I welcome the Minister for Health and Children, Deputy Mary Harney, the chief executive officer of the Health Service Executive, Professor Brendan Drumm, and their officials to the meeting. I intend first to ask the Minister to make some opening remarks and I will then call on Professor Drumm. As members will be aware, we are trying to implement a new procedure whereby I hope we will maximise the output of the meeting, and we will be trying as much as possible to stick to the time schedules we have set out. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.
Quarterly Update on Health Issues: Discussion with Minister for Health and Children and HSE.
I am pleased to be here before the committee. In the period since I last addressed the committee there have been many positive changes in the health system. However, there has also been a deterioration in the economic position of Ireland, as in many other countries, which will be a challenge for the public health services in 2009.
We have had an increase in spending on the health service over the past 11 years by an average of almost 9% per year. That will be reduced dramatically next year when we take capital and current expenditure to about 1.11%. It is about 3.5% on the current side year on year. Thus, by any standards we are facing a very challenging year. That is the reason for the importance of the reform that is under way to deliver more cost effective services and better value for money to patients in the appropriate settings. Since the last meeting we have agreed a new consultants' contract in which more than 1,000 consultants have indicated they wish to participate. We will have for the first time 300 public-only consultants who will be committed totally to the public health system. This is a major achievement.
Professor Tom Keane is making major progress on the implementation of the eight designated specialist cancer treatment centres. Breast cancer services have moved already from Mayo General Hospital to Galway and from Tralee General Hospital to Cork. It is anticipated that all services in the south east and the midlands will have undergone the transition by March of next year. The remaining hospitals to undergo the transition are South Infirmary-Victoria Hospital in Cork, Tallaght Hospital in Dublin, Our Lady of Lourdes Hospital, Drogheda, from which the service is moving to Beaumont Hospital, and Sligo General Hospital. It is anticipated that these moves will be completed by March of next year.
The new Medical Practitioners Act is now taking effect. This provides for a medical council with a lay majority, a much more robust form of regulation for specialist designations, greater authority in training and a greater role for public fitness-to-practice hearings. It includes many options for the council to deal with issues that fall short of fitness-to-practise issues. The same applies on the pharmacy side. We now have a pharmaceutical society that is structured under very modern legislation. The previous legislation was more than 100 years old.
Many members are interested in the fair deal legislation which is going through the Dáil. We expect this to have completed its passage through the Oireachtas in February of next year, or sooner if possible. It will take the National Treatment Purchase Fund three months to complete the procurement of the beds on behalf of the Health Service Executive. A total of €55 million has been allocated in the 2009 Estimates to implement the fair deal during next year. The purpose of the scheme is to establish equity between those in private nursing homes, for whom approximately 60% of the cost must be met by the care recipient or his or her family and 40% is paid for by the State, and those in publicly funded beds, either publicly provided beds or beds procured in a private nursing home by the HSE, for whom 90% of the cost is met by the State and 10% by the recipient. The new legislation, for the first time, will provide equality of treatment. It is long overdue. It will also take away much of the trauma and worry for older people and their families when they have to go into long-term care.
This legislation clearly cannot be seen in isolation. Home and community support, which is the preference of the Government, the HSE and older people and their families, must continue to be rolled out. In an ideal situation we would only place in long-term care those who have no alternative.
I will mention the issue of medical cards as I am sure it will arise in the course of the meeting. Clearly, the cost of medication in Ireland has risen very rapidly and currently accounts for approximately 16% of the cost of our public health services. It has risen by 4% since I became Minister for Health and Children four years ago, when the figure was 11%. It accounts for 25% of the services that are procured. Recently, we established a group, chaired by Dr. Michael Barry, that will look at cost-effective prescribing and identify areas for potential savings. I look forward to receiving Dr. Barry's report in due course.
In respect of nursing homes, Members will know that the Health Information and Quality Authority, HIQA, has been in consultation concerning draft standards for those in residential care. The regulatory impact assessment is almost complete and we hope to sign the new regulations into law early next year. There will be some months of run-in period in order for HIQA to have the resources in place to do the inspections and have the appropriate people trained. Many of those who will work for HIQA will move from the HSE. Discussions are under way between the HSE, HIQA and the Department of Health and Children regarding that matter.
With regard to the pharmacy contract, a court decision was made which we must honour. The court maintained that the Minister for Health and Children has the right to change the contract but only after pursuing a particular course. I am considering that and am taking advice from my officials. I hope to take an initiative in that regard very soon because I believe major savings can be made in that area.
I had only five minutes and the Chairman warned us not to go over time. I am sure that many other issues, for example, health insurance, will come up during questions and I will be happy to deal with them at that point.
I thank the Minister for facilitating us. I am sure Professor Drumm will be equally concise.
Professor Brendan Drumm
I thank the Chairman. I am joined by Ms Ann Doherty, national director of the National Hospitals Office, and Ms Laverne McGuinness, director of the primary community and continuing care, PCCC. In attendance also are Mr. Seán McGrath from the HSE human resources department and Mr. Liam Woods, the organisation's finance director.
I know that the committee has revised its protocols. We were given a list of priority issues and local issues. We have responded on the local issues and today my colleagues and I will try to address the other priority issues raised by the committee. I hope we can deal with all questions.
In brief, 2008 has been a challenging year. It was always going to be that way for the health services with regard to the service plan we had in place. This is not a surprise for an organisation that is implementing a major transformation programme and at the same time delivering and developing thousands of existing services. However, I emphasise that during the year we have made considerable progress on our journey towards a first class health service.
It is important to remind ourselves that we are experiencing the same challenges that face health services across the globe. It is sometimes forgotten in Ireland that services in Australia, Canada and many European countries face similar challenges. It could be argued that although we are behind what other countries have achieved as we move our focus to primary and community care instead of the acute hospital setting, we are well ahead of others in tackling this difficult issue. We are definitely on the right road. If we stick the course we will look back at this time as the period during which we put in place the building blocks for a truly patient-centred service that may eventually be an example to others.
The facts show that we are ahead of our service plan targets in many areas this year. This increase has been provided within budget, as indicated by data. I believe this is a most significant achievement for the organisation, considering that we are ahead of service plan commitments.
Day case attendances and outpatient attendances are up by approximately 8% on last year. Home care packages that involve tailored community-based services such as public health nursing, physiotherapy and occupational therapy provided in people's homes, are up by 10% on last year. These are intense services to provide. Home help hours are up by 3%. The number of people receiving palliative care services is also up significantly. The number of adults waiting over 12 months for inpatient treatment is down by 48% from this time last year and the number waiting over six months is down by 12%. The number of adults waiting over 12 months for day case treatment is down by 64% and the number waiting over six months is down by 16%.
The number of medical cards issued is at a record level of 1.38 million and the increase in September of almost 14,000 was double the monthly average increase. Long-term illness claims are 57% ahead of target and the drugs payment scheme claims are 29% ahead of target. The number of contacts with the out-of-hours general practitioner services is 11% ahead of target. Although presentations at our accident and emergency departments are up 3.5%, the average daily number of patients awaiting admission has fallen from 179 in 2005 to 106 in 2008. Patient waiting times for longer than 24 hours, following a decision to admit, have been totally eliminated in 21 of our 34 hospitals and a further eight have very infrequent waiting times of that duration. In addition, 25 hospitals, a majority, are now fully or substantially compliant with the 12-hour wait target.
Despite what many people would like to suggest, every day thousands of HSE staff are providing excellent services to the community at large. They are focused on delivering results and deserve recognition for this performance. I wish to point out that the delivery of this increase in services within budget was obtained by focusing on the value for money savings programme during 2008, amounting to €280 million. The staff of this organisation have delivered on the changes necessary in order for that saving to go to front-line services.
With regard to 2009, the allocation by Government to the HSE is ahead of that last year by 3% to 4%. Given our country’s very challenging economic climate, we obviously welcome that. Next year will be financially demanding and maintaining 2008 service levels will be a considerable challenge for us. We will have to do more with what we are given and, as an organisation, we are prepared to take up that challenge. It means significant change for all of us. We will have to maximise our efficiency, streamline how we do things, trim costs, cut out duplication, reduce over-reliance on high cost acute hospitals and provide more integrated community-based care. During 2009, not only must we repeat our strong value for money performance but we must also reduce or avoid further costs by reaching additional savings targets.
The organisation is determined, as am I, that, despite these savings, we will maintain essential service levels. However, we cannot deliver on this challenge alone. We need continued leadership and buy-in for our programme of change. This must come from a whole host of groups, internal and external, that are in positions of influence. They include clinicians, managers, all staff funded directly and indirectly by the HSE, union representatives, Government, including the Department of Health and Children, public representatives and the public. I hope that in the current climate this support will be forthcoming.
Modernising services gives us the best chance to improve quality and safety and to maintain overall service levels. Three or four years ago we said that an increase in beds would not solve the accident and emergency department issue. With a reduction in bed numbers over that period, that issue has improved very significantly. This is evident in specific instances.
Taking our programme forward will involve winding down some services that are not viable from a safety or cost perspective. It will involve building up services that are more relevant to the requirements of the people in the communities affected. These types of changes are in keeping with our overall strategic direction as set out in our corporate plan 2008-11. Our focus on strengthening community-based services continues and, as a result of the commitment from Government, more new developments will be rolled out in 2009 at primary care team level. By 2011, the infrastructure for well over 200 such teams should be in place.
We will continue to integrate hospital and community-based services to provide more streamlined services. We will develop more direct clinical involvement in management and at the same time devolve more responsibility and authority locally within our newly evolving structures.
In July we outlined details of our programme, National Integration with Local Responsibility, to accelerate us in this direction. Our objective is an integrated model of health and social services that has service users at the centre. It ensures that all services are delivered as close as possible to people's homes.
Since July a significant amount of background work has been carried out. Successful implementation of this initiative will empower front-line clinicians, other clinical staff and managers to make more effective local decisions that will benefit patients and clients. It will enable them to identify with a single entry point to the health service rather than having to navigate their way around the system. They will be confident that through this single access point they will be able to receive all the health and social services they need in a joined-up co-ordinated way. This should result in a significant reduction in the number of people having to use hospitals and take beds to access services that should be available locally.
I take this opportunity to emphasise that these changes will continue to be introduced on a gradual basis during 2009 and 2010. There will be no big bang. That is what people seem to expect. There has been evolution since we began. I stress these changes will enable us to build a service based on a structure that is locally driven, integrated and lean, with the minimum number of organisational levels. It will enable us to better focus on local needs.
Throughout the process we will remain true to our organisation's values. All engagements with staff, who can sometimes feel threatened by these changes, will be shaped by our commitment to dealing with people with fairness, equity and respect. Despite the challenges ahead, our direction and focus is strong. We are continually making progress in developing a health service fit for purpose in the 21st century, which I maintain is totally different from a health service fit for purpose in 1950. We must acknowledge the inspiring commitment and enthusiasm of staff in caring for others at local level. If one travels throughout the country one frequently witnesses the tremendous commitment of the staff of the organisation, who often take a great deal of criticism. I acknowledge the great commitment they make to our clients.
I find it very difficult to believe what I have just heard, but I will make several points. We have been told that the number of those who must wait in excess of 24 hours for admission has been virtually eliminated, but there are reports in the newspaper stating there are twice as many such people now as last year. We were told substantial progress has been made in the accident and emergency sector. Deputy O'Sullivan can show the committee the front page of a newspaper which reports a 40% increase in those waiting on trolleys for more than 12 hours. It beggars belief and we seem to be living in different worlds.
I will direct questions to the Minister for Health and Children before I ask questions of Professor Drumm. How will we maintain existing levels of service next year when 450 or 500 beds have been taken out of the system already this year and the Minister intends to withdraw a further 600? Perhaps the Minister will contradict my assertion and say that that report is incorrect. Can the Minister confirm whether 450 beds have gone out of the system and if it is intended a further 600 will go next year? These reductions negate the 1,300 put into the system and are in spite of the promise by the Minister in 2002 and again in 2007 of a further 3,000 beds.
How can we believe what we have been told today? The waiting time for a colonoscopy procedure, which was several months when Ms Susie Long passed away, is now nine months. The waiting times are contained in a report from the Irish Nurses Organisation, but perhaps those figures are wrong too. Let us return to reality. Why did the Minister for Health and Children proceed with the decision to change medical card entitlements when four days in advance of the budget she received advice from the Department of Finance to the effect that the changes would not achieve the goal sought, that they would cause litigation difficulties and so on, and that the easier course to follow would be to do what she eventually chose, albeit having upset the nation and all the pensioners throughout the country?
I question the Minister directly about another matter. I have a newspaper containing a quote from the Minister. In the report we were given to understand from comments made by the Minister that in vitro fertilisation, IVF, treatment would receive favourable tax consideration in that the applicable tax rate would not be reduced from the marginal rate to the standard rate. It appears that is not now the case. Will the Minister comment on that matter?
There is another report today that the recruitment of consultants under the new contract arrangements has run into difficulty. Will the Minister or Professor Drumm provide an update on that matter? I refer to the contract negotiations and repayment of fees to pharmacists. Is it the Minister's intention under the proposed legislation to allow the representative body to represent its members to facilitate orderly negotiation, having due consideration to competition law, especially since it is five years since they renegotiated their contract? When will the maternity hospital report be published? There are reports that it is in a crisis at this point.
I refer to the private health insurance measures. I asked the Minister in the Chamber some days ago for concrete examples, similar to those related to the fair deal, of how the measures will work for different types of families and I hope she can oblige us today. As I previously mentioned, of the nine fair deal examples cited, none included children.
Will the Minister provide an update on the Health Information and Quality Authority? When will it be given powers to inspect and censure both public and private hospitals? The Minister provided an update on the national cancer control programme. I note there have been delays in the north east with the programme. Will the Minister expand on this, explain when it will be rolled out and when the necessary levels of staff to run the programme will be put in place?
Will the Minister provide concrete information on primary health care? I submitted a parliamentary question on this matter but I have no record of a response. This relates to signed contracts for general practitioners and for new buildings. The proposals have been in place since 2001 and it was suggested they would cost €1 billion at that time, but the latest figures suggest a cost of €2.1 billion. Will the Minster consider kick-starting the programme with tax incentives or some other initiative? Clearly, there is not sufficient money in the Exchequer to do this.
The disability situation is of grave concern to people. People are very concerned that funding given to this sector in the past has been used elsewhere. Will the Minister provide an undertaking that funding allocated will be fully delivered, that the HSE will not unilaterally remove that funding and use it elsewhere, that delayed and removed funding for 2007 and 2008 will be returned and that a transparent and credible process will be put in place? Such a process could, through various mechanisms, prevent the HSE from spending elsewhere funds allocated by either the committee or the House for a particular area. In the case of palliative care and A Vision for Change strategy, the HSE decided certain allocations were excessive and decided to use these elsewhere in the system.
I welcome the Minister and Professor Drumm and I thank them for the presentations. I concur with the remarks of Professor Drumm that there are excellent people working in the HSE throughout the country. I wish to put that on record. The issues raised today deal primarily with structures and the spending of money rather than individuals. I am concerned for patients in the coming year. I read in a newspaper today that the HSE seeks savings of between €400 million and €500 million on operational issues. Given the cutbacks, of which we are already aware, and what has happened in the past year, it seems this is bound to affect the treatment and care of patients, which is very worrying. Will Professor Drumm indicate how the HSE will protect patients in that context? As Deputy Reilly suggested, there are figures and then there are contrary figures. The Irish Nurses Organisation website published figures outlining the number of people waiting on trolleys in hospitals and information on levels of nursing staff. I listened to Professor Drumm's presentation which sounds like a different picture.
The article in the newspaper, referred to by Deputy Reilly, suggests the number of patients waiting on trolleys has risen by 40% since the emergency in November 2006. In November 2008 there were 40% more people on patients on trolleys than at that time. What will the Minister do to address that issue? It is bound to get worse during winter and we now face what is traditionally the most difficult period with regard to patients on trolleys. One of the reasons for the increase is there are 756 people in acute beds ready for discharge. They are described as delayed discharge patients. I have the breakdown of figures for various hospitals throughout the country. These people cannot leave the acute beds because they cannot access nursing homes, public long-stay beds or supported care in the community.
I note there has been some increase in funding for home care packages and so on. However, there has not been nearly enough to cater for the need. Professor Drumm said there would be a 3% increase in home help and I am not certain whether that applies to 2008 or 2009, but the levels obviously do not cater for the need. What progress is being made in increasing the spend in Ms McGuinness's area of primary community and continuing care? It is illogical, a total waste of money and very hard on patients when there is such a number of people in acute beds. Beds are being clogged up to which other patients should have access. This increases waiting lists. The delayed discharge patients cannot return to the community because the services are not in place to support them.
The HSE will have been established for four years in January. What efficiencies have been achieved as a result of having a centralised service? Where has there been streamlining and a reduction in costs of overheads and management in order that the money can be spent on patient care? Savings have been identified in centralised procurement, but that should have been achieved by now. On the same day it was decided to proceed with the HPV vaccine in August there was a report from the Department of Finance which identified a sum of €20 million in wastage concerning bank accounts and salaries in the HSE. The money for the vaccine could come from such savings. What is being done in that regard? Have the savings identified by the Department of Finance been addressed?
On the issue of medical cards, I am not sure how a sum of €100 million will be saved and ask that the decision to take the medical card from those over 70 years be reviewed. There are ways by which savings can be made, particularly on drug prescription costs. Some issues were identified by Dr. Barry. I received a reply to a parliamentary question which stated there would be new guidelines on the prescribing of nutritional supplements. Have dieticians who are the experts in this field been consulted? Has the fact that savings could be made as regards nutritional supplements been considered? What consultations have taken place in this regard?
Will the Teamwork Management Services report on the mid-west which has been completed for over one year be published? It is being implemented but few have seen it. I have seen a copy, even though I was not supposed to see it. It should be published in order that we know what will be done.
On implementation of A Vision for Change, will the five year plan for hospice care be published? I understand the implementation plan of the national advisory committee on palliative care is ready. It is important that we know the road ahead. Even if there are issues with the availability of funding, it is important that the plan be published.
I thank the Minister for the reply on the Brothers of Charity services in Bawnmore in Limerick. I received a reply from the local disability service in the mid-west which does not have the money to give to the service in Bawnmore. There is a danger than 100 people will lose services and that 60 people will lose their jobs. Can the HSE find some funds at national level for the service at Bawnmore to keep it going next year? It is providing services for those who need them.
Will any savings result from the new consultant contract? It seems it will cost more, not less. Will more consultants be recruited? Was it a bad deal in terms of payments to individual consultants? I think it was, particularly as regards how much consultants will be paid and the cost to the public purse. Will their use of public hospitals and facilities, as well as the 80:20 breakdown, be monitored in line with the report of the Comptroller and Auditor General?
Public patients wait much longer than private patients. There are 1,000 people waiting for more than six months for appointments and bowel cancer surgery. Will the Minister confirm that money has been allocated to the national cancer screening service for the preparatory phase of the roll-out of the national bowel cancer screening service? Will the vacant gastroenterologist posts be filled?
I could say much more. However, my colleagues will raise the issues of disability services and hospital staffing.
I thank the Minister and Professor Drumm for coming to discuss these issues.
We must look at the background against which we are working. The funding available to the health service will be €16 billion in 2009, almost €15 billion of which will go to the HSE. It is a substantial figure and amounts to 25% of the total budget of the State. We must also recognise the improvements which have taken place which were mentioned by the Minister and Professor Drumm. They include cancer control, the provision of new consultants, the fair deal legislation, the provision of funding to provide for improved maternity, renal and cystic fibrosis services. It is important that we recognise what is being done, what has been done to date and the increases in output referred to by Professor Drumm, because we owe it to the 120,000 who work at the front line in providing a first-class service. We recognise that there are difficulties in access, but we must also recognise the good work being done. No country is able to provide the level of service required to meet demand.
On medical training, it begs the question of whether we should teach health economics as part of the undergraduate curriculum from pre to final med. Irish medical professionals, wherever they go in the world, will encounter the same problem — they will not have the funding to do everything they would like to do. However, I would like to see them take a greater interest in decision making. Against a background of limited resources it would be useful if health economics were taught as part of a training course.
We will have financial difficulties in 2009; we have been around this track before. We like to think it is possible to exempt health services from having to save but social welfare, health and education services account for 80% of the budget; therefore, it is not possible to exempt them. Against this background, many of the savings that must be made in the health service can be made through greater efficiency. What new initiatives have been taken to ensure we achieve savings through greater efficiency? There is an increase in the number of day surgical procedures to prevent patients from having to stay in hospital and the length of stay in hospital has been reduced significantly during the years. What figures are available for a comparative analysis between hospitals delivering the same services to ensure we can obtain value for money and best practice?
A question arises as regards the National Treatment Purchase Fund. One example is the orthopaedic unit in Navan. Is there a way for staff to be paid to do the work and secure better value for money rather than having to resort to the fund?
Another question which arises is the funding specifically designated for particular services such as disability services. That funding may be transferred elsewhere within the Health Service Executive. Can something be done to ensure that funding so designated goes to the specific area for which it was allocated?
On the question of the development of primary care units, how is that area expected to progress in 2009? We all have the same mission irrespective of what side of the fence we sit on, whether Members of the Oireachtas, the Department, the Health Service Executive or those working at the front line, which is to provide the highest level of service possible for the people who must always come first. I do not want to be parochial but my final comment is that I would not like to see any change in the existing level of hospital services in any of the five hospitals in the north east until we can guarantee a better and safer service for the people.
Three minutes are available in the protocol to each other member. I call first Senator Phil Prendergast followed by Deputy Margaret Conlon.
Where, and in what numbers, does the HSE intend to close acute hospital beds in 2009 to operate within its health allocation? Where, and in what numbers, does the HSE intend to introduce continuing care beds in 2009, as part of its service plan for 2009? In view of the marked increase in the levels of overcrowding in accident and emergency departments across the country in recent weeks, what contingency measures will be brought forward and applied within the next three months to deal with the situation which is worse than when it was called "a national emergency" by the Minister more than two years ago? In view of the stated intention by the HSE to reduce its overtime by 50%, its agency bill by 75% and its on-call bill by 25%, how is it intended to maintain services at a level safe for patients and in a manner which meets all their needs in 2009?
Has any recruitment been achieved in the nursing home inspectorate? Will the CEO confirm the assurances given through responses to parliamentary questions to my colleagues in respect of the continuation of maternity services at the present site at South Tipperary General? I had also tabled a question on an ambulance service for Carrick-on-Suir which has not been addressed.
In respect of the report on St. Luke's Hospital on last night's news, which was flawed and unbalanced, the staff and management in the facility provide an excellent service. RTE did not ask for a comment from any member of staff or management which is a disgrace. An independent inquiry carried out by an consultant orthopaedic surgeon showed there was no improper service or mismanagement of any of its facilities. Such reports are unfair.
Will a Supplementary Estimate of €60 million be provided to pay the consultants increase to the end of the year? Is there a proposal to suspend the introduction of a pension scheme for home helps to save €6.5 million next year? It is unfair if home helps pension schemes are to be suspended to save that amount and yet consultant increases proceed at a cost to the Exchequer. I see no validity or fairness in that proposal.
Will the witnesses clarify if there is a proposal to replace half of the estimated 850 retiring nurses next year by health care assistants at a saving of €10 million?
For the purposes of clarity, our three minutes in this slot are to focus on priority national issues. We have 30 minutes later to look at general and local issues flagged by way of questions.
I too welcome the Minister, Professor Brendan Drumm and officials to the committee. I wish to commence with an issue in respect of the north east which is of national importance. However, I will be a little parochial as I wish to discuss Monaghan General Hospital and its future. I agree, as do many people with whom I have spoken, that rationalisation is necessary. That an area covering four counties has five hospitals is not sustainable into the future. Services have already been removed from Monaghan General Hospital. I am not seeking their return because I believe that was in the best interests of patients. People are prepared to travel for complex procedures and they are happy with that. The medical unit in Monaghan General Hospital works well. We are dealing with an elderly population. The last time the hospital came off call, people died in ambulances at the side of the road. I do not want to return to a situation where that happens.
We are seeking increased home care packages and a thrombolitis service which has not been tried and tested in the area. I have to say directly to the HSE that the public lacks confidence in the HSE. It has lost the PR battle. It is always on the defensive. Following the leaking of a document or memo into the public domain, the HSE reacts and defends rather than being proactive.
So far as I am concerned — I have yet to be proved wrong — Cavan Hospital will not be in a position to cope. It cannot cope at present with the patients it has, not to mention an influx of patients from County Monaghan. The medical assessment unit is welcome. However, it is not in operation and has not been tried and tested, reviewed and monitored.
Professor Drumm talked about increased home care packages but they are spread too thinly. If an elderly person is offered half an hour per day, with no cover at weekends, that is not a quality service. That is the reality. We are getting telephone calls from people on a daily basis who are seeking a little more.
The difficulty is that there is a rush to move things. While Professor Drumm said there would be no — I forget the phrase he used — big bang in regard to this issue, it is almost here and people do not have confidence in what is going to happen. We need to know that additional beds will be available and that resources will be put in place to ensure a safe and better service. I would argue that any person, irrespective of class, creed or location, is entitled to a high quality, high standard safe level of care. The north east has not been resourced properly and is the Cinderella in terms of health spending. A bed in the medical unit in Monaghan General Hospital is a far better quality service than lying on a trolley in Cavan Hospital.
When will the extension to Our Lady of Lourdes Hospital, Drogheda, be completed? What will be the net gain in terms of beds? What are the plans for the other floors in that extension? Are there any plans for a medical assessment unit?
My final point concerns disability and the provision of disability services. This has been a priority of Government but I am not convinced it has been a priority for the Health Service Executive. How is it that €53 million was not spent in 2006 on disability and mental health? Many of the disability organisations have not gone over budget. Many provide independent voluntary funds, yet the HSE took funding allocated to them to pay off other elements in the health service. Who was aware of this? Were the disability stakeholders made aware this was going to happen? The disability stakeholders have no confidence that commitments entered into will be honoured. I do not believe the Health Service Executive can unilaterally use any disability and mental health funding for other purposes because as the economy continues in its current direction, there will be greater challenges facing us in terms of mental health. People will find it extremely difficult to cope and they will be looking for services. I want to know that the money will be available to resource those services.
I will try to remain within the time available to me. I welcome the Minister, Professor Drumm and his team. From the level of interest here they will realise that we appreciate their attendance.
I have specific items on the agenda on which I hope the representatives will be able to give me some answers. In the briefing document we got from the HSE, I note there are now 98 fewer hospital beds in Cork. I listened carefully to Professor Drumm earlier, and had already read his script, and the point he made that fewer people are spending less time on trolleys. I had reason to be in the Cork University Hospital in recent weeks. The person involved got the best of treatment, and the staff were particularly sensitive and caring, but leaving that hospital on several nights through the accident and emergency department the same people were on the same trolleys lined up along the corridor. I passed an outpatient department late one evening and met a nurse who told me that she was still there because a patient in the outpatient department was waiting on a bed. That was between 7.30 p.m. and 8 p.m. The notion that the structures have improved is wrong.
Cork University Hospital may not be among the 21 hospitals Professor Drumm mentioned but it is dealing with a huge volume of people because 98 beds have been closed in the other two hospitals. That does not make sense to me in terms of trying to relieve the burden on the hospital. The other beds should be opened but that will not happen because the money is not available to open them.
If I do nothing else in my time here, getting a rehabilitation unit for the south, which I do not consider a major achievement, will make me very happy. A new committee has been set up by the Minister, which I appreciate, on which there are between 18 and 20 members. Of those people, 16 are from Dublin and two are from Galway. All of them are involved at a professional level in the delivery of a rehabilitation service in the Dublin area. What interest do they have in providing a rehabilitation service for the south? Human nature being what it is, they will say that the service is better off being centralised, yet 1,500 people are admitted to hospitals in the south every year with acquired brain injury. I can tell the witnesses what will be the recommendation of that committee. It will call for an expansion of the service in Dublin, yet we know from all of the research that people fare better if they are treated as close to their own locality as possible. It is a quicker, better service and it is a question of reintegrating them into communities. We must examine that issue.
Several speakers mentioned ring-fencing the funding for disability services. As legislators we cannot pass an item in a budget only to have it removed. That should not happen but it happened in respect of the mental health services.
What is the protocol regarding cases involving those who attend at psychiatric units with suicidal tendencies but who are sent home? I have had two terrible experiences this year already in respect of that area. Has the Minister made any progress on the contract with doctors and the over 70s medical card?
I will conclude by asking the question that no one wants to answer. Will the executive of the HSE be taking their bonuses this year?
I, too, want to be associated with the warm welcome extended to the Minister, her staff, Professor Drumm and his colleagues. I will remain within the Chairman's protocols which means that any mention I make of Tallaght is in the national context.
Tallaght is a national hospital.
I am happy to acknowledge that the Minister knows all about Tallaght.
Not as much as the Deputy.
There is an important point to make regarding what Deputy Kathleen Lynch said. We all have priorities. Everybody wants to make a case for themselves, which is only fair. In that context, I support what other colleagues said about the ring-fencing of funding for disability and mental health services because that is an important issue. Everybody will want us to lobby for them but it is important that those services, which are important, are retained.
It is also important that Professor Drumm in particular would understand that at a time when the economy is being challenged the people expect us to speak up for the various services required. Primary care budgets are something in which I am interested, not only in my own constituency but throughout the country. When there is pressure on hospital services it is important that we would make that point.
The presence of my colleague, Deputy Dan Neville, and Senators Phil Prendergast and Mary White, reminds me of the work we are doing on the sub-committee on suicide. We hope to bring forward a report in that regard. I say to Professor Drumm that there is a demand, even at a time of constraint, that those issues would not be neglected, and I am making a serious pitch for that.
In the report before us there is information on the question of the delivery of national paediatric services and the new so-called super hospital on the Mater site. The Minister will be aware that the Tallaght Hospital Action Group has been given the impression by people involved with this project — I have mentioned this to the Minister — that this project will not go ahead because of the difficulties facing the economy. It is important that Professor Drumm and the Minister would make their intentions clear because I do not want my constituents to believe the super hospital will not progress. That will have a spin-off effect on the delivery of children's services, particularly in Tallaght.
I realise everybody will have a go at me for mentioning Tallaght only, but Tallaght is the third largest population centre in the country. It has its own children's hospital. There is an expectation about the services and we need to deal with the issue up-front. Will the super hospital project go ahead and, if so, what is the position with regard to the future delivery of services? We have addressed the issue of the future delivery of services previously with Professor Drumm but it has arisen again and some people within his circle, if I can use that phrase, are creating some confusion, and I need to know what is going on.
There is a report before us on the delivery of cancer services in the Dublin region, particularly from Tallaght Hospital. I do not mind being accused of being parochial but everybody knows that first class cancer services are being provided at Tallaght Hospital. Reference was made earlier to bowel cancer. A radical programme was introduced recently dealing with bowel cancer, which will have many positive effects in terms of the rest of the country. Even in this report we are being told that given the current breast cancer workload at Tallaght Hospital, there is still considerable work to be done. There is no question that the cancer services being provided at Tallaght are first class, yet confusion remains about what will happen in the future. It appears the plan is to remove those services from that area. Those questions must be answered.
Along with other members I welcome the Minister, Professor Drumm and the officials to the meeting.
Like my previous colleague, I will be briefly parochial, as I have heard comments about other hospitals throughout the country concerning waiting time for accident and emergency departments and bed capacity. I compliment the Minister and Professor Drumm on the excellent work they have done. I had a stay in my local hospital in Letterkenny. Vast improvements have been made in reducing waiting times and in the management of beds. Two or three years ago the national outcry around health issues concerned the blockage in access to hospital services, the waiting times for patients in accident and emergency departments and shortage of hospital beds, but that is not the case now. Credit for that change is due to the two individuals present.
I am aware of the great lengths to which the hospital management and staff of accident and emergency departments have gone to streamline the treatment of patients in accident and emergency departments. If that same workmanship was adopted elsewhere, hospital services and the workings of the HSE would be much healthier. If the work ethic that currently prevails in accident and emergency departments and in the management of hospital beds prevailed across all services there would be good times ahead. We need to work to ensure such a change in mentality occurs.
A letter sent to Ms Ann Doherty, whom I am glad to see here, seeking the appointment of a second consultant neurologist for the north west region, was copied to me yesterday. I have a copy of it for the Minister and Professor Drumm and will give it to them before the meeting concludes.
The question I put down, which some people might say is not related to health, concerns a pertinent issue, that of the HSE pre-tendering for contracts such as a hospital extension. A condition applies, although it is not standard across the board, concerning the turnover a contractor must have for the previous year, in respect of which a figure has been picked out the air. Local contractors, in the main, have built hospital extensions for the past ten, 20 or 30 years. Under the current process, they are being ruled out of tendering for this work and in current economic climate that is not healthy. Only the multinational companies can tender for these jobs. The building of a hospital extension is not rocket science, the work involved is fairly simple. I appeal to the Minister and Professor Drumm to ensure that the process is reconsidered as this is necessary in the current economic climate.
Deputy Awlyard had to leave the meeting and requested that I ask his questions. If there is agreement on that, I will use the three minutes allotted to him to ask those questions.
He is listed to speak and I will come back to the Deputy.
He may be back at that time.
I welcome the Minister, Professor Drumm and their advisers to the meeting. The Minister will understand about accountability and transparency.
On a personal basis, I thank Professor Drumm for his reply to my request for the provision of a dialysis service in Limerick. I have experience of the service as my wife is one of the people who has travelled the 12-hour return journey from Limerick to Galway for dialysis since January. I note that arrangements will be made for the treatment service to again be provided locally in December. I thank him for his reply, which was important to me and to my family.
I would like to raise with the Minister and Professor Drumm the issue of psychiatric services on suicide prevention, which they might have expected me to raise. I put down three questions, replies to which are not included among those given. They might advise why the three questions I put down on 22 October are not included in the replies we received. I put down four questions and received a reply to one of them. There is protocol in place for these questions, perhaps there is a good reason replies were not given to these other questions but I do not know it. The chairman is privy to the questions I put down.
I want to raise with the Minister and Professor Drumm the issue of psychiatric services for suicide prevention in times of recession. I am sure they are aware of research by Durkheim dating back to 1897 which found that in periods of recession an increase in psychiatric illness, especially depression, and in the incidence of suicide occurs. The most spectacular example of that occurred at the time of the 1929 crash, but research throughout the world has shown that in the 1930s, 1940s and 1980s an increase in the incidence of suicide, depression in particular, and in other psychological illnesses occurred.
The Minister, Deputy Hanafin, rightly said she will protect the vulnerable who are in receipt of social welfare benefits and ensure they are taken care of. She said the physical conditions and needs of those who are unemployed and are rendered unemployed will be taken care of. I put it to the Minister, Deputy Harney, that the psychiatric and psychological needs of our people must also be taken care of in that services must be able to respond to the increased incidence of mental illness and suicide. We have had indications from the Department that there will be a reduction in the funding for psychiatric services. This is to happen at a time when we must respond to a need in this area that requires increased funding.
At the previous three meetings we discussed A Vision for Change. On the last occasion I was told €30 million of the funds allocated for 2006 and 2007 had now been spent. The commitment was that €25 million would be spent over a period of six years to implement A Vision for Change. However, €25 million was allocated for two years. The Minister informed me earlier this year that she would not allocate any money for A Vision for Change because she was not sure it would be used for the purpose she intended. Of the €51 million allocated only €27 million was spent for the purpose intended. I can understand where the Minister is coming from if she allocates money for a purpose and it is not spent on that area. The Minister and Professor Drumm might both respond on the progress being made on the implementation of A Vision for Change because if only €3 million of the €51 million allocated is spent on this area each year, it will be nine years before the funding allocated for it will be spent.
I wish to briefly and succinctly deal with the issue of suicide. The National Office for Suicide Prevention has an allocation of €3.5 million for the implementation of the provisions of Reach Out, the report of the expert group on reducing the incidence of suicide. In times of recession when there will be an increase in the incidence of suicide, in attempted suicide and in self-harm, I put it to the Minister that the budget for suicide prevention should be substantially increased and it might not be unreasonable in the circumstances for it to be increased from €3 million to €10 million.
I welcome Professor Drumm and the Minister, Deputy Harney. I have a few national questions that I would like to ask them. There has been quite a number of reports in the press in recent weeks indicating that the people who will invest in the co-located hospital projects are encountering difficulty in accessing funding. How many of the original eight co-located hospital projects do they expect to go ahead? What is the time frame for their completion? Have there been any cancellations of those co-located hospital projects? I would like them to give us an update on that.
When does the Minister intend that letters will be sent to medical card holders aged over 70? Have they already been sent to them? The Minister said she would make sure a new application form would apply and that it would be much simpler than the current one. Has progress been made on that? If so, is it intended to introduce a simplified version of that form for all people applying for the medical card or will there be a different form for those over 70? Perhaps the Minister would also update the committee on the situation with the general practitioners and the recommendation for a flat fee and Mr. Eddie Sullivan's report. How many general practitioners have signed up to that? What is the current situation?
With regard to mental health funding, what saving is being made by not implementing the EPSEN Act? How many people will be affected by that? How many would have received services and been assessed if it had not been postponed in the recent budget? With regard to the €25 million that the Minister told this committee had effectively gone missing from the mental health budget, has it been found? Where will it now be spent? Will it be spent in this year's budget? Can the Minister give a timeframe for when we can be sure that children with psychological problems will not be placed in adult psychiatric wards? The number has been reduced somewhat but a significant number of young children, some as young as 13 years old and many aged 15 and 16 years, are still being put in adult wards. Is there a timeframe for this practice to end? What is the Minister's expectation on this issue?
My final question is for Professor Drumm. In the Fitzgerald report there was considerable concern about people in the HSE not being clear about their jobs as their roles were not clearly spelt out. Professor Drumm was to take action to change this situation. Can he update the committee on how he has gone about that and what progress has been made to tackle the issues of lack of job definition and people not knowing what they should be doing in the HSE?
I compliment the Minister and the Department for bringing forward the nursing homes support scheme, the fair deal. As the spokesperson for the Government party in the Seanad, I am an ardent supporter of the scheme and have spoken about it on local radio stations throughout the country. I have received many requests from people for information on details about which they are apprehensive. I thank Mr. Darragh Scully for his support in the work I have been doing in spreading the word about how good the scheme is.
I am Vice Chairman of the Oireachtas committee on suicide. I am convinced there is an epidemic of suicide in Ireland. It is not hitting the political radar. There is a stigma surrounding suicide and mental illness and that is the reason there is not a sufficiently strong lobby demanding that this issue be dealt with. There is also evidence that the recession is causing people to die from suicide. I have dealt with requests that I go to talk to people and help them to deal with banks and so forth that have them under pressure. Currently, four suicide prevention officers are not in place in the health service. Cavan, Monaghan, Louth, Meath, west Dublin, Kildare, Longford, Laois, Westmeath, Offaly, Wicklow and south-east Dublin, which comprise four regional areas of the HSE, do not have a suicide prevention officer in place. This is serious neglect. If there is a crisis, I would not wish to be the person responsible for suicides in these areas if a suicide prevention officer is not put in place. Many people throughout the country are desperate for help on this issue. When will these officers be in position? This is my third time to ask about this.
In my document, Suicide in the New Ireland, I drew attention to the inadequate training general practitioners are given on suicide in the course of their training. People have told me that when they brought their children to general practitioners, the children were told there was nothing wrong with them and that they should pull themselves together. Training of general practitioners is a serious issue. In addition, for the third time I wish to raise the weekend availability of social services. Most suicides happen at weekends and on Mondays, when the social services are down.
Will the Minister indicate the main features or initiatives of the national task force on obesity that will be advanced in the coming year? With regard to the ring-fencing of disability and mental health funding, there are ongoing problems related to the €53 million that was not spent in these services. The Comptroller and Auditor General states in his conclusion to his 2007 annual report that the HSE must address a number of key factors, including ensuring that once service choices and priorities have been established and included in a service plan with an associated allocation, the focus at each level of the organisation is on providing an agreed level of service within the agreed resource allocation.
Will the Minister confirm that money has been allocated to the national cancer screening service for the preparatory phase of the roll out of a national bowel cancer screening service in 2010? Could she inform the committee when she intends to introduce the cervical cancer vaccination programme? It should not have been stopped and I hope it will be introduced as quickly as possible.
The issues I wish to raise are also national. Any diminution in acute hospital services, wherever it happens, diminishes each and every one of us. How does the Minister and the chief of the HSE account for the daily figure for patients on hospital trolleys? It reached 283 in November 2006, 290 in November 2007 and this month it has reached 406. This is contrary to what was repeatedly promised since the health strategy was published in 2001 and the establishment of the HSE. We were promised that the placement of patients on trolleys and in other inappropriate settings would be reduced. The contrary is the case; it is rising continuously. Will the Minister and the chief of the HSE note that there was a record 45 sick patients on trolleys and in other inappropriate settings in Cavan General Hospital on 17 November?
The second point I wish to raise is the apparently imminent closure of acute medical services at Monaghan General Hospital and the displacement of a further 3,000 inpatients annually from that hospital site to Cavan, where there are currently 5,000 inpatient admissions. That is operating on the basis of 160% bed occupancy. With 45 patients unable to secure a bed on a day earlier this month, how will Cavan General Hospital cope with the displacement of a further 3,000 patients from County Monaghan from a date early in 2009 when not a single additional bed is to be provided? That is the reality the Minister, the Department and the HSE propose to visit on the people of Cavan and Monaghan. It not only involves suffering in County Monaghan, but also in County Cavan, where already hard-pressed front line service providers find the situation becoming intolerable.
Despite the stated intent concerning the so-called outworking of the team-work report, I make an eleventh hour appeal to the Minister and Professor Drumm because if the time frame for the closure of these acute services at Monaghan is to proceed as currently signalled, we will not have another engagement with them beforehand. Are they aware that what they propose to do comes against the backdrop of an internal audit of the provision of acute medical services at Monaghan General Hospital? I am a cardiac victim who presented there only last year; I can attest to the high level of service provided at that hospital's cardiac care unit under Dr. Brendan McMahon. The HSE's internal audit demonstrates that Monaghan's standard of service provision is as safe, comparable to and in many areas superior to that at many larger hospitals.
I sincerely ask the Minister and Professor Drumm to pull back from their insane plan, which will result in untold suffering. It is unsustainable in any shape or form. One cannot sustain the arguments by the Minister and Professor Drumm, which do not hold up to serious scrutiny. They must retain acute medical services at Monaghan, which is the only answer both for those who depend on them, as well as for the future of services at Cavan General Hospital.
My next point concerns the closure, as of 17 November, of all elective orthopaedic procedures throughout the entire north-east region. Doctors have continually pointed to waiting times in Navan as being well below national targets due to the orthopaedic unit's efficiency, yet some 44 patients — and that number will grow — will have to wait until 2009 with the consequent suffering that comes from that. However, Professor Drumm has repeatedly stated that efficiency will be rewarded. If, as the statistics suggest, it is efficiency that has seen such a throughput at Navan in recent months, why is the HSE penalising the hospital by closing elective orthopaedic work there, rather than recognising efficiency and allowing the service to continue?
Can Professor Drumm quantify the savings when one must retain the hospital along with lighting and heating costs, as well as paying consultants, nursing and support staff?
The Deputy's point has been very well made.
How can Professor Drumm sustain his arguments on the basis of cost savings when there cannot be any?
Can Deputy Blaney briefly put the questions that Deputy Aylward had?
I will do so as quickly as I can. His three issues concern primary care centres in Callan, Ferrybank and Thomastown in County Kilkenny.
They will come up later in the meeting concerning the clarification of general issues on which written replies were issued.
May I make a general point?
Yes, please.
I think I speak on behalf of all members here concerning the polio group that met us earlier this year. The group made a plea for the committee to ask the Minister and Professor Drumm about providing medical cards for people with polio. It would make life much easier for this small group of people whose circumstances are very difficult. I ask the Minister and Professor Drumm to give this matter due consideration.
I have two brief questions. The Minister and Professor Drumm cannot but have taken on board members' concerns about disability funding. There is grave concern that such funding appears either not to have been spent or to have been diverted to other areas. Can Professor Drumm envisage a situation in which he would report to this committee regularly on future expenditure of disability funding?
Our committee intends to embark on public hearings on primary care provision. I note from more than 30 submissions we have received to date on this matter that many of them focus on the question of tax incentives or capital allowances for those in the private sector who might get involved in providing these centres. Since it is very much part of public policy to drive forward the primary care strategy and deliver these centres, do the Minister and Professor Drumm see merit in some form of tax incentive that would be carefully targeted at the medical profession for the provision of these centres?
The Minister and Professor Drumm have 25 minutes to answer a host of questions. If we can, we will try to stick to 25 minutes for those responses. I call on the Minister to reply first, if she so wishes.
Many of the issues raised centre on resources and how we use them. I very much share the view expressed by Deputy O'Hanlon that no country has unlimited resources, whether its health system is funded by a social insurance model, central taxation or a combination of private insurance and taxation. Therefore the choice is always to decide what the priorities are within the resources available. Clearly we must continue to drive efficiency and value for money. There was a misunderstanding on the part of Deputy O'Sullivan when Professor Drumm spoke about procurement. The impression created was that it is just happening now, whereas it happened quite some time ago. It is delivering results now, so perhaps Professor Drumm would like to speak about that later.
As regards Deputy Reilly's questions on the taxation system, any Minister for Health and Children would look at whatever vehicles are available to get more money and investment for the health system. However, the prerogative for deciding taxation matters, including the health sector, is exclusively that of the Minister for Finance. That applies to IVF treatment and primary care centres. My understanding is that EU approval would have to be sought to extend capital allowances to primary care facilities. I also understand that many of the expressions to the HSE for the 200 centres have not sought changes in the tax regime, but perhaps the HSE would like to comment on that.
Next year's service plan, which has come in from the HSE, is currently under consideration. Sometimes we become a bit obsessed with the number of hospital beds, but no matter how many we have if they are not used effectively we will not get value or throughput from a patient point of view. Into next year, as over the past year, we will reduce the amount of inpatient activity and increase the amount of day case activity, in accordance with international best practice. For example, 64% of the Mater Hospital's surgery is done on a day case basis. Some 82% of St. James Hospital's surgery cases are admitted on the morning of the surgery. These are fantastic improvements. In Cork, the discharge at weekends is twice the rate of other hospitals in the country.
I grew up in Dublin so I know there is a particular issue in that it is supposed to be unlucky to come home from hospital on Saturday. We must get over some of these things. The new consultant contract is central to that. We want a consultant-delivered service, not just a consultant-led service delivered by junior doctors. We know that in all hospitals around the country, out-of-hours services, including at weekends, are delivered by junior doctors. That is not in the interests of patient safety or good patient outcomes, and it is certainly not in our financial interest. Effectively, junior doctors cost almost as much as full consultants. The new consultant contract therefore is not about giving more money to consultants, in case anybody thinks it is. It involves changing work practices, consultants working in teams, extended days, structured weekend cover and working under the direction of a clinical direction from among their peers. In our opinion, these are the ingredients that make for the best run hospitals in the world.
We were happy to agree the contract, which was implemented with effect from 1 June. We will be making provision in next week's Supplementary Estimate for the €70 million for the six months of this year. However, the HSE is not to pay that money unless the change has been implemented. This is not a pay increase; it must be made clear it is an increase in moneys to consultants for changed work practices. The money will only be paid on the basis of changes being implemented. When the HSE assures us that such changes have been introduced, the money will be paid. We hope we will be in a position to begin to pay it from the start of next year when the clinical directors come into play and the new practices come into effect. All the new consultants recruited into the system from now on will work under the new arrangements. Those arrangements will deliver much better outcomes for and throughputs in respect of patients.
We hope to sign the new HIQA standards into law early in the new year. There will be a transition period of a couple of months before those standards come into effect. We also want to transfer staff from the HSE to HIQA. It would not make sense to make people from one organisation redundant and to begin recruiting new personnel into another. There is major scope to transfer staff between the two bodies. Discussions are ongoing among the HSE, HIQA and the Department in respect of this matter.
For 2008, moneys for new developments have been ring-fenced. I am happy to state — perhaps the HSE will confirm this — that by spring of next year, 94% of the money allocated in respect of A Vision for Change will have been spent. I welcome this development. I accept that delays occurred early in the process but I am glad progress is being made.
When will that occur?
By the first quarter of next year. As already stated, 94% of what was allocated will have been spent. Members will be aware that in the past moneys that were allocated went in other directions.
Deputy Reilly referred to health insurance. The Government's new initiative regarding tax relief at source for those over 50 will be scaled up from €200 to €1,175 for those over 80. We are aware that this is necessary in order to make health insurance affordable for older people. One cannot have community rating without a form of transfer from younger people to older people. Following the Supreme Court case it was not possible to have risk equalisation. As a result, a tax relief scheme with a levy to fund it is to be introduced through legislation. The intention is to publish the legislation before Christmas but not to have it enacted because EU approval is first required. We need to present the legislation to the EU and provide it with an outline of the scheme. It would not make sense to spend time, in very pressurised circumstances, between now and the end of the current session passing legislation that might have to be changed. The intention is that the Government will approve and publish the legislation. Subject to EU approval, it will be debated by the Oireachtas early next year. It will be effective from 1 January. The scheme will last for three years because we want to work on a risk equalisation model. All the advice is that such a model will take some time to develop.
With regard to GPs, the new contract, etc., the new fee will come into operation on 1 January.
Will it replace the old fee?
Yes. Instead of fees of €640 and €163, there will be a single fee of €290. This will apply from 1 January. We are not free under Irish or European competition law to enter into negotiations. We have given a commitment to change the competition law but that is a matter for the Tánaiste and Minister for Enterprise, Trade and Employment. It is not intended to ring-fence it in respect of one organisation. However, this is all subject to legal advice. Fixing prices will not be allowable but it would be desirable to be able to consult and negotiate in respect of the nature of contracts with those who provide such contracts under the GMS.
I will ask Professor Drumm deal with the matter relating to the NTMA's views on banking. However, I understand ICT and other implications may arise in respect of some of the issues relating to banking.
Deputy Jan O'Sullivan raised many issues in respect of service provision, accident and emergency services, etc. I will ask Professor Drumm to comment on these. However, I am confident, on foot of the data available to me, that huge improvements have been made. We know that pressure points remain in existence. We have had discussions with the HSE, particularly in respect of late discharges from the acute hospital system. We want to consider the most innovative way of catering for the needs of long-stay patients. It does not make sense to have such patients cared for by acute hospital staff. This is not an effective use of the resource and it is far more expensive to provide care this way than to do so in a long-term setting. Resources may have to be transferred from the hospital side to the community side in order to allow for the adoption of innovative solutions in respect of this issue in certain parts of the country.
Deputy O'Hanlon referred to health economics, of which I am a major fan. The Department has begun a programme in this regard for all its officials, who are addressed by an economist from Trinity College one day each week. It is important that everyone who works in the area of health should be conscious of budgets and the limits on resources. I met a delegation in respect of a particular matter recently and someone said to me that what was being sought only amounted to €2 million. I made the point that already that day I had been asked to provide up to €100 million. Single issues often require small amounts of money but when one adds up all such amounts, one arrives at the kind of growth in expenditure that has occurred in this country in recent years.
We must all be conscious of budgets. I am strongly in favour of clinicians being involved in leadership positions. The great strength of the cancer control programme is that the policy was essentially devised by doctors. Either 17 of the 21 or 19 of the 23 people who recommended the policy were clinicians. Those responsible for implementing it are also clinicians. Policies implemented with clinical backing and leadership have a much better chance of succeeding.
Reports are important as roadmaps. Outside advice is always important for all of us, particularly in the context of how we should organise our services. There is a report relating to the mid-west. It has been the case for many years that as soon as a report is compiled, those who feel threatened by or who are frightened of its contents organise themselves and it never sees the light of day. The intention behind these reports is to discuss them, in the first instance, with staff and to obtain clinical leadership. I am sure members are aware of Dr. Burke, who has become clinical leader for the mid-west. Dr. Burke has engaged with many people in the region in the context of encouraging buy-in on the part of those who will be obliged to work under the new arrangements. That is the first prerequisite and, in my opinion, it is quite important. Spending taxpayers' money on consultants' reports when we are not in a position to implement what emerges from those reports does not represent an efficient use of such money.
The Minister will not publish the report because she is afraid of the public reaction to it.
No, I am not afraid of that reaction. We want to encourage buy-in from the staff in the region. It is a matter for the HSE to decide when the report will be published.
What about the public and the patients?
The manner in which structures are being put in place in the mid-west is extremely impressive. In my view, the new system will work. As the Deputy is aware, there has already been major buy-in to it on the part of the four acute hospitals in the region.
Professor Drumm and the HSE will comment on the issues relating to the north east. I thank Senator Mary White for her comments on the fair deal legislation. We hope to have the legislation enacted by February or March. I look forward to the speedy passage of the legislation through both Houses.
On mental health services, the National Office for Suicide Prevention has been allocated an additional €1.75 million for 2009 to allow it to introduce further prevention measures, particularly in the context of the national strategy for action on suicide prevention or Reach Out. I share the perspective of Deputy Neville who has been one of the strongest advocates on this issue for many years. I share his view that at pressured times such as when people are faced with unemployment or major financial difficulties in their lives there is often a connection between the two. Therefore, we must be ever vigilant in the services we provide. The majority can be provided at primary community care level. Perhaps the HSE delegates will talk about the progress being made in that regard.
Senator Fitzgerald raised the matter of young people in adult wards. Next year two new units will be constructed, one in Cork and the other in Galway, with 20 beds in each for young people and adolescents in order that we can reduce the need to have adolescents and children in inadequate and inappropriate facilities.
Deputy Blaney made a number of points with regard to issues being dealt with in County Donegal. I thank him for acknowledging the position has improved greatly on the ground and I am delighted that is the case. I know one issue of concern was the new development at Letterkenny hospital. People were pleased that the HSE was in a position to be able to proceed with it.
The issue of contracts is not entirely one for me, but I share the Deputy's view. The same applies to schools. We require people to be very big to get a slice of the action. From the point of view of the HSE, it wants to ensure it can get value for money and have the job done well. The criteria are matters for it. The same applies to the education sector. Many of my colleagues in the Government and I frequently receive complaints from small to medium-sized construction companies which in the past were able to successfully tender on a value for money and quality basis and win contracts. This is an important issue.
Senator Prendergast raised the issues of a skills mix and too many nurses being replaced by care assistants. We must have a better skills mix in the system. We do not work to best practice where there is an over dependency on nurses to perform duties that can be done by care assistants. Therefore, we must move to that model of care. The Senator is well briefed on the proposals the HSE has put to the unions with regard to a change in work practices that could deliver significant savings. Perhaps Professor Drumm will deal with that issue. We must all be open to greater flexibility.
Senator Fitzgerald asked about the timeframe for the co-location of hospitals. I am not aware that any company has cancelled. Project agreements have been entered into with a number of companies, but contracts have not yet been agreed. I understand there are discussions ongoing between the HSE and those which have succeeded in signing project agreements. Earlier this week Deputy Reilly raised in the House the issue of tax compliance of the successful bidders. One of the companies in question sent me a note yesterday on its situation. I do not know whether there is another company which is not tax compliant. It is the case that firms must be tax compliant to be in a position to engage in projects of this kind.
Senator White mentioned the obesity report, on which the Minister of State, Deputy Wallace, spoke this week. A new nutritional policy is being devised by the Department and we are very much engaged with other Departments on it. We must take a cross-departmental approach to the issue and work, in particular, with the Department of Education and Science which is implementing guidelines for schools on health eating and so on. There are also issues with regard to food labelling and advice on sugar and salt content, as well as transport. My colleague, the Minister for the Environment, Heritage and Local Government, believes there is a need for more cycling lanes. Perhaps the new car parking levy will make a small contribution in this regard.
Deputy O'Connor mentioned Tallaght and spoke about a super hospital. We hope all our hospitals are super. That is the ambition. He also asked about the children's hospital. This has been given priority for capital funding and, notwithstanding the wishful thinking on the part of some, the development is proceeding. It is important it proceed and that we have a single entity to cater for sick children. In Dublin city we have three children's hospitals with three accident and emergency departments. Professor Drumm probably has the figures for the numbers of children who will go to these three hospitals where there are expensive staff on call. This does not make sense and is not in the interests of sick children. The new hospital will not just deal with sick children from the Dublin area. Over 40% of the children who will use the hospital will be from outside Dublin.
We hope that in the new economic environment, particularly with the pressures on the construction industry, the cost of some of these capital projects will drop by 20% to 25%. The early indications from the HSE, from the estates manager, Mr. Brian Gilroy, are that this is the kind of reduction we can expect. Therefore, notwithstanding the fact that we had to reduce the amount of money available in the capital budget, we believe the amount provided should be able to deliver the same, if not more, in terms of projects. This is encouraging and a benefit.
Most of Deputy Ó Caoláin's comments related to service provision in the north east. I will ask Professor Drumm or someone from the HSE to deal with these issues.
The provision of colonoscopies was raised, in respect of which there have been significant improvements. A statement issued by the National Treatment Purchase Fund today states it is available to deal with all those who are waiting and a number has been provided for people to call. Approximately 900 people have been waiting more than six months and 1,636 people in all for more than three months. The National Treatment Purchase Fund can provide a service for all these patients. We know from the National Cancer Registry that the majority who require a colonoscopy do not have cancer. That brings me to the issue of colorectal cancer services. We have provided €1 million through the national screening service to prepare for the roll-out of a colorectal cancer screening programme because we are aware that there are huge deficiencies in screening programmes nationally.
It is regrettable that we are not in a position to introduce the HPV vaccine in 2009. I accept the health technology assessment and we will introduce the vaccine. In the context of budgetary constraints, we still have an additional €50 million for cancer services next year, €15 million to continue the roll-out of the eight centres and provide for Professor Keane's budget to recruit the expertise required and €35 million for the cervical screening programme. By the end of this year some 300,000 women will have been screened, either under the programme that began in September or the mid-west pilot programme. By any standards, that is fantastic. We know that 95% of women will not develop cervical cancer if they avail of the screening programmes available during their lifetime. They begin at 25 years of age and on average there are ten or 11 checks. On an individual basis, this reduces the possibility of developing cervical cancer by 95%. In the context of choices, therefore, such screening programmes must come first. However, it is hoped we can and intended to introduce the vaccine quickly.
Will the Minister indicate a timescale? It would be good to do it.
I hope it can be done in 2010. We cannot start for one year if we do not have the funds to continue the programme and the demographics increase each year. Also, we cannot start the programme on the basis that the company will provide us with the vaccine for nothing and we can get the money at some point in the future to pay it. We cannot introduce any State programme on that basis. However, it is hoped to introduce the programme. The childhood catch-up immunisation programme is being rolled out this year. When it is completed, I hope the same staff will be able to administer the HPV vaccine. I understand the catch-up programme may be completed during 2009. If that turns out to be the case, it would be an efficient way of undertaking the vaccine programme in 2010.
On rehabilitation services, Deputy Lynch made the point that if she only achieved a rehabilitation unit for the south in her time in the House, she would be happy. I share her view. I know from family experience that people who come from outside Dublin often have to go home on Friday and come back on Sunday and that transport services have to be provided. That does not seem to be efficient. I am not certain that the review will recommend centralisation. The review committee comprises the national experts in the field and includes representatives of the HSE, the Department and medical experts. However, I am not as certain as the Deputy that they will not recommend the provision of a regional service. I await their report. If it makes sense from a quality point of view, from the point of view of the quality of service to patients, we should provide services as close as possible to people, realising that rehabilitation cannot be provided everywhere. However, I would be happy if it could be provided in a region like the south and other regions. That would mean smaller units rather than one single big national hospital.
On the question of the medical cards and the letters, the intention is to publish the legislation at the end of next week and thereafter for the HSE to communicate with the over-70s. It will be a self-assessment and simplified model for the current holders. We had some discussions with the relevant officials in the HSE and it is hoped to simplify the application process, recognising that we need to get a great deal of information. As politicians working at a local level we all know that very often people are daunted by the prospect of having to complete official forms from many areas and not least in the area of health. Officialdom can often be a little bit over-bureaucratic and I mean all of us when I say that. The more we can simplify the application process for people applying for medical cards, the better. The current application form is eight pages with a four-page explanatory memorandum and it is quite detailed. The detail is required but we could look at simplifying it.
Will the Minister comment on the extension of the long-term illness card?
The long-term illness card has not been extended since 1978 because we have moved away from the idea that benefits would be distributed on a class basis, an illness basis, rather than on a means basis. Professor Drumm referred to the huge growth in the number of medical cards. For instance, a couple in their late 60s will not get a medical card if they have a disposable income of more than €300 a week so the limits are quite low. However, 1.3 million people have medical cards. I know there are groups such as the group referred to by the Deputy who already have a long-term illness card but do not have access to a GP as I understand it. I could reflect on that and take some advice.
It is a small number of people.
It is a small number and they are not a rolling number.
I will discuss it. In light of what the members say I will look at it.
I appreciate that.
Is there an estimate of the numbers affected?
It is €150 million for the health sector.
I invite Professor Drumm to speak and remind him that we have 25 minutes only.
Professor Brendan Drumm
Some of these are major issues such as accident and emergencydepartments and movement of funds. I hope members will take the one answer as being applicable.
I will comment on beds and the accident and emergency issue. Since I have been chief executive both the HSE and I have tried to focus on the development of community-based services. Nobody has the money to continue to run their own hospital services and build up new community services and so we have to decide which model to choose. We cannot continue to run hospitals with four doctors per one admission across the system and equal staff in other parts of it and still say we will build our community services to the level of a state of the art modern health service to which most developed countries aspire. I do not have the resources and I do not suppose they will ever appear, to continue with the current hospital system and build what people should get. There is a choice to be made and I know what train I am following. If there is a decision to put that money into the hospital services or to maintain it in the hospital services, then that is a different journey and perhaps is one that I should not be on. I have made the decision as to which way I will go.
I refer to yesterday's statistics on accident and emergency services and figures such as increases of 47% which appeared in the Irish Examiner last weekend.
It was 40%.
Professor Brendan Drumm
In 2005, that same group, the Irish Nurses Organisation, I think, took a very dismal view of my proposal that we could improve accident and emergency services greatly by dealing with the same number of beds and in fact reducing beds. Nobody from outside this country has ever proposed that beds would solve this problem. Multiple groups have looked at it and realised that we have huge numbers of beds and the problem was actually growing. We have several examples of vested interests who want to portray that more beds and more people associated with those beds would solve the problem. However, this is not a reflection on their own members who have worked extraordinarily hard to produce the tremendous turnaround from 2005. We have to face the challenge of the issue of long-stay patients. We took up the challenge back in 2005 and the situation is now very different.
We said that all hospitals needed to improve their processes. Deputy Blaney is completely correct. Letterkenny hospital and many other hospitals had huge problems as had Cavan hospital. Good management under people like Seán Murphy in Letterkenny or Dermot Monaghan in Cavan who got their clinicians to work with them, have produced dramatic turnaround in the number of people there.
In the Dublin area, our problems are now specifically focused in about five hospitals. We have problems continuing in Tallaght, Beaumont and the Mater and in Cork University Hospital and in Our Lady of Lourdes Hospital. However, hospitals like St. James's Hospital and St. Vincent's Hospital have shown dramatic changes with the same bed numbers and with an increased number of patients. We said from the beginning we would focus on management processes and we have had huge success in many institutions, despite the fact that their bed numbers have decreased. We still have work to do and we still must make headway with some institutions. I ask anyone to come and make an independent assessment of our accident and emergency departments.
If we do not challenge processes and if we decide to take the historical easy approach of just throwing more capacity at the problem and make the public pay for that capacity and try and convince them that we can build new community services at the same time, we are wasting our time. The development of medical assessment units is critical as we move forward. Currently patients come into accident and emergency departments and are placed there unnecessarily and the situation in Cork is an example. Those patients should never have to go through that department. Up the road in Waterford, the accident and emergency department handles 62,000 people, more than in Cork and they go through a tremendous process. I am currently working with the Irish Association of Emergency Physicians to see why that process cannot be applied in every hospital in the country.
It is a very simple process. On arrival at the door, medical patients go one way and are seen by the hospital physicians, injury patients are seen by the emergency doctors and minor injuries patients are seen by advanced nurse practitioners who work with the full support of the consultants and which is applied particularly well in that institution. This is not rocket science. A focus on those processes has brought significant improvement. Throwing money at that problem without focusing on those processes is a case of continuing to shovel it into that hole and people will love to hear it is coming at them. Change is messy and is a huge challenge to everybody working in that system and change will not come if people believe that by having patients on trolleys, more money will follow them. It has been tried for 20 years and I suspect without much success.
With regard to yesterday's figures, Deputy Ó Caoláin mentioned 25 people on trolleys on one day but that is a complete outlier. I will give the figures.
I heard 45.
Professor Brendan Drumm
It is a complete outlier and I do not believe it should be used in this situation. They hit a particular problem.
I am not depending on the IMO. The source of that information is front line staff——
Professor Brendan Drumm
No, that is our figure.
The number is 45 from front line staff.
Professor Brendan Drumm
It is our figure and it is a complete outlier. Cavan hospital has performed superbly in the recent past. This is just off the press and I did not pick the date.
I ask Professor Drumm to translate his "outlier" reference.
Deputy Ó Caoláin, please.
Professor Brendan Drumm
Here it is. Yesterday the number was above 6 hours, zero, in Cavan hospital. I will give the figures per months and on average. If we are going to use vested interests figures rather than the health service figures, then we have a problem.
Who are the vested interests? We are talking about people here; we are talking about patients.
Professor Brendan Drumm
We will have our figures audited by anybody. They are on the web for anybody to audit them any day.
If Professor Drumm contends that ——
Professor Brendan Drumm
If the Deputy is suggesting that our staff——
Please, gentlemen. I ask Professor Drumm to address the questions and I ask Deputy Ó Caoláin to allow Professor Drumm to proceed.
Professor Brendan Drumm
Our figures are returned to us by our accident and emergency staff through our accident and emergency consultants. If there is a suggestion that their figures are dishonest, let us have that suggestion made frankly. I trust my staff to insert the right figures. The medical assessment units are critical. The community intervention teams are now up and running in several areas and have proven to be a great success at keeping people under treatment in their own homes. The development of rapid access clinics has also proved to be a success. The community intervention teams are critical.
Let me finish on accident and emergency services by saying that the figure that gets forgotten is the figure for admissions through accident and emergency units. Last year, for instance, 370,000 people or each day an average of 1,000 people were admitted through accident and emergency units. Our average figure for waits last year was 108. We have said this many times. Practically 90% of people who attend accident and emergency departments are consistently admitted practically immediately under the requirement for a bed. That gets forgotten. All these percentages are percentages of the 10% that wait any length of time. If anybody wants to challenge those figures and call them into account, they can be audited. That also gets forgotten in terms of how our staff perform. Our staff do a remarkable job in getting that huge number of people in. We have challenges in a number of areas and are continuing to pick up those challenges.
The other issue related to the movement of funds, which has come up several times in this committee. For long before the existence of the HSE the health services deferred the use of development funds for budgetary reasons each year. It did not arrive with the HSE. Any suggestion that it did is disingenuous. It was used consistently to balance budgets. It was built into the system in terms of budgetary approaches each year. I am delighted to say that last year the Minister and the Department and probably following on from the Comptroller and Auditor General removed that flexibility from us. I am delighted because I do not now have to make that decision. That decision has to come back in terms of the disability sector and everything else. If somebody wants to keep the hospital running in Navan — it would be lovely to keep doing those hip operations — somebody else must now make the decision to move funds from development money or whatever to do that. That is the only choice I have. This year we spent no development money, other than for the developments it was actually applied to. Regarding the development money, I believe the Minister's figure is right.
In terms of mental health——
Ms Laverne McGuinness
It was 94% for the first quarter.
Professor Brendan Drumm
In terms of disability——
Ms Laverne McGuinness
All of the disability funding for the multi-annual investment programme has actually been used.
What is that 94%?
Ms Laverne McGuinness
Regarding mental health, the figures there were €25 million and €26 million. At the end of 2007 there was more than €10.7 million of that spent. To have 94% of the money spent at the end of the first quarter of 2009, that is bringing in line the 12 new consultant posts in child and adolescent psychiatry and the additional child and adolescent psychiatry beds of which there will be——
What about the €51 million for A Vision for Change?
Ms Laverne McGuinness
That is the money that came for A Vision for Change, the €26 million and the €25 million.
Some 94% is €45 million.
Ms Laverne McGuinness
It is all spent by the first quarter of this year.
Has the number of child and adolescent psychiatry beds now been increased to 30?
We can cover that another time.
Ms Laverne McGuinness
On the child and adolescent psychiatry beds, the four are already open in Galway. There are eight in St. Vincent's Hospital in Fairview. They are currently recruiting the staff for those. Hopefully they will be open by the end of the year or certainly in the first month of next year. The same is true of the additional six beds in Cork. The new units in Cork and Galway will be under construction next year, but the teams are being recruited to put the facilities in place.
Professor Brendan Drumm
In answer to Deputy O' Sullivan. Accident and emergency unit efficiency was a focus and it is a focus for us also. We have delivered on €280 million in value for money. It has come from many areas, procurement being the biggest one, decreases in overtime, decreases in travel and subsistence and decreases in telephone costs. Practically all of our meetings now take place by conference calls. Travel by anybody in the organisation other than for clinical work has been practically removed this year. There has been a huge focus on value for money. In terms of procurement, we have centralised our procurement. We have hit some IR issues. It was a focus of this organisation from day 1: estates and procurement. We have focused very successfully on estates in terms of value of money and the estates function of this organisation is a model, to which the public service in general could aspire in terms of getting value for money.
On procurement, we have run into some IR issues in terms of centralising from the districts. We will overcome those. We have already brought in significant savings in procurement. Our biggest procurement is actually pharmacy. As members of the committee know we moved to make a fairly minor reduction in our pharmacy bill last year and ran into significant resistance albeit from right across this House as well as everywhere else. It was subsequently found in the courts that we were not in a position to do that and that right still lies with the Minister. The challenge to that massive procurement bill was perfectly realistic. Those are the types of areas that were taken on board.
We can give a list of our value for money to anybody here in terms of the specific savings if it is of help. It is a huge challenge going forward into next year. We have to repeat that €280 million into next year. It cuts down on the number of areas we can target. However, it must be a challenge we take up because times are tough for many more people than us. As Deputy Neville said there are great challenges in terms of increasing need for services at this time. We have to drive very significant further value for money in the next year. It is a huge demand on people who work in this organisation, but they are up to it. I have great confidence in terms of what they have delivered this year. I do not believe anybody predicted we would be even close to breaking even in this difficult year and because of this, this organisation will focus on breaking even.
On the Department of Finance savings, Liam Woods is here. I need to take his note but he can come up if there is any need for clarification, I am sure. The HSE has moved to a single bank contract for the entire country. That went out to tender. It is now implementing it across the country. It will be completed in three months. We have moved to "cash in" daily and have removed €60 million of cash from the system. These issues are being dealt with. If further details are required we might ask Liam Woods to come forward.
On the Teamwork Management Services report for the mid-west, at this stage we just want it to be released and then perhaps——
Is Professor Drumm trying to pull the wool over our eyes? He has been telling us that the HSE was going to publish. Until today nobody has said that the HSE does not really want to publish it because it is afraid of the public reaction.
We are usually attacked because we do not consult with the staff and we just put a report out there. This is dealing with it the other way around, which is the right way.
A year later the rest of us might be able to share this information.
Professor Brendan Drumm
Maybe at this stage we have done the consulting and maybe that is what we do. To be fair there has been huge interaction, not least by many people at this table and elsewhere with people in the mid-west. We have put a big effort into it in terms of meeting——
The HSE has not met the public. It obviously does not have faith in democracy given that it only consults with people who work in hospitals.
Professor Brendan Drumm
We have asked our people to engage with the public representatives. I will take that back. If people want the report, that is certainly a demand that we need to take on board.
I ask Ms McGuinness to comment on the hospice plan.
Ms Laverne McGuinness
The Deputy asked about the hospice plan. They know it is available and want to know if it is to be released. It is available. It has just gone for internal consultation. We have just passed it over to Professor Keane as part of the cancer control programme for his input before we release it. It is ready and will be circulated to the Department of Health and Children.
Professor Brendan Drumm
Deputy O'Sullivan mentioned the consultant contract. The piece that was relevant for me was the 80:20 measurement. I believe there was some confusion. The Comptroller and Auditor General was speaking about the old contract. I would absolutely accept it was not measured or implemented. That is why the new contract brings a tremendously different approach. We have a very specific system up and running and agreed with the consultants for measuring their activity. Each month we will produce activity figures across the system on the 80:20 or whatever the consultants' activity profile is. This is a huge step forward for the health system. Putting such a system in place so quickly has been a challenge that has been dealt with very effectively in the context of the contract. The Minister commented on the other relevant features on the contract.
In response to Deputy O'Hanlon, I accept that €15 billion is a huge amount of money. I have never denied that whenever I have come here. I have said constantly that the taxpayer invests very highly in health care. I have said constantly that we have huge challenges in terms of our efficiencies. I am here today to say we are meeting some of those challenges. We are not meeting them all. We have a long way to go. I suggest that we have come a long way from where we started. We have focused on the areas of value for money and clinical efficiency.
I was asked about the comparative analysis of care costs in hospitals, as opposed to community settings. If one does a crude analysis, one will find that such costs in hospitals come to €2,500 per bed, per day, whereas the equivalent costs in community settings come to less than €1,000. I do not doubt that significant savings can be made at a bed level.
I am interested in the difference in costs between hospitals.
Professor Brendan Drumm
They are significant. We can get those figures. We probably have a costing at hospital level. We can get specific figures for hospitals across the country. We will come back on that.
I will deal with the issue of the orthopaedic unit at Our Lady's Hospital in Navan, which was raised by a few members. It was funded to do a certain amount of work. It delivered that amount of work. I accept Deputy Ó Caoláin's view that if it could be delivered inside a year, that would be efficient. We did not have the funds to continue to pursue that. We have to try to remain within the confines of the service plan. We have not succeeded, but we have had to come up with the value for money to make up the difference. We did not have the money to keep going. It is efficient at doing the work it does. I will be totally honest about this. The efficiency of orthopaedic units cannot be measured accurately by examining what has gone through and what is on the waiting list. The real waiting list is the list of people waiting to get on the waiting list to see a consultant. At present, we are working intensively to ascertain the throughput per consultant in outpatient clinics up and down the country. We are setting a bar — the number of new patients we expect to go through — in each specialty. When one looks at that in the north east, it is clear we are not reaching that bar. Far too many people are waiting to get on the waiting list. That is as honest as I can be.
I welcome that acknowledgement. That is something we have been saying for a long time.
Professor Brendan Drumm
I suggest that the biggest challenge in the acute health system at the moment is providing access to that system for elective work. If one has a heart attack, or if one drops on the street with a stroke, one will get a very good response. If one has a bad hip, the HSE does not deal with that particularly well. I accept that as we are getting €15 billion, it is a challenge we have to take up. We are very focused on it at the moment.
Professor Drumm has six minutes.
Professor Brendan Drumm
I will be very quick. The development of primary care units is moving at real pace. I assure Deputy O'Hanlon that there is huge interest from general practitioners. I will deal with the Chairman's question on the matter. We are going to lease space in primary care centres, regardless of who builds them. We will sell our own space, essentially, in towns up and down the country. Such space is often not of a great standard for community services. It has proven hugely attractive to the sector that is involved in that kind of thing, without tax incentives. We are getting very significant take-up. We are happy that it is progressing at the moment.
Deputy O'Hanlon asked how we can make the existing service at Monaghan better and safer. Deputy Ó Caoláin took the matter up. We need to have a system which ensures that when a person has a heart attack, an emergency medical technician can get to him or her at the point at which it occurs. If necessary, the technician should be able to intubate the person, which is a very advanced skill. Such people are trained and we are training more of them. Thrombolysis can be given, although it is set to disappear from our repertoire soon. It is now clear that a person who has a heart attack needs to get to an intervention centre that offers advanced cardiology services, rather than merely being given thrombolysis, within the first two hours. I do not doubt that we will have to aim to meet that target. We need to face the challenge of dealing with medical units in hospitals where the service has been moved much more towards day and community involvement. When we measured it, we found that 56% of the patients in Monaghan General Hospital did not need to be in an acute hospital. That figure is not unusual. The people in question need services. They can continue to avail of such services as inpatients in Monaghan. We are focused on that. Perhaps we need to give people more reassurance about the model of medical care that will remain in place. I will come back to Deputies O'Hanlon and Ó Caoláin when I meet the transformation team to see what their views are. Deputy Conlon is also interested in this issue. I will tie them all in. I will arrange for someone to meet the Deputies and go through that process with them.
I have to say that what Professor Drumm is indicating as the position in Monaghan General Hospital is a far cry from the reality. He has suggested that the beds at the hospital are being used inappropriately by people who should not be there, but that is not the case.
Professor Brendan Drumm
Across the country——
We cannot devote any more time to these individual issues. Professor Drumm has offered to arrange a meeting with Deputies from that part of the country. I suggest that it would be wise of them to avail of that opportunity.
Professor Brendan Drumm
We have a very good transformation leader up there. I will get that person to have a discussion with the Deputies. Monaghan General Hospital is not unique in this regard — the relevant figure is between 40% and 60% across the country.
Senator Prendergast asked me to outline where the HSE will close beds, and in what numbers. The HSE will not close beds if that would bring us below service plan levels. We have to get to a certain point. As we move services to the community, we have to close beds. If we do not do so, those beds will remain totally in action. We have a remarkable admission rate in those parts of the country with a high number of beds, such as the north east and the midlands. The facts speak for themselves. If we do not close beds as we move money out, we will have no hope. We can give the Senator the actual bed plans if that is a help.
I will speak about long-stay beds.
We are running out of time to deal with all questions.
Professor Brendan Drumm
I can give the committee a full outline of the planning of long-stay beds. I was also asked about maternity services in south Tipperary. We have not yet met the consultants, or anybody else, in the south east to discuss the reconfiguration. We will meet them in the next couple of weeks to consider the manner in which services will operate in the four hospitals in the south east in the future. That appraisal has not yet taken place. Some matters were examined as part of the review of services in the southern region. At this point in time, there is no plan to move maternity or surgical services. That could well change over the next two or three years, however.
Professor Drumm does not need me to tell him that maternity services do not need to be based in centres of excellence. Geography and demographics need to be considered if they are to be measured appropriately.
Professor Brendan Drumm
There are lots of ways to provide maternity services.
I was also asked about the St. Luke's Hospital inquiry. As the committee is aware, the Mental Health Commission is undertaking that inquiry. Its findings have not been published to date.
Deputy Conlon mentioned that there has been a loss of confidence. We will try to meet the relevant authorities to discuss what is happening. She suggested that the level of resources in the north east is low. That has to be considered in the context of the fact that a huge number of people in the north east come to Dublin for certain services. The percentage of the people of south Meath who do so is spectacular. It can be difficult to compare figures. She also asked about the extension to Our Lady of Lourdes Hospital in Drogheda. I will give that information at a meeting with the transformation team there. The fabulous new facility that is being built there is on schedule to be finished on time, in late 2009. It will contain a significant number of additional beds and much-improved facilities. I have spoken about the issue of disability funding.
Deputy Kathleen Lynch suggested that there are now 98 fewer hospital beds in Cork. There is no proper medical assessment unit there. We need to work on a different process. I will meet the accident and emergency consultants to see whether we can get that process up and running. I have spoken about the comparisons that have been made in this regard. People from the cities of Waterford and Cork are twice as likely to be admitted to hospital as people from rural Waterford or rural Cork. They are no more likely to live a day longer, however. If one lives near an accident and emergency department, one's chances of being admitted to hospital are increased. We need to be very aware of that. Different systems are needed. I have a great deal of sympathy for the point Deputy Lynch made about rehabilitation. I understand that the committee she mentioned is examining this. I did not realise that so many of its members are from Dublin.
Neither did I.
Professor Brendan Drumm
It must have been Brian Gilroy who set it up. As a culchie, I sympathise with what Deputy Lynch is saying. It is obvious that it is a concern. Now that it has been highlighted, perhaps we need to ensure the committee bends the other way. People in every part of the country realise that it is important to get disabled people closer to their homes. It is a personal opinion. We need to wait for the committee to complete its work. It is not something we should be aspiring to. I am sure everyone here will agree. I have dealt with the issue of ring-fenced funding, which Deputy Lynch also mentioned. On suicide prevention, there are liaison nurses in the accident and emergency structure. Would anyone like to comment on the issue?
Ms Laverne McGuinness
Yes, on suicide prevention officers——
Professor Brendan Drumm
I am referring to people who attend accident and emergency departments and are then sent away.
Ms Laverne McGuinness
Liaison nurses are working in many accident and emergency units. I can get more detailed information for Deputy Lynch.
Professor Brendan Drumm
Deputy O'Connor has left the meeting. I reiterate that we share the Minister's commitment to the children's hospital. I liked the Minister's comment despite what others may wish because everyone, including Government and Opposition Members, has shown great commitment to the new hospital. While it is difficult and will continue to be a challenge, we must keep focused on the matter.
Deputy Blaney raised an issue about Letterkenny. I acknowledge that the clinicians and manager at the hospital are showing what can be achieved when people work together to provide a solution to a major problem. This encourages us to spend more on the capital side to support this.
I will come back to the Deputy on the issue of the consultant neurologist. We have to try to do this.
On the pre-tender for contracts, Mr. Woods has passed me a note. We need to re-examine the issue based on the case the Deputy made. As the Minister indicated, this is standard procedure. Mr. Woods and I may speak to the Deputy after the meeting as it may be necessary to re-examine the issue of pre-tenders for contracts in light of the changing economic position.
A further area requires clarification.
Professor Brendan Drumm
Deputy Neville raised the return of dialysis services in Limerick. I hope the answer he received was accurate. My view is that this may take place in March but I need to check because I am aware that a delay occurred as a result of planning issues. I do not know what is the position but I will confirm whether the date is December or March. I am aware of a planning objection.
The planning objection has not been an issue for 12 months.
Professor Brendan Drumm
It delayed the whole project. I need to check to confirm the position.
We were promised the service would resume in July last, not December.
Ms Laverne McGuinness
I appreciate that.
Professor Brendan Drumm
We will come back to the Deputy on the issue. I am flagging that I need to double-check.
The Minister and I acknowledge that suicide is a major issue. The suicide prevention officers——
They are suicide resource officers.
Ms Laverne McGuinness
Four of 11 suicide resource officer posts are vacant. Two of these, one in the midlands and one in Naas, will be filled in December. The post holder in Naas will also fill the post in the east coast and Bray on an interim basis. The post in the north east has been advertised and the interview board has been established.
When will the four vacant positions be filled?
Ms Laverne McGuinness
Two positions will be filled in December. These are in Naas and the former Midland Health Board area. The person appointed in Naas will also fill the post in Bray. An interview board is in process in the north east. The timing will depend on the successful applicant. For example, it could take a period of six to eight weeks before the person leaves his or her current role.
That is very good news, which I very much appreciate.
Will Ms McGuinness confirm they are permanent positions?
Ms Laverne McGuinness
I will have to check who is coming off the panel. I am not sure if it is temporary.
It is important the positions are permanent.
Ms Laverne McGuinness
They are permanent post holders.
Professor Brendan Drumm
On child and adolescent psychiatry and children ending up on adult wards, there is no doubt we are making headway. Deputy Ó Caoláin is absolutely correct.
On roles being clear, our whole move towards an integrative process is a complete redesign of how we manage the system. This will be rolled out over the next six to 12 months. Members will have seen significant changes on issues, such as the cancer misdiagnosis challenge in the north east, which are now managed. Significant changes are taking place on how we manage our services all the way down to local level, as well as on clarity and accountability. This is a big undertaking but it is well under way.
We will take up the issue of GP training raised by Senator White. Deputy Ó Caoláin raised elective orthopaedics and Monaghan hospital. I believe we dealt with these issues. We will try to come back on the medical issue and, while we may not have news that everybody wants, at least we will be able to bring clarity. Deputy Blaney referred to the issuing by the Minister of medical cards for people with polio. We have dealt with disability funding and tax incentive issues.
Unfortunately, I had to leave the meeting to lead a deputation to meet a Minister. On the issue of primary care, on which there have been some advances, there is considerable frustration and anger about the roll-out of primary care centres, especially in Callan, Thomastown and Ferrybank in south Kilkenny. It is seven years since the primary care strategy was announced in 2001. The HSE, which established a project team four years ago, has announced it has withdrawn the Callan project and will proceed with a public private partnership. While there is nothing wrong with PPP schemes, it is difficult to obtain answers or get anyone to sit down with community representatives. Great community efforts are being made in Callan and representatives of the community are willing to discuss the issue. As a public representative, I have done my best to get someone to discuss the issue with the local community. Focus is required. Irrespective of whether the project is done by a PPP or another means, the aim is to have services provided in primary care centres and keep people out of hospitals and accident and emergency units. The sooner such centres are rolled out, the better.
The HSE provided a verbal and written commitment in 2006 and 2007 that it would provide €300,000 in funding for a primary care centre in Ferrybank. To date, no money has been paid although a building is available. Although a child care facility is in place on the ground floor, the top section of the building, which was reserved for primary care services, has been a shell for three years. The HSE has not provided the money to complete the project. The community has made a great effort on this issue.
In Callan, the local doctor is so frustrated after four years of negotiating that he withdrew from the project when it was announced that it would proceed by means of a PPP scheme. He is now trying to do something privately. If a PPP scheme is used, I ask that negotiations take place with local communities to ensure the project gets off the ground as soon as possible.
I am not certain members are fully satisfied with Professor Drumm's comments on the disability issue. Does he envisage the establishment of a system of regular reporting under which the HSE will detail how funding allocated to the disability and mental health areas is being expended in 2009? We do not want to discover half way through the year that the money has not been spent. Will Professor Drumm address the issue?
Professor Brendan Drumm
The HSE does not have the legal capacity to spend the funding in any other area. We can do as requested.
We would like to hear about the funding being spent. Perhaps Professor Drumm will respond to the point made by Deputy Aylward, after which spokespersons will make concluding remarks.
Professor Brendan Drumm
It is great that people are interested in primary care. This is the pride in local primary care developments that we want. We are obviously not communicating. The HSE has a very good national manager in this area, Mr. Brian Murphy. I will get back to the Deputy on the issue but Ms McGuinness will speak on the specific issue of Callan.
Ms Laverne McGuinness
Deputy Aylward is correct that Callan had been considered. An overall review of the capital plan was undertaken by the HSE during 2008 in line with Government policy. It found that the primary care centre envisaged for Callan did not offer the best value for money. The project which was in the capital plan was not part of the public private partnership initiative about which Professor Drumm spoke. It will be included as part of this initiative. A response has been provided to the joint committee and we will provide further detail should it be required. We will also have someone meet the Deputy if required.
The HSE should arrange to have someone meet the group in Callan which wants to proceed with the project. May I have an answer on the project in Ferrybank where not a penny of money promised over two years has materialised?
I ask that a local meeting be arranged for Deputy Aylward to deal with all the issues he raises.
That would be progress.
I ask spokespersons to make closing statements after which we will have some brief closing remarks from the Minister and Professor Drumm. I take it that the general issues on the agenda have been fairly well ventilated.
Three questions have been asked to which I would like answers. How many contracts were signed with builders for buildings where doctors were involved? Perhaps Professor Drumm could answer that because it is a HSE issue and he would have the information. This is in relation to primary health care, real achievables and what is actually happening in terms of legally binding contracts.
I also asked the Minister when we would have sight of the maternity report. This is a huge issue because maternity hospitals are not able to cope. We need to know where the future lies. I asked for concrete examples, five perhaps, of varying situations with different families — Mr. and Mrs. Murphy, Tommy and Margaret O'Brien with two children under the age of 12, etc. — and how the new levies and regulations the Minister wishes to put in place will work. She might also tell us when she will commit to the substantive legislation necessary to address the risk equalisation issue.
Reference has been made to a 46% reduction in inpatient procedures. Surely that could have something to do with the fact that people are finding it very difficult to see consultants in the first place to get on to those lists. If I send a letter referring a patient for an ENT appointment, I will get a letter saying there is no appointment available, that the waiting list is two years. That has been the situation for the past year or 18 months.
The number of medical cards at 1.3 million is a figure I recall from the past, but it does not represent anything remotely like a high in relation to the percentage of the population covered. Medical card income thresholds have not been reviewed for years, other than in conjunction with the CPI index, which means that somebody on little more than the minimum wage is not entitled to a medical card. That remains a fact. The discretionary medical card is not now available to ordinary people on very modest incomes who are terminally ill. That is disgraceful. The Minister has said it is a capped fund, but I ask that it be uncapped. I know at least two examples where terminally ill people who live in Ballyfermot and Walkinstown were refused the discretionary medical card. That is as bad as we can go as a society if we allow that to continue.
Five hundred beds have gone from the system, but the Minister did not confirm this figure as I asked her to do. There are 600 beds to go and 756 blocked — that is 13.5% of the total complement of beds. There is a 3% increase for home care packages, but that is not a great deal from the public's perspective.
Does the Minister realise the importance of nutritional supplements for the survival of cancer patients, cystic fibrosis sufferers and others with a range of medical conditions? I hope she will take this point on board before Dr. Michael Barry reaches any conclusions in relation to nutritional supplements on either the GMS or the drugs payments scheme.
I appeal to the Minister to instruct the Irish Medicines Board to examine products available in so-called head and Rasta shops, which are in Balbriggan, Swords and many other places, to protect young adults and children from the deadly effects of substances like BZP and other "health" products which cause very serious mind altering effects and long lasting damage. They are freely available, without regulation.
The Minister mentioned tax incentives and I put it to her that the EU would have to approve them. Has any approach been made to the EU? I know that the EU makes particular allowance for measures that will result in national health gain and I would have thought that the development of primary care slotted into that very nicely. I have asked to the Minister to state when the VHI legislation will be available.
Has cervical cytology been completely outsourced to Quest? My understanding is that those laboratories, the equipment and the staff are still all in place and costing the taxpayer. What are they doing? Regarding obesity, my information is that none of the task force recommendations made two or three years ago have been put in place. Mention was made of the ability of the national treatment purchase fund to take on colonoscopy. The taxpayer needs to be informed about this. Operations have been cancelled in Cappagh, orthopaedic procedures all over the north east have been cancelled and they are to be cancelled elsewhere. When this happened during the summer, patients went off the waiting list in Cappagh and on to the NTPF to be treated in a private hospital at nearly three times the cost to the taxpayer. It does not make financial sense that perfectly good, efficient orthopaedic units are being closed. Will this be the case with colonoscopies as well?
The issue of cervical cancer has been mentioned. I hope the Minister is not still adhering to the idea of vaccine or screening, one or the other. We all know we need both in order to rid ourselves of this scourge that takes the lives of so many women each year. A vaccine prevents cancer, screening detects it. If detected early enough, treatment can prevent death. We need both strategies, not one or the other.
I repeat the call for an independent inquiry into the north east. I want HIQA to do this because there were so many issues that were not addressed, in particular the failure of management over many years. Is Professor Drumm at variance with the Minister and the Government who said they would provide 3,000 extra hospital beds? Did not St. James's Hospital, which was specifically mentioned, receive extra beds by way of a medical admissions unit some years ago? I agree with Professor Drumm in one respect, but disagree with him in another. The basic problem is that people are sick and in pain today and they need treatment today. While plans are made for the development of primary care, with which I agree, service must be provided for those who need it now. Plans for tomorrow are no substitute for action today. I know of a man in Galway who was injured in an accident and lay in a coma for at least four or five weeks and is still awaiting a bed in the neurology unit in Beaumont. That is not a service that is working.
The budget is being made to stand up by the removal of beds and services, home care packages from the elderly, disabled and children, the cancellation of operations all over the country and the withdrawal of medical cards from the terminally ill and elderly, while depriving young girls of a life saving vaccine against cancer. That is why the budget matches. That is the reality.
I did not get an answer in relation to Bawnmore services. One hundred people are likely to lose services and 60 are likely to lose jobs. I want to clarify the answers relating to the roll-out of the bowel cancer screening service. Has the sum of €1 million been allocated for the roll-out? If so, that is welcome.
Professor Drumm said that under the new contract the consultants will definitely be doing what they are supposed to do. However, I understand a lot of consultants will be still on the old contracts. Will they be monitored to see that they do 80% public work and 20% private? One of the findings in the document presented by the Comptroller and Auditor General to the Committee of Public Accounts indicated that 3,802 patients were treated under the national treatment purchase fund by the same consultant who had that patient on his or her public waiting list. I presume some consultants were doing more than the 20% private work. There must be an opportunity for savings there. It seems crazy to pay a consultant twice for doing the same work, especially if he or she was doing more private work than they should have been. Will consultants on the old contract be monitored, as well as consultants on the new contract?
I mentioned plans to save €100 million in regard to medical cards, the GMS and so on. I understand a 9-point action plan for the community drugs scheme was put to the board of the HSE. Will consideration be given to nutrition and so on before decisions are made, so that damage is not done to patients?
I refer again to the Teamwork report. I have been reassuring St. John's Hospital that its accident and emergency facility will be preserved, because I was told this was so. According to a written reply, the plans currently being worked on are not only to retain the existing services but also to enhance these services further. There is fear because people do not know what is in the plan or what will be done. There is particular fear in places like Ennis and Nenagh that beds will be closed and new beds will not be provided anywhere in the region to cater for those people. We want to know what is planned and whether the public, the patients, can have a say before it becomes a fait accompli? I find it amazing that the Minister, who is democratically elected, is afraid to publish a plan because of what people might say about it. That beggars belief.
It is no surprise at all.
I detect some hope with regard to the vaccine. The Secretary General might be a little worried about whether it will be possible to implement. The Minister hopes to be able to do it in 2010, but I ask her to find the €10 million in September 2009, the start of the school year. People cannot understand why a life saving measure should be announced in August and withdrawn in November.
I thank the Minister and Professor Drumm and those who accompany them for the very useful discussion we have had for over three hours. It has been very positive. The Health Service Executive and the Minister had an opportunity to hear the issues we are concerned about and we also had an opportunity to hear the good work that is being done. In my view, we and the public do not hear enough about it. The improvements in the service should be highlighted, as well as what you hope to do in 2009 in the provision of new services and the enhancement of others.
Professor Drumm raised the very important issue of the number of people on the waiting list to see a consultant so that they can get on the waiting list for hospital. In terms of comparative analysis, it would be very useful to look at what is happening all over the country to identify best practice and ensure it is implemented everywhere.
In many of the smaller hospitals there are mainly elderly acute medical patients who get state-of-art treatment. We are fortunate in Monaghan that this is available through the good medical and nursing staff there. I do not think it is necessary to send these people 30, 40 or 50 miles to another hospital. I take the point that some people need more sophisticated treatment in the case of heart attacks, but some elderly people with asthma and chest conditions go into hospital two or three times a year, usually during the winter. I believe it should be possible to find a solution to the Monaghan problem. There are anaesthetists who attend for day surgery five days a week. I ask that this be considered so that we might be able to protect the existing service into the future.
I will respond to the questions raised by Deputy Reilly. On the number of primary care centres involving doctors, I will allow Professor Drumm to answer. My understanding is that unless doctors are involved, the centres do not proceed. The maternity report is a matter for the HSE. I would be very happy to see that report. Like all reports, it is generally leaked and most people know about it anyway. In case there is any misunderstanding regarding reports, one of the criticisms we have faced from stakeholders in our health care system is that we commission outsiders to do a report, we publish the report and start implementing but they are never consulted and the report is implemented in a very prescriptive fashion. A report is a tool to help perform and it is much better if there is consultation with the stakeholders before implementation. From the discussions I have had regarding the mid-west, there is huge clinical buy-in to the reforms, the purpose of which is to deliver higher quality patient care. I am not afraid to publish reports. All of these reports are generally discussed with the people's representatives who are elected to this House and others at local level.
They have not been discussed with the people's representatives.
Have you not been involved in discussions?
I am sorry. I understood you had been involved. I think the Deputies for the region should be consulted.
Deputy Reilly referred to the impact of insurance changes on premium prices. The Government has no role in relation to pricing. We do not approve the prices of any company. It is a very competitive marketplace. The fact that we are introducing lifetime community rating which will incentivise young people to take out insurance early and disincentivise people to wait until they are 50 or over will, I think, help to grow the market and make it attractive. I believe there is scope for companies to subsume this levy into their pricing structure because there were huge margins. We know when BUPA operated in Ireland it had a profit margin of 16% or 17% against 6% or 7% in the United Kingdom. If we did not do what we are intending to do, Mr. and Mrs. Murphy aged 70 or over would have seen their premiums grow by 60% to 70% for a basic plan. That would make it unaffordable for older people. It is no coincidence that in the UK 11% of people have private health insurance because it is not community rated. In Ireland, it is over over 50%.
With respect, it is community rated here and remains so. If it goes up for Mr. and Mrs. Murphy at 70 years of age, the same plan goes up as well for Tommy Murphy who is 22.
It is community rated to this extent. There is a plan for somebody who wants maternity benefits, for sports injuries, for someone who joins a gym, teeth whitening. That is not very attractive to a 70 year old. There is a much more expensive plan to cover cataract treatment, hip replacement and so on. That is the way the market has been segmenting. We know that to be a fact. You offer everybody the plan at the same price, but you gear the products you offer in the plan in a way that makes them attractive only to a highly profitable group, namely young people. I know of a company which has 2,000 staff who have health insurance. They have not had a single claim in two years. That company is very attractive to any insurer. We know that an 80 year old has a claims experience which is four times greater than that of a forty year old. A 60 year old's claims experience is twice that of a 30 year old. Older people clearly are more expensive. One company has 320 times more over 80 year olds than another company. The only way to maintain community rating is by younger people supporting older people. When we had only one provider, it was done internally in the company. When the market liberalised, younger members were in one company and older members stayed with the incumbent. We have to provide intergenerational support.
I am advised that the risk equalisation legislation will take about two or three years. Fourteen issues were advanced in the Supreme Court. The court dealt with one issue but 13 other issues must be addressed in the context of new legislation. Every Government and every Minister for Health since 1994, beginning with the current Leas-Cheann Comhairle, Deputy Brendan Howlin, who introduced the first legislation, followed by Deputy Michael Noonan, the current Taoiseach, Deputy Cowen, Deputy Martin and me, has introduced legislation in this area. Unfortunately one aspect of that legislation was struck down in the Supreme Court decision.
Nutritional supplements are a matter for expert clinical advice, not for political decision. Perhaps Professor Drumm will deal with that. General practitioners, dieticians and other with expertise in this area are involved. My understanding is that over 50% of these products are wasted.
I do not think dieticians have been consulted yet, and that is a major concern.
I will let the HSE deal with that.
The Minister is not a clinician.
I am not making the decision.
The Minister stated that 50% of these products are useless.
That is the clinical advice of the HSE. I have asked the HSE to deal with nutritional products. Perhaps Ann Doherty will deal with cytology services. We have outsourced the screening programme and the selection was based on quality, although it was substantially cheaper as well. I will allow Professor Drumm to deal with the discretionary medical card. Clearly we have to manage within budgets. We are all aware that we do not have unlimited budgets.
We do not want unlimited numbers of people dying.
A child born in Ireland today will live longer than a child born in Germany, Belgium, Denmark, Sweden or the United Kingdom. Life expectancy here has increased by nine years since we joined the European Union and for the first time is ahead of the EU average. Half of this is due to better health interventions and half to our growing prosperity.
Smear tests detect cancers but also detect pre-cancerous cells. Seven or eight other European countries have not yet introduced the cervical cancer vaccine. No country has introduced a vaccine that will save lives 20 or 30 years from now ahead of a programme that will save lives today, tomorrow and next year. We want to do both. If we introduce the vaccine in 2010 in second level schools, as opposed to national schools, we will pick up the same girls. I hope we can do that.
I share the view of Deputy Reilly about the products sold in the shops to which he referred. We need to extend the controlled substances legislation to include other products. I need to take advice in relation to that matter. There is also an EU dimension to some of the issues. Some years ago we banned magic mushrooms, and there are products coming on the market and being sold in an uncontrolled fashion which are highly dangerous. I will be very happy to give consideration to that matter and take some advice. As I understand it, the Irish Medicines Board cannot have a regulatory function if we do not introduce control measures.
Deputy O'Sullivan mentioned a €100 million saving on the medical card scheme. That is the plan. We anticipate savings in three areas — the reduced fee to general practitioners, the 5% of people who will not get the card and Dr. Barry's group. We have moved to disposable income as a criterion for medical card eligibility. Child care costs, transport costs, mortgage or rent, ongoing health expenses can be factored out. Effectively, we have increased the threshold by about 30% on income and the scheme is much fairer than it used to be. In the context of our enhanced prosperity, 1.34 million is by any standard a hugely increased number of people with full medical cards.
I asked about the percentage of existing consultants.
For those who do not sign the new contract we have other mechanisms. It is not, in my view, acceptable that in a hospital funded by the taxpayers one group of citizens should have preferential access to diagnostics and others without private health insurance are told they must wait. That was the story of the late Suzie Long and it is not a good story. That cannot be allowed. When we see how many consultants sign the new contract, which will create one for all access to public hospitals, we will have to consider what instruments we can use to deal with those access issues. There are some examples where 60% or 70% of the activity is private. It would be ludicrous if public hospitals were to become hives of private activity, while we used the national treatment purchase fund or other money to procure services in the private system.
Mention was made of the use of the treatment purchase fund in relation to some of the capacity isssues in the public system. I spoke yesterday to Professor Drumm about this matter. We will use in a sensible way whatever funds taxpayers can provide to treat patients.
Professor Brendan Drumm
Regarding the number of GPs who have actually signed, we can get this figure.
Not signed up — signed contracts. Signing up is a euphemism for expressing interest. What legal documents have been signed by any GPs to get involved?
Professor Brendan Drumm
We can get the number which have been processed, what percentage of GPs have signed up and how many have refused to sign up. We can get Deputy Reilly that figure.
The maternity review can be made available very soon. It is being dealt with through the stakeholders as an umbrella for the maternity hospitals in Dublin.
Before the end of January?
Ms Ann Doherty
We have met them twice. The clinical advisers will work with KPMG just before Christmas and then we will be ready to publish.
Professor Brendan Drumm
There is a suggestion that we are talking about trying to fix things but not actually fixing them. I have outlined massive improvements in the system of processes. St. Vincent's Hospital accident and emergency waiting time has dropped by 33% without an extra bed. St. James's Hospital's medical admissions unit, which is a very different process, has been there for several years. Letterkenny, Sligo and Castlebar have done this. We have to accept this as actually happening. We are not talking pie in the sky. We can show many examples on the ground where this is working. The outlyers are small in number and they are the ones on which we have to focus. That is being achieved today by nurses and doctors. We know we have the best nurses and doctors in world. I would suggest that they have not worked to the best processes in the world, not through their fault. I am suggesting that they are now doing that and we still have improvement to make. It is sometimes unfair — I do not suggest this in a political context but outside a political context — to see their work undermined by some pieces in the newspapers which suggest they are not reaching those achievement levels. They are. The figure say that the nurses and doctors in the system are achieving a much higher standard of performance.
Nobody is questioning the doctors and nurses.
Professor Brendan Drumm
The figures are there. To suggest——
Is that why the Mater and Beaumont are in the situation they are in?
Professor Brendan Drumm
You will not ask me about the ones which have improved massively or why they have improved without an increase in beds.
I would like to discuss with you applying those principles to Beaumont and the Mater.
Professor Brendan Drumm
We are. Beaumont has hugely improved year-on-year by applying those principles. If people do not like success, I cannot deal with it. Making budgets work is amazing. This organisation and the people who work for it have delivered significantly beyond the service plan commitment to the taxpayer and the public, within budget. Then we are accused of making budgets work by cutting. Are we dealing with evidence or not? We have delivered way beyond what we committed to deliver, within budget. I rest my case. If that is cutting, it is unique.
There are cutbacks. Closed wards speak for themselves.
Professor Brendan Drumm
That is an insult to the people who work here.
Professor Drumm must be allowed to finish. We are dealing with concluding remarks.
Professor Brendan Drumm
The Brothers of Charity is a significant and lengthy issue, which we can discuss with Deputy O'Sullivan later if she wishes. From our perspective, it relates to the appointment of people way beyond the allotted number of places. I would need time to go into it.
A good question relates to what we do with the consultants who are on the 80:20 or on the old contract. It is a huge challenge to us. At this late stage, practices being what they are, the question is how much of it we can implement. I am a firm believer that if we highlight the actual figures, sometimes practices will change.
We need a little more than that.
Professor Brendan Drumm
I am not saying it cannot be done but I suggest it will be difficult when practice has been in place for 20 years, but we will be challenging it.
On the 9-point plan, every time we hit on a pharmaceutical issue it seems to reach an extraordinary high level of sensitivity. There was general practitioner and dietician input to a group that worked on this within the HSE. We know that 50% of nutritional supplements are not used by people. It is an issue for the taxpayer that this is dealt with, hopefully in a constructive way.
Ms Ann Doherty
St. John's accident and emergency services have been enhanced to a seven day service.
Professor Brendan Drumm
In response to Deputy O'Hanlon, we do have a huge challenge on outpatient waiting times. We are in the process of trying to set up a structure that will allow us to begin to move patients through outpatient departments much more efficiently. This will create a problem for us because it has to go through the system. It is a much more honest approach. We would be happy to come to the committee in, say, three months if it is an issue you want to address. It is a bottleneck in the system. We will have our own data at that stage in terms of changes in numbers. It might be a useful debate to have. The position is variable across the country. It is a major issue for the health services and it would put us to account. While it is always combative, we appreciate the input of the committee. There have a lot of useful suggestions. We accept that there are still major challenges.
On behalf of members of the committee, I thank you, the Minister and your officials for being here. It is very useful for all of us to hear the very positive developments which have taken place within the health service. We hear all too often about the negatives. We thank you in particular for emphasising the positive developments. I also thank members for their co-operation.