock-on effect on the numbers of people insured and the cost of insurance, but it is necessary from the perspective of the public and taxpayers in terms of measuring what we do and how we do it, in particular in regard to access to services.
Accident and emergency department are the only place in our hospital system where patients are treated equally because no fees are paid by private patients to accident and emergency consultants. As Professor Drumm stated, it is an issue in the context of the negotiations. Accident and emergency is the only place where everybody is treated on the same basis. However, if a private patient goes to a ward, the doctor gets a fee for treating him or her.
There are real issues in this regard. All over the world, including in Canada, which I visited recently and where there was resistance for years to private provision, health care systems are moving to consider whether private providers can in certain areas provide the service that is wanted for patients. My view, which is not an ideological view, is that if a suggestion is pragmatic and makes sense from the point of view of the workforce, staff, services and particularly patients, we must think outside the box and do whatever we can to provide services in a cost effective way.
We are spending just under €600 million by way of capital provision on health. If we were a private company, we would probably spend 10% to 15% of our revenue on capital investment — that is roughly how it happens. We do not have such resources. That €500 or €600 million is well spoken for. The capital plan for this year has not been approved but I hope to approve it shortly and the Department is in discussion with the Department of Finance in this regard. Nonetheless, the resources the State can make available for services and capital expenditure is limited. Every year prior to the budget, Oireachtas Members support campaigns to retain tax relief for films and all kinds of other reliefs. Why not have tax breaks for the provision of health care facilities where it makes sense to do so? It makes as much sense or more to provide state-of-the-art facilities for patients than to provide films or otherwise. That is the perspective from which we come.
BreastCheck was always going to begin to be rolled out at the beginning of next year in the area to which reference was made. That does not mean that everybody in the affected area will be contacted.
With regard to cervical screening, I accept the point made on GP discussions. The service in Limerick has been a good model but we are paying substantially more there than is paid in the UK for a similar service. As Deputy Twomey knows, even when we announced the doctor only card, which was not going to impose additional requirements on doctors, there were issues with the IMO. Each time a new initiative was announced, including the over 70s initiative some years ago, there were issues with the IMO. Once it is announced that there will be a new service which will be provided by GPs, we must enter a long process. While this may not be unique to health services, it is different from my last job, where the parties could sit around the table and get business done quickly. That does not seem possible with the different representative organisations in the health services. Processes that should happen in a couple of days tend to take a couple of months. If we announce that we intend to roll out a programme in the immediate future, are the GPs prepared to operate it on the same basis as it is operated elsewhere? If one spends more money in one area that one can afford, there are other things one cannot do. HSE areas were entitled to run an overdraft. Deputy Twomey is correct in saying that the figure of €120 million includes PRSI, as I confirmed in a parliamentary question.
In response to the question raised by Deputy Fiona O'Malley, I have not yet succeeded in ensuring that VAT is not applied to home care packages, although the Minister for Finance and I are very sympathetic to such a proposal. However, it is difficult to make certain things VAT-free in the tax system. If some companies which provide staff to enter people's homes are forced to charge VAT, it will make home care 13% more expensive than if they are not forced to do so. My Department and the Department of Finance are trying to address this issue which has not yet been resolved.
The majority of Deputy Fiona O'Malley's questions, which dealt with matters such as best practice, were directed towards Professor Drumm. I think I have dealt with Senator Feeney's questions. In respect of the Hanly report, the reason we did not travel around the country writing up a report is because vested interests sometimes put their own interests before those of patients. It did not appear to be a worthwhile exercise for us to draw up a report. The Hanly report aimed to increase the number of consultants in particular and bring about appropriate manpower levels in the health care system. It came about mainly as a result of the working time directive. The report's basic message is that we must double the number of consultants and halve the number of hospital doctors. This is roughly what we must do.
We need centres of excellence in the regions, to which smaller hospitals can feed. The report never aimed to close down hospitals and take services away, except where patient safety is an issue. Breast surgery was once performed in Roscommon County Hospital, which I visited recently, but such surgery is now performed in Galway because this will result in the best outcome for patients. As politicians, we must support this process because otherwise, we will put patients' safety at risk and none of us would wish to do this.
The Hanly report aims to ensure that hospitals work together in a region and in particular, to increase the number of consultants and other staff. We want to move to a situation where the services are delivered by consultants. People have talked about services being consultant-led or consultant-delivered. The reason why people are not discharged from hospitals at the weekend is because the consultant is not there. When consultants are on holidays, they discharge for each other and it would be preferable if such an arrangement could be introduced at weekends.
We want to move to a situation where we effectively double the number of consultants. Under the old way of employing consultants, this would cost €1 million per consultant, which would amount to €2 billion, taking into account all the back-up services which accompany the consultant. Clearly, we need to do this. It is a matter for the HSE to decide in which specialties it should be applied first and how it is rolled out around the country. In particular, we need a new contract of employment that serves the needs of our health care system.
Deputy Cowley mentioned some areas where there are large gaps. I accept that there are gaps in these areas. I am not sure whether he was referring to neurologists or urologists.
Urology.
I understand we have 26 or 28 consultant urologists, which is too small a number. I understand we have approximately 16 consultants nationally. Every time I meet Dr. Orla Hardiman, she tells me how few neurologists we have. There are undoubtedly significant pressure points in some of these areas. We must quickly ramp up the number of consultant positions, particularly in regional areas. Many people end up travelling to hospitals in Dublin because the consultant manpower does not exist in other places.
In response to Deputy Twomey's question, the vaccine damage compensation scheme is being examined by the Department. We recently launched the sudden cardiac death report, which makes a number of very sensible and practical suggestions in respect of defibrillators and other issues. This is an implementation issue for the HSE.
The Galway Clinic could be used to provide a digital breast cancer screening service before the national roll out of the BreastCheck programme in 2009. I am not promoting the clinic but if somebody could be found to provide a breast cancer screening programme for people in the west, it would save hundreds of lives that would otherwise be lost.
I am always a fan of buying services if possible in order to provide them more quickly for patients. It is effectively a matter for BreastCheck and I have discussed the matter and the issue of whether mobile screening units can be provided in advance of the roll out of facilities with BreastCheck. BreastCheck expressed the reservation that it would not be possible to provide the back-up staff, such as radiologists, to carry out the readings and provide the follow-up services. These are genuine issues in terms of rolling out the service.
My question concerns the charging of patients on trolleys.
A charge is levied for accident and emergency service services because we wish to discourage people from visiting accident and emergency departments to avoid having to pay €60 to visit their GP. The accident and emergency charge is slightly above what GPs charge. We also have an inpatient charge, which is capped. It came to my attention recently that hospitals were charging people on trolleys and we have asked them to cease this practice because it is unacceptable. I understand this practice has ceased.
Some people were beingpursued in court for non-payment.
I was unaware of this. Clearly, if someone is not being admitted to the hospital, he or she should not be charged an inpatient fee.
So people on trolleys will not be charged?
This matter has been dealt with.
I want to ask about a neurosurgical bed.
Professor Drumm has been invited to this meeting to answer a few questions.
Professor Drumm
I will focus on the questions directed towards me. In respect of Deputy Connolly's question regarding our own structures, the official structures across the health service are to be finalised by 28 April 2006. It is a major task but many of our area people have been appointed. It is hoped that this structure can be more or less completed by 28 April. This places a major demand on our own system but we hope to achieve the task.
The issue of accident and emergency services arises in respect of issues raised by Deputy Twomey. I did not say that nurses are found in all units. I said that there are units, some of which are very productive and have a very low number of nursing personnel. I quoted a figure of one nurse for eight attendances, as against one nurse for two to 2.25 attendances. Why would one have this disparity?
Second, I asked whether it is due to the process issue. If a person must see four doctors and a clinical nurse specialist, he or she also needs nurses to look after him or her in the system so the more complicated the process is made, the more people will be needed. This is not a criticism of the work of nurses. It is merely acknowledging that if the process is made sufficiently complex, more and more people will be needed. According to a famous statement in the business world, if the process is made sufficiently difficult, 90% of the people who are working will be very busy but 90% of customers will be very idle. We may well be in danger of bringing about such a scenario due to the complexity we have introduced into the system, as opposed to a patient seeing a doctor who will treat him or her at the front door with a nurse and make a quick decision, as happens in general practice every day.
If general practice managers were brought in to examine practices in accident and emergency departments, they would ask significant questions. This is not a criticism of the people who work in accident and emergency departments because they have been put into this process. However, there are considerable disparities in numbers within the system which I suspect is because some of the processes have become so complex. The Deputy is correct in saying that this is a challenge for us at a management level. We must manage our way out of this and we are taking up the challenge.
The Deputy raised an interesting question about the sale of estates, some of which are very valuable to the HSE in terms of development and there are areas where they are being used. For example, there are plans to carry out a significant amount of health service development on a site in Killarney, County Kerry, and to use some of this site to fund some of the development. I understand the Deputy's perspective, which is to use it for what is needed for the health services, an aim to which we are very committed.
If the quality of answers to parliamentary questions is poor, it is a shameful state of affairs. We certainly do not aim to frustrate the system. We have put considerable effort in the last few months into the parliamentary affairs division and we are completely committed to improving it. We will be quite willing to take that criticism on board each time we appear before the committee if the situation is not improved. There is no excuse if we cannot bring the division to a certain level of quality. We can provide written responses to the questions submitted by people here who have not yet received any.
Senator Glynn asked whether specific infection control officers would be appointed in each hospital, to which the answer is "probably not". The goal is to identify a person and include the function as part of his or her role. Mr. O'Brien could tell me whether that would be fair to say.
What would be wrong with appointing specific infection control officers?
Professor Drumm
There are significant differences in size between some hospitals.
I accept that.
Professor Drumm
This matter arises in different areas. It would be of considerable cost to a hospital with 100 beds to have a specific infection control officer. There are some areas where it could be justified but others where one must try to get someone else to take on the role as part of another job. The same applies to risk management, which is a difficult situation. Does Mr. O'Brien wish to comment on this matter?
Mr. O’Brien
In virtually all of the hospitals there is someone with a degree of full-time responsibility for infection control. In some hospitals there are five or six people involved in infection control. As Professor Drumm said, it depends on the size of the hospital. As part of the exercises, we are working on issues of hygiene and MRSA to try to equalise them and come to a position where we have the appropriate level of individuals working on infection control in particular institutions. The principle the Senator is espousing of someone being in charge is one that we would adhere to.
I also referred to people disposing of waste. The disposal of waste is an important procedure within the hospital setting and I am reliably informed that the people handling the waste have no training whatsoever. This is not a practice I would advocate and it should stop immediately.
Professor Drumm
I will come back to that matter. Will Mr. Browne comment on the Tallaght issues?
Regarding the Millbrook Lawns health centre, I understood that Deputy O'Connor had received an answer but apologise if he has not. The centre has been prioritised in the 2006 capital plan and we intend to start it in 2006.
We want to see it done.
Mr. Browne
I appreciate that. The Tánaiste has already dealt with the matter of the Fettercairn area. We recognise that as an area of social deprivation, it needs comprehensive primary care services. Part of the issues of 100 primary care teams and requests for expressions of interest with which we are dealing is to try to make existing services and individuals in areas work as teams in order to cover broader areas such as Fettercairn. I am aware that the Fettercairn community health centre has the capacity for us to utilise some outreach facilities or move them——
The community centre. There is no health centre.
I am talking about the community centre. In many communities, we have an opportunity to use existing facilities and work with local communities to develop services. Regarding the Kilnamanagh family recreation centre and the day care centre, the increase in funding for day care services in this year's budget will facilitate us in developing them. I am aware that Kilnamanagh has been prioritised for services.
Professor Drumm
Senator Browne raised the issue of what information on MRSA we give people. One question was how many people died with MRSA. Everyone is probably aware at this stage that this is a difficult figure to determine because all people who die with MRSA are critically ill for other reasons, which is why MRSA becomes relevant to their conditions. It can become difficult to say that someone died of MRSA, not only in this country but anywhere in the world, because they were already——
They can die with MRSA.
Professor Drumm
Exactly. To give the figure of how many people died with MRSA to the public would be almost unfair and would frighten people. As the Tánaiste said, MRSA is a major problem across all of southern Europe, the United Kingdom and here, but has been more carefully measured here than in most places. As we know, most people colonised with MRSA will not have problems, only those who are very ill. We could examine the possibility of telling the rest of the population going into a hospital about how many people have died with MRSA therein but a lot of study should be done before it becomes mandatory to give that information. It would risk traumatising people unnecessarily in that situation.
Does Professor Drumm agree that if he needed to go to hospital tomorrow morning to have an operation and he had the choice of two hospitals and if he knew that hospital A had no deaths with MRSA and hospital B had five or six deaths, it is obvious that he would choose hospital A? Information is key for patients. They have known about the winter vomiting bug outbreak and are given information in other areas. They should know about MRSA. For example, a study was carried out in England on publishing the rates of death due to surgery. This is a dangerous road to go down but it is not harmful to give patients information. If I need an operation in the morning and know that a particular surgeon has a record of four times as many deaths while performing surgery as another surgeon, I will opt for the latter. I appreciate that every case is different but information is key and patients deserve to have it.
Professor Drumm
There would be no major argument if one could define what the information is. For example, there are other hospital acquired infections, such as clostridium difficile, C. difficile, which is probably a bigger killer of people than MRSA but on which no information is given by hospitals. C. difficile is a clostridium infection and is a significant cause of morbidity and mortality in hospitals, which is related to the use of antibiotics. The question is how long a list of risks to hand to people. I do not have a particular objection to giving people this list if it becomes public policy but I will caution the committee that there are many matters of equal relevance that we do not discuss here.
The bottom line is that hospitals, even with the best practice in the world among doctors and nurses, are still dangerous places to be in terms of risks. It is a fact of life the world over. There is no point in anyone denying that there are significant numbers of deaths in hospitals. There is always a risk when accessing health services, particularly in a hospital setting. I do not have a principled objection to giving out the information if it were considered right to do so.
The issue of employees and health and safety dates back a millennium. When someone joins the health service, what risks is he or she exposed to? There are many reports of people losing their lives from infections, although not MRSA specifically as that would have been unlikely. However, people die from E. coli infections they pick up while nursing patients. We must do the best we can to protect people from this but, at the same time, patients with these conditions must be nursed. When people make a wonderful contribution to the health services, we must minimise the risks they take on.
I presume that a small number of people are involved in the disability issue, with which I am sure the Department is dealing. Dr. Kelleher and Dr. Heinz, who are our in-house experts, will meet with the families and discuss the matter because, to be honest, they are the absolute source of information within this organisation. If I can add anything, I will do so but it is fundamental that they and the families meet and we make that connection with what is our expert group.
It would be preferable if Professor Drumm could also attend as the head of the HSE. The problem is that no one is taking responsibility for the issue. They are all passing the buck.
Professor Drumm
To be fair, Dr. Kelleher——
Will the Senator allow Professor Drumm to continue without interruption?
Professor Drumm
Dr. Kelleher has taken responsibility and I will not accept that he has not.
I am not saying that he has not. There must be a clear chain of command.
We will be here all evening if we try to deal with the specifics of replies.
Professor Drumm
Deputy Neville raised the matter of private hospitals on public sites and referred to dates of several meetings with the Tánaiste. I was not at the meeting on 7 July 2005 as I had not joined the Health Service Executive at that point but I might have attended the other meetings he mentioned. We have had numerous discussions on the matter Deputy Neville raised and other policy areas. Our commitment is to conform with Government policy but also to ensure we clarify our staffing arrangements. The Tánaiste has been open on this matter and is concerned our service delivery level does not suffer. Someone with a television asked me the same question as I came through the gates of Leinster House this morning. I have had no major conflicts with the Tánaiste but we have a straight-talking relationship with her. When I have concerns, they will be aired. My major concern is that our staff will not be affected by the development of new services. We have received a clear response on this.
The Department of Health and Children has allocated €4.5 million to cystic fibrosis services and this will be a major boost. We need a better system of measuring performance. We will have a better performance measurement system in future and will continue to improve the situation.
Deputy Cooper-Flynn referred to the accident and emergency units in Mayo. I am aware it is a large county. I was surprised to hear that five of the 500 home care packages were allocated to Mayo. I understand this relates to the low number of home care packages in 2005 which will be significantly improved by the commitment of funds this year.
The issue of people awaiting tests elsewhere is very important. This is happening in Galway, Letterkenny and throughout the country. We must contract, for example, Galway and Castlebar to carry out such tests so that hospital management in Galway knows it must provide these tests. This relates to the entire system, not just hospitals in Deputy Cooper-Flynn's constituency.
Nursing home subvention rates differ throughout the country. The standard rate is the approved rate but the practice in Dublin is to have enhanced subvention rates because of the difficulties in moving people into long-term care. This has not occurred across the entire country so subvention rates have been skewed. We seek a balance on this. There is better uptake of subvention rates outside Dublin than in the Dublin area. People are not availing of subvention in the Dublin area and this is driving us into the contract bed area. This occurs mainly in the Dublin area and the money available is for either subvention or contracting. We do not have enough money to provide both.
People in my constituency are not getting the subvention rate or the contract bed.
The funding allocated to the west is pro rata the same as allocated to the rest of the country. There may be some historical differences that we must address in the unified system.
An additional €30 million has been allocated to home help, equivalent to approximately 1.5 million additional home help hours. This is a significant increase in home help services. There is a major lack of standardisation throughout the country in how home help services are delivered, monitored, allocated, reviewed and withdrawn. We are trying to standardise this and we are working with SIPTU to implement the home help agreement. This has significant implications for the efficient and effective use of money available. The Tánaiste has restated our commitment to implement appropriate home-based services.
Professor Drumm
There has been focus on the national children's hospital, which is a national issue. The challenge is to find a location people can attend using public transport within Dublin for secondary care services. It is also important that the location be served by road and rail links to facilitate people who must bring their children to the hospital frequently. Rail links are very important to those who must stay in Dublin without a car while their children are in hospital. Regardless of what is conveyed on Joe Duffy's show, "Liveline", we are focused on the issue.
Deputy Fiona O'Malley asked about processes in hospital systems. I am accompanied by Mr. John O'Brien who has much experience in the hospital system. The task force on accident and emergency is focused on processes. As we put performance measures into place we believe we can dictate process. This is the only way the system will change.
The pharmacy bills are considerable and we are negotiating to reduce them. Deputy Fiona O'Malley also referred to the general practitioner issue. I believe the Irish Medical Organisation will take up the challenge of assisting the HSE in resolving the problem of the number of general practitioners in north Dublin. It is in the interests of the IMO and the HSE to do so. The majority of IMO members would like to see a reasonable number of GPs in north Dublin. We have challenged the organisation to negotiate and overcome the hurdle of restricted numbers. We will accept any help the committee members can provide in communicating this message.
Senator Feeney referred to the national children's hospital. This is of interest to her because of the issue of travelling, upon which we focus. Senator O'Meara referred to the report drawn up by the Nenagh hospital action group. Nobody has been appointed but we are in the process of beginning a review. A movement is beginning in the mid-west and this is most welcome. All these issues must be resolved at a local level. Whether one implements the Hanly report, creates the HSE or leaves administration of the health services to the Department, local people are best placed to resolve these matters. I was encouraged by recent meetings between consultants and others in the mid-west, especially in Limerick and Nenagh. The HSE offered to facilitate that by producing an area review. Perhaps the document to which Senator O'Meara referred, the Nenagh report, has application on a wider level throughout the country.
It is a specific report on Nenagh and the mid-west.
Professor Drumm
This must inform the review but nobody has been appointed at this stage. Procurement is a slow process but we will have definite timeframes for its completion. We must address the challenge of moving to a system provided by decision makers rather than a huge number of junior hospital doctors, which costs us a fortune. This presents a challenge in terms of how we are configured locally and our primary care services. The country demands that we deal with this in a mature fashion. Major opportunities exist for Nenagh from that approach.
That is correct. It is contained in the report.
Is there a difference between Professor Drumm's use of primary care teams and primary care centres?
Professor Drumm
No. I refer to Deputy Cowley's point regarding the urology services that ten new patients and ten review patients are seen every month. There has been an effort to improve the service in Galway. I do not know if this has had an impact on Mayo.
There is a third consultant but a urology unit is needed. There is also a locum who will be appointed to a permanent position. However, this is still not sufficient.
Professor Drumm
We must address that issue. We accept a rheumatologist is necessary and we intend to include it in this year's Estimates.
Will Mr. O'Brien comment on the issue of neurosurgery beds?
Mr. O’Brien
The only comment I will make is to state that a total review of neurosurgery and neurosciences is underway. It is an internal review comprising a number of people from population health, the NHO and the PCCC. We hope to report on it shortly.
Professor Drumm
The National Rehabilitation Centre is part of the country's major capital plan. It is a voluntary agency and we must reach agreement on its size and on how it affects the rest of the country. It is on the agenda. We will have an earlier response on the neurosurgery report.
Before we finish, I pay thanks to the Tánaiste and her officials. Her appearance has created a record as she is in her fifth hour before the committee. We appreciate her direct responses to questions. I am extremely impressed by Professor Drumm who also has been direct with us and we appreciate it. Very little was left uncovered this morning and afternoon.
This was billed as a meeting where a dispute might arise between the Tánaiste and Professor Drumm. I am delighted to state that no difficulties between the HSE and the Tánaiste presented themselves. We are all at one. I am also extremely impressed that both the Tánaiste and Professor Drumm see the difficulties as a challenge and they are up for it. I thank them and look forward to their next appearance before the committee, which I hope will not last as long. I am glad of the commitment to return every three months.
The joint committee went into private session at 1.45 p.m. and adjourned at 1.50 p.m. until 11.15 a.m. on Thursday, 6 April 2006.