Health Issues: Discussion with Minister for Health and Children and HSE.

I welcome the Minister for Health and Children, Deputy Mary Harney, Professor Brendan Drumm and their officials to the meeting. We will try to stick as rigidly as we can to the time limits we set ourselves in previous meetings because that worked fairly effectively. It maximised the input of members and allowed the Minister and Professor Drumm to make the necessary points.

Members of the joint committee have absolute privilege but the same privilege does not apply to witnesses appearing before it. 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. The Minister would like to make some opening remarks.

Thank you. I am happy to have this opportunity to address the joint committee. I circulated a copy of remarks and do not intend to read them since everybody can read them.

Nothing was circulated. We received Professor Drumm's remarks but not the Minister's.

I am sorry. I understood they were sent to the joint committee yesterday. I will get my officials to circulate my comments.

Fine. The Minister may proceed.

As we know, we will spend approximately €16 billion this year on the health services. That is the gross spend which is obviously offset by a contribution from the health levy. To put it in context, that is 50% of the money we will collect in all taxes this year — €32 billion. It is substantially more than we will collect from the entire income tax collection.

Notwithstanding that, we are operating in a very challenging time financially and notwithstanding those challenges — I believe Professor Drumm will deal with this in his remarks — the level of activity is up on what was even anticipated in the service plan. The issue is the resources which can be made available to our public health system this year and next year and how we can get the best outcome for patients. There is often a debate in Ireland about how we raise the money for health. The debate should be more focused on how we allocate money however it is raised, be it from general taxation, insurance or a combination of both. According toThe Irish Times poll last week, 80% of people favour general taxation as the way to raise money for health. Recently, I established a group, chaired by Professor Frances Ruane, comprising a number of experts in this field, including Professor Charles Normand and others who have examined health funding systems, to recommend to me and the Government the most effective way to allocate health resources from the perspective of delivering the best outcome for patients. I invite the committee or any members of the committee to make a submission to that group, if they wish. The group is due to report next April.

I will not discuss beds and activity in these opening remarks, but the base we are coming from. There has been a huge improvement in the health of our citizens in recent years. In the last ten years, for example, life expectancy in Ireland has increased by five years. Ten years ago our life expectancy was two years shorter than the EU average; today it is one year longer. That is a tremendous achievement. Infant mortality rates have greatly improved in Ireland over the last ten years. The number of deaths from circulatory diseases has reduced by 25% in recent years. In the space of ten years we have added one extra year to life expectancy, ahead of the EU average. With regard to cardiac care, the number of deaths from cardiac disease is substantially down and in the case of cancer, it is down by 10%. In the case of specific cancers such as breast cancer, the pace of improvement is the fastest in the OECD. The five-year survival rate from breast cancer, for example, has increased from 73% to 80%. While there is significant scope for further improvement, I consider that a very healthy position.

The mortality rate for circulatory diseases such as heart attack and stroke has decreased by 25% and infant mortality has declined by almost 50% since 1998 and 38% since 2002. With regard to psychiatric illness, admissions to psychiatric hospitals continue to drop and have fallen by 22% since 1997. This has occurred in the context of more psychiatric services — an increase of 33% — being provided in day hospitals and in community services. For the first time in Ireland, since 2004 we are supporting older people in their homes with a range of measures. Currently, 10,000 older people and their families are receiving that support. We have introduced BreastCheck for the entire country as well as cervical cancer screening. There is a great deal more to do in the cancer screening area. Preventive care has also shown a significant improvement, with immunisation rates ranging from 83% to 92% between 2002 and 2007, an increase of 9%. This is welcome.

I mention those statistics because sometimes one would get the impression from what passes for debate in Ireland that things were not improving at the rate they are. We should be very proud of those improvements and try to build on them to secure further improvements. Earlier this week I announced the introduction date, from an operational perspective, of the fair deal. From last Monday, people can apply to have a care assistant appointed where that is necessary and from 27 October, financial support will be given to everybody on a universal basis, whether they are in a public or private nursing home. Everybody will get the same support. This year €55 million has been put into the Estimates to provide for that; next year it will require an additional €97 million. Although the fair deal is budget capped, the figures have been calculated on the basis of the need. There are 24,000 people in long-term care at present, many of whom will qualify for the fair deal. We anticipate approximately 9,000 people per year from now on.

The figures we have made available this year for the end of October, November and December, and the money we will put in the Estimates for next year, will be on the basis that everybody who requires that financial support will get it. For the first time we have a system of support that is fair, as between public and private care, that takes from everybody on the basis of their means and that greatly relieves the stress that many older people and their families endure having to fund long-term care, along with the huge uncertainty, worry and lack of transparency that have gone with it.

Clearly, there are a number of pressure points, particularly as we go into next year. I have said publicly that cuts of €800 million will be required from the public health budget next year to meet the Government's budgetary target because of the financial situation in which we find ourselves. That will be a major challenge. To meet that challenge we must continue to make improvements in the amount of day case activity, for example, and length of stay in hospitals. If we move to best international practice, for example, the Canadian rate of day case activity, we could improve substantially. Ireland's day case rate is 12% below the OECD average and less than 50% of best performers such as Canada. Our length of stay in hospital compared with the UK, when adjusted for age-related analysis, is between 0.6 of a day and 1.9 of a day longer than that of British hospitals. These are the types of matters on which we must continue to make progress, although huge progress has been made in recent years.

According to the European health consumer index published last week, Ireland has moved from 28th to 13th out of 33 countries in the performance of its public health system. Great credit for that must go to the reform measures being implemented by the Government and the HSE. We should not underestimate the significance of that huge leap in a three-year period. We want to go further. As I said previously, we want Ireland to be one of the top performers in the world from the perspective of its health system.

The Government established the Health Information and Quality Authority, another important element of health reform. It will now inspect nursing homes both in the public and private sectors against standards that are now enshrined in law by way of regulation. Its first nursing home inspection report was published a week and a half ago. I commend that report. First, it is written in easily understood English and, second, the residents and those receiving care in the nursing home were spoken to at length. I encourage people to read the report. If one is a family member of somebody in that nursing home, one will find it very reassuring that such high regard is paid to the wishes and needs of the residents, not least from a dietary point of view among many others. Until now, nursing homes were inspected for environmental and care standards but sometimes the regime we had in place did not put sufficient emphasis on the concerns of residents. HIQA will carry out many other inspections against standards and will enforce those standards independent of the service provider.

The challenges we meet are not just financial. We have the challenge of the pandemic at present. The chief medical officer, CMO, is with me and might like to deal with that at greater length. Although the pandemic is probably reaching a peak, we anticipate that 25% of the population might become infected. In the last four weeks, for example, the rate per 100,000 has virtually doubled from 42 per 100,000. We know that 1% of those who get influenza require hospitalisation and 20% of them will require intensive care beds. The Government recently approved a doubling of our intensive care capacity. Perhaps the HSE representatives will deal with this matter for the committee. We know that 50% of patients in an intensive care unit, ICU, will require ventilation and, on the recommendation of the national public health team, we will increase our ICU capacity, procure additional ventilators and train approximately 300 nurses to staff ICUs. That will pose a big challenge to the HSE this autumn and into next year.

There is also the financial challenge and, finally, the industrial relations, IR, challenge. As I have said previously, we have tremendous staff working in the health system. Sometimes, however, the manner in which people work is not as effective as it could be from the point of view of outcomes for patients. Clearly, we must move to a regime where there is greater flexibility and more team working. That is the model that can deliver best outcomes for patients, particularly in the current challenging financial situation.

Professor Brendan Drumm

I thank the committee for the opportunity to speak to it. So far this year we are meeting and, in many instances, exceeding the service plan targets for 2009. Between inpatient and day cases we are ahead of target by over 24,000 patients. Importantly, we have seen 30,000 more new patients in our outpatient clinics so far this year compared with the same period last year. This is critical because I believe outpatient access has for a long time been probably one of the biggest problems in our health service. Overall, we have seen 80,000 more outpatients than we had planned to see.

Year on year, the number of people waiting over six months for inpatient care is down by over 15% and 38% for day case care.

Last week there was media comment on cancellations during the first six weeks of this year and it is important to put these figures in perspective. The figures show that there were almost 9,000 inpatient and day case cancellations. This, in isolation, sounds high but it amounts to approximately 1.4% of total inpatient and day case activity during the period. I appreciate cancellations whenever they occur are distressing for patients but in a health service, one must adapt swiftly and put emergencies first. Against this backdrop, it is a tribute to staff across the country that the cancellation rates are relatively low, albeit we must focus on reducing these even further.

In regard to the primary care teams, at the end of August, 127 teams were holding clinical team meetings. This is 60% of the target for 2009 which is to have 210 teams holding clinical meetings by the end of the year.

In regard to staffing, we are operating slightly below the allocated ceiling and absenteeism rates are coming down. Again, this has been a major focus for this organisation. At the start of the year, absenteeism was at 5.95%, almost 6%, and at the end of July, it came down to 4.96%. Our absenteeism target is 3.5%. This is closely tracked through our HealthStat process on a monthly basis.

As indicated to the joint committee last March, a number of issues are emerging that are putting pressure on our budget. For example, an increasing number of people are now eligible for medical cards. At the end of August, 14,288 more medical cards than planned had been issued. This upward trend is likely to continue.

Last week the annual euro health consumer index report was published. The index compares health care systems across Europe. The report shows that since the HSE's transformation programme started in 2006, we have moved up 15 places to 13th out of 33. The report points out that the Irish health service has been steadily climbing up the ranks and stated that "the creation of the Health Service Executive was obviously a much-needed reform".

In addition to improving services, more transparent performance data have contributed to our improved ranking. We believe one of the big successes of this organisation has been bringing transparency to the performance of the services throughout the country and no longer simply throwing money where services have failed to perform. It demonstrates that our transformation programme is delivering results thanks to the commitment and support of staff throughout the country.

I refer to the corporate plan. We recently completed an analysis of our performance in regard to the three year plan's objectives. The analysis shows that in 23 of the 35 representative areas measured, we are performing at 70% or greater against our 2011 target. With two years to go in the life cycle of the corporate plan, these are positive results.

We are performing well in terms of the speed of reduction in MRSA levels, although in this part of the world and not only in this country, this remains a significant challenge. Other areas of significant success include childhood vaccination which is now reaching 95% and the establishment of child and adolescent mental health teams.

Areas that need focused attention continue to be identified. These include a very low breast-feeding rate by any international comparisons and high Caesarean section rates. Disability assessment rates against regulations and emergency department experiences in selected hospitals are also challenges.

I acknowledge that in the vast majority of hospitals which were experiencing major accident and emergency problems three to four years ago, these have been resolved. However, we must accept that approximately four hospitals consistently continue to have significant challenges in this area. This is the first time we have carried out such a detailed analysis and in line with our total focus on performance measurement, it will be repeated every six months.

I refer to the influenza pandemic, and Dr. Holohan who is an expert in this area is here. The rate of influenza-like illnesses has risen from approximately 45 per 100,000 to 76 per 100,000 following the reopening of schools. It is important to note that the vast majority of cases are relatively mild and, in most situations, people can look after themselves at home.

Plans are advanced for a mass vaccination programme to begin later this year, although this could extend into early 2010 in terms of start up depending on the availability of vaccine which has been challenging for the supplier companies. Prior to this, high risk groups will be vaccinated followed by health care workers.

General practitioners have played a very important role in dealing with the pandemic to date and they have the best record of who in the community is considered at higher risk. Therefore, they have been invited to play a central role in vaccinating this high risk group.

I refer to integrated services. This week we introduced two important initiatives that will, over time, deliver many tangible benefits to patients and clients and, indeed, health care staff. First, we have devolved a significant amount of decision-making from national level to our four regions. This is a major change for us. The immediate impact of this new arrangement is that operational responsibility is being transferred from the national hospitals office and the primary, community and continuing care directorate, PCCC, at national level to the four local management teams headed by regional directors of operations.

This means regional directors will be responsible for all service delivery and reconfiguration in their areas. This will simplify our management processes and enable strong local responsibility coupled with national consistency. I stress that it is different from any older system in that there will be national consistency.

The second initiative involves bringing together the national hospitals office and the PCCC directorate into a single unit — the integrated services directorate. This unit will hold the regional teams to account by monitoring and measuring their performance against agreed targets.

These are not changes for the sake of structural changes. This integration process will make it easier for staff to form effective teams unencumbered by whether somebody works in a hospital or in the community. It will enable us to forge stronger connections between our services, such as acute hospital, long stay care, general practitioner, mental health, child care, emergency, rehabilitation, social work services and so on. Most important, it will make it easier for patients and clients to get access to all the health and social care they need without delay or inconvenience.

I hope we will see an end to the day when a patient cannot go home on a Friday afternoon simply because extra budget would have to be applied in the community over the weekend which is not available because it is tied up in the hospital. There will be a common purpose focus on the patient rather than on where budgets reside in the organisation.

I wish to comment on paediatric services because there have been some major changes even in the past week. In regard to acute paediatric service, I advise the joint committee that we are establishing a team to be headed by Mr. John O'Brien, chief executive officer of St. James's Hospital, who is on secondment to the HSE, to manage the relationships between the HSE and the acute paediatrics community.

The team's focus will centre, in particular, on the three paediatric hospitals in Dublin in the context of ensuring the total resource deployed is used to maximum effect and assuring their preparedness for the move to the new children's hospital in 2014. We have spoken before about the need for co-ordination of the spend of this money across the entire system.

The team will also manage the HSE's relationships with the National Paediatric Hospital Development Board and, ultimately, acute paediatric services in hospitals outside Dublin and in primary and community care. This team will begin its work over the coming months. It will lead to a much more co-ordinated approach to the spend of money on child care in hospitals and, ultimately, in the community.

In a related development and perhaps most important, Our Lady's Hospital for Sick Children is to begin engaging fully with the development of the new paediatric hospital and will have representation on the hospital's development board. I cannot overemphasise the importance of this development. It is a major step forward for paediatric care in Ireland.

I am conscious that for a number of years, there has been a degree of uncertainty among staff at the hospital. They have had genuine apprehensions about the model of care to be provided in the new paediatric hospital. While there will never be a perfect plan for such a development, the full participation by Our Lady's Hospital for Sick Children will ensure that the best possible decisions are made as we go forward. It will add hugely to the overall project which will deliver a paediatric service that will be admired across the world.

The urgency of moving forward with this project cannot be overstated. Nobody who has experienced the infrastructure in place at the Children's University Hospital in Temple Street or in Our Lady's Hospital for Sick Children in Crumlin would propose it is an acceptable level of infrastructure. The fact we have run specialist teams across numerous sites has undermined the capacity of those teams to perform at the level they can for the children of Ireland.

Now that we have arrived at this important point, where all three hospitals share a common purpose, it is an opportune time for these hospitals — Temple Street, Our Lady's Hospital for Sick Children and the National Children's Hospital in Tallaght — to move towards a single governance structure. The benefits of such an arrangement would not only deliver many better services to children and their families and, indeed, for staff but would also pave the way for a smooth and more effective transition to the new paediatric hospital.

When we talk about hospitals coming together, I am always conscious that they have their own history and have pride in their delivery for their local communities. However, it is extremely important the boards move forward in a conjoined way to develop a common governance structure. I encourage the boards of these hospitals to move in this direction. I am very happy to pledge the HSE's full support to this development which has become all the more possible in the light of the recent decisions.

I thank the Minister and Professor Drumm. As always, we are constrained by time. Spokespersons have five minutes each. I am conscious some members wish to attend the Order of Business so they may have to leave and return later. If we stick tightly to our timescales, everyone will be able to speak.

I welcome the Minister, Professor Drumm and their teams. I will have to attend the Order of Business and I would not like the Minister or Professor Drumm to think I was showing any disrespect. However, I will return.

I wish to comment on some of the comments made but I will focus on the major areas of concern to people. An issue not mentioned by the Minister or Professor Drumm was the insurance situation. We had discussions earlier this year on this issue and on the levy which was brought in. The Minister was warned it would have the opposite effect to that which she sought, that is, that it would remove the very people we wanted to keep in insurance schemes from them — the young, the healthy and young families. That is precisely what has happened. Some 200,000 people have left the schemes.

There was a 23% rise in the VHI premium in January 2009 and, if we are to believe what we read in the newspapers and what we hear from the VHI, we are looking at another 20% rise in January 2010. That is a 43% rise in one year. This is Argentinean inflation at the worst time. What does the Minister intend to do about that and to keep insurance affordable? She certainly has not managed to do so and has made the situation worse.

I would like to ask Professor Drumm about the redundancy packages and the career breaks. He should not quote the response I received to a parliamentary question which was laughable and stated that the unions were opposed to them. Numerous people have been in touch with my office who have sought the career break but they have been stonewalled. They have received no information and there has been no progress. This was supposed to be a money saving initiative.

I wish to ask about the vaccine, the logistics and the planning. We were told the HSE would set up clinics and that there would be some involvement by general practitioners. Where are the clinics? How many clinics will be set up? What hours will they open and who will staff them?

I refer to cervical screening. There is a report today, about which people have known for quite some time, that the National Cancer Screening Service has decided it will invite women and people will only be able to turn up by invitation. This is causing huge delays and the number of people being screened has dropped considerably. Most people believe it is a cynical move to reduce costs and the number of women being screened. I would like to know the logic behind that.

We had a dissertation from the Minister which would indicate all is well and that things have improved massively. The reality is that 900 beds have been blocked because of delayed discharges. Some 700 beds have been cut because of cutbacks. We were told at least another 700 beds are occupied because of hospital acquired infections. That is a large proportion of the beds available and it has led not to the spin we hear but to an increase in the number of people lying on trolleys for prolonged periods. The Irish Nurses Organisation's figures show an increase of 30 per day this year over last year.

We have seen a 70% increase in delayed discharges and an increase in the number of operations being cancelled. Last week a colleague told me of a case where a lady was waiting for a long time for an operation on her gall bladder. She was offered a bed in Cork after several months but it was too far from north County Dublin. She was eventually offered a bed in Beaumont Hospital. She was told on the Sunday morning she was due to go in that the bed was not available. However, she was telephoned on the Monday afternoon asking her where she was. That is a shambles in terms of organisation.

How will the Minister cope with the €1.4 billion cut put forward as being necessary? I refer to the fair deal scheme, although I will leave most of this to my colleague, Deputy Paul Connaughton, who is very much in touch with rural Ireland and the impact it will have on people there. There are concerns about the cap on the funding and what services will be available. Will we warehouse the elderly into nursing homes with nothing but bed and board? Will physiotherapy and chiropody be available? Will there be a social programme or will they be left to wither on the vine?

I am concerned the Health Information and Quality Authority does not have a role in assessing standards and establishing standards in home care and in ensuring value for money. I came across an incident recently where a man took over an existing service and found that 20% of people did not have Garda clearance and people were in and out of people's homes in 20 minutes. We need standards and to be able to monitor them. That can be done.

Our Lady's Hospital for Sick Children in Crumlin was alluded to. Does the Minister still consider it wise to spend €5 million per year on a virtual planning team for a hospital which has been delayed for another two years while there is an intensive care unit in Crumlin which is not fit for purpose? I have a report stating that only one of 22 recommendations has been put in place since they were released.

Will the Minister report on her meeting with Patients for Dignity and the progress made in regard to its issues? I refer to our delayed bed stay and our poor performance in day cases, etc. I subscribe fully to the idea of more care in the community and to shorter bed stay in hospital but it is not achievable if one does not have the supports in the community. Supports have not been put in place in the community. It is quite simple.

In regard to the European consumer health index, ECHI, one of the areas in which we scored top marks was diabetes. I find that extraordinary given that 50% of diabetics in this country have not been diagnosed. How do we know they are well controlled? A diabetologist appeared before the committee last year. He told us he came across a patient in his clinic who had never been seen by a diabetologist in his 55 years of life. It is all very well to tell us about the improvements, and there are some improvements, in particular, in life expectancy, but there are major issues over which we cannot gloss.

We need reform. It was said the HSE was a major part of the reform process. The HSE gave us the north east and Drogheda. Thousands of people were left from September until May even though a freedom of information request revealed it was known in May that there was a huge problem. People died as a result. There was also Portlaoise hospital.

I welcome the Minister, Professor Drumm and their teams. I wish to concentrate mainly on the big picture. I have grave concerns for the sick people of this country over the next year because of the financial cutbacks. We face an €800 million shortfall and there is a questionable extra €400 million as well.

We were told 14,288 more people have medical cards than planned. The Department of Health and Children is being targeted with a larger percentage of the cuts being made than any other Department. Has the Minister sought to have her Department protected in some way from the size of these cuts?

There is a grave danger to patients in this context. Has the increase in the number of medical cards been addressed by Government? The Department of Social and Family Affairs was given protection because of the increase in the number of people unemployed. The increase in the number of medical cards is as a direct result of the increase in the number of unemployed. There are major political issues in terms of the Minister fighting for her Department.

More than 900 people are in acute beds but cannot move out of them because there is nowhere for them to go. Perhaps the fair deal scheme will help that. The INO said that more than 700 beds are closed and that between September 2007 and September 2009, there were more than 1,000 more people on trolleys in outpatient departments. We face a possible pandemic, H1N1, which will place a huge strain on services. The entire picture is worrying. I seek honest answers from the Minister and Professor Drumm on the future care of patients in the public health system.

On financial matters, has the €97 million allocated for the fair deal programme been ring-fenced? This sum is the absolute minimum required to address the needs of elderly patients next year. I appreciate that the €55 million allocation for this year is safe.

I will respond to a point made by Professor Drumm about devolving a significant degree of decision making from national level to four regions. When I first heard it was intended to devolve power to the regions, I welcomed the news. However, rather than devolving power to four regions, the HSE should devolve decision making to hospital networks. If the hospital and community care network in the mid-west, from where I come, were given devolved powers over budgets and control over developments in the network in the mid-west, the proposals would work. However, the decision to devolve power to the whole western region, from County Donegal down to County Clare and west County Limerick, will not be successful. Why was it decided to devolve power to four regions rather than a series of networks? The networks need to be able make decisions and integrate community and hospital care at that level. I do not agree with devolving power to four large regions because it will create a further layer between national and local level and will not be good for patients.

On the figures, will we receive information on the number of patients who are waiting for appointments, having been referred by a general practitioner to a consultant or as an outpatient? While we have figures on how long people wait within the system, we do not have information on waiting times for people who have been referred. This information is crucial for patients. The other day, I spoke to a lady with a serious heart condition who has been told she must wait for six months before she will be given an outpatient appointment. We need to have these figures because it is a crucial information gap and a significant problem for patients.

On Crumlin children's hospital, what is the position regarding the promise to reopen the theatre and ward which were closed? Particular concern has arisen regarding children waiting for heart operations. Are waiting times for operations for very sick children improving? Will action be taken in the interim to address concerns raised by a consultant paediatrician at the weekend with regard to the state of the ICU ward in Crumlin children's hospital?

Is capital available for a new children's hospital? The Minister for Justice, Equality and Law Reform, Deputy Dermot Ahern, has indicated that not a red cent is available for a central hospital in the north east. Are enough red cents available to fund the proposed new paediatric hospital? We need an answer to this question because if funding is not available, we must address the problems in Crumlin children's hospital and the general problems in paediatrics.

On the issue of child and adolescent psychiatry, while mental health services in general are neglected, I am especially concerned about young children with psychiatric problems. While I understand some of the additional beds promised have been provided, I seek an assurance that all the promised beds and child and adolescent psychiatric teams will be provided as promised. I have in mind a family who cannot secure the services they require for their 14 year old son who has serious problems. Having failed to have the boy's needs met in their own region, the family has tried to get an address in Cork to have him treated there.

I thank the Minister and Professor Drumm for their contributions. We all recognise phenomenal improvements in the delivery of services and the development of new services. As the Minister noted, this information does not always get out. Members have been provided with a copy of Professor Drumm's presentation. Perhaps the Minister will circulate a copy of her contribution and update us from time to time on the good news in the health service.

I have a couple of questions arising from the discussion. On the question of figures, particularly those on the number of people waiting on trolleys, we receive conflicting reports all the time. Apparently, the Health Service Executive has one set of figures and the Irish Nurses Organisation has another set of figures. It is important that everyone agrees on a standard procedure for deciding who is waiting on a trolley and for how long. If the figures are to be authentic, they must be based on a procedure which everyone, including the INO, has bought into. It is frustrating and difficult to receive figures from the HSE indicating that ten people are waiting on trolleys on a given night, only to read later in a local newspaper that 45 patients were waiting on trolleys on the night in question. Some effort must be made to ensure the figures being provided are accurate.

Professor Drumm referred to the increasing number of patients attending outpatient appointments and different areas where problems are occurring. Does the comparative analysis between hospitals show any specific trends which could be addressed? Are many patients turning up at hospitals who would be more appropriately seen by their general practitioner in a primary care setting?

The relationship between general practitioners and hospitals is an important one. Although they used to have a close relationship, hospitals and GPs later went their separate ways. Has this relationship improved? Achieving efficiency in the health service requires that hospitals and general practitioners work hand in hand. It appears many patients are being referred to hospitals unnecessarily. What action is being taken in this regard?

Waiting lists are clearly a problem. It is my experience that people are very pleased with the service they receive once they have accessed the health service. I receive few complaints from those who have accessed the service but access is a problem in some areas. When the issue is one of waiting for cold surgery, as it were, or some other procedure that can wait, we must reluctantly accept that people must wait. This is true of every country in the world. While instant relief cannot be provided in all cases, long delays are occurring, even in cases of potentially serious illnesses. In neurology, for example, there are delays in securing access to outpatient appointments. Is action being taken in this regard?

Efficiency is very important and there is no doubt there is scope for achieving greater efficiency in an organisation as large as the health service. It is incumbent on politicians, the Minister, Professor Drumm and the 111,000 people working in the health service to examine ways and means of improving efficiency. When I was Minister for Health the Minister for Finance never stopped talking about the opportunities for efficiency and refused to accept that all the fat had been trimmed from the service. In times when money is scarce, as it is across the world at present, it is important to seek better ways to do what needs to be done.

In light of the large number of new and expensive treatments being developed, I am concerned that we may, unfortunately, have to refuse drugs to certain patients because we cannot afford them. Meeting the cost of medicine will be a worldwide problem, not only a phenomenon in Ireland, and the issue should be addressed now. The political system has failed the people by the adversarial nature of debate. We should have a more objective view. We should try to identify the real causes of the problems. It does not matter who is in government. It is too easy to blame the Minister. We would be better served by trying to identify the problem and dealing with it.

The Minister and Professor Drumm might be disappointed if I did not mention Monaghan Hospital. As everybody is aware, all the acute facilities have been moved out, although elderly patients are coming back for step-down care, but I understand if they need a procedure such as an intravenous drip they must return to Cavan General Hospital. As I have suggested in the past, it is possible to run a good, low-grade pathology acute medical unit in Monaghan. That is something that should be examined in conjunction with the general practitioners to ensure elderly patients with low-grade pathology like pneumonia, stroke, asthma or whatever would be treated in their own local hospital rather than have to travel 40 miles back and forward. I would like the possibility of getting the GPs involved to ensure that level of service could be provided.

Other members have four minutes each and I ask them to keep within that time.

I, too, extend a welcome to Professor Brendan Drumm, the Minister, Deputy Harney, and her team. I raise the issue of the appalling deficiency in the provision of dermatology services in the south east. Twelve years ago Dr. Colin Buckley was appointed as the dermatologist in the south east and at that time Comhairle recommended that he should treat 100,000, following best practice in the United Kingdom, Australia, the United States, Canada, etc. Dr. Buckley provides a service single-handedly for a population of 460,000. There are 3,500 patients waiting two to three years for a routine hospital appointment in the south east. Clinics are held in the four hospitals — Wexford General Hospital, South Tipperary General Hospital, Waterford Regional Hospital and St. Luke's General Hospital in Kilkenny. There is a six-month waiting list for babies to be seen by this dermatologist and Professor Drumm, more than most, can well imagine that for a baby with eczema, which causes weeping and soreness, that situation is less than ideal. They remove approximately 700 cancers annually. The department runs a pigmented mole clinic for the early detection of melanoma and provides a mole mapping service. It is also one of the few units in the south east providing a photodynamic therapy service. For many people skin disease has a huge impact on their quality of life, interpersonal relationships and even job prospects. I would like the witnesses' views on the plans they have to appoint another dermatologist to the region in view of the facts outlined and the current appalling waiting times.

On the proposed reconfiguration model in the south east, there appear to be two proposals — a one plus three or a two plus two model. The two plus two model would appear to be St. Luke's General Hospital in Kilkenny with South Tipperary General Hospital, and Waterford Regional Hospital and Wexford General Hospital. I want to make some points on that. First, South Tipperary General Hospital is only operating a surgical service, which is amazingly efficient, since Cashel amalgamated two and a half years ago. With the new road between Kilkenny and Waterford it will leave a travel time of 25 minutes between those two cities. The current travel time is more than one hour from Clonmel to Waterford, and one hour from Clonmel to Kilkenny. The road is extremely bad and there are no plans in the current climate to improve that.

Regarding acute service provision and centres of excellence, I see a difficulty arising if it is decided that it would be ideal to locate a maternity unit where paediatric services and acute services, both medical and surgical, are provided. I refer to the occasional need for those in the relationship of delivering general midwifery and normal midwifery care and services. Will the witnesses comment on what they see as the future impact on maternity services provision? Maternity is a normal life event which does not require women to be corralled into a centre of excellence. If there is a plan to have community midwifery services in the south east, are there plans to set up a pilot project whereby there will be a roll-out of the provision of women-centred care on the basis of their demands? Has that been costed and what is the proposal regarding the paediatric services? My understanding from an analysis of the numbers, and we examined many with the consultants recently, indicates that in South Tipperary General Hospital the children are treated to discharge but I understand that in other units in the south east they are admitted to treat. If bed occupancy is to be the measure by which we assess the throughput, the treat to discharge cases will come in under the radar but it is an extraordinarily efficient means of treating children of whom more than 4,000 are treated in South Tipperary General Hospital annually. The service is excellent. I would like the witnesses' comments on those issues.

I welcome the delegation. I will begin by acknowledging the good news because we talk a great deal about what needs to be done but the improvement in the breast cancer survival rates over five years is excellent. I want to ask a related question to that but it must be acknowledged that the strategy has been very positive, as is the improvement of 15 places under the European health consumer index. If it were going in the opposite direction we would have a great deal to say about it. Those are major achievements for the health service and are something we must recognise.

I will address my first question to Professor Drumm, which relates to the study on hospitals. He referred to it under the corporate plan performance and said that four hospitals in particular needed extra attention. I am quite familiar with one of those hospitals and I wonder what is being done in terms of the hospitals that performed badly in the recent assessment. What action has been taken by the HSE to improve their performance? I am especially concerned about the H1N1 virus, how those hospitals will cope with the increase in the number of cases of that virus and if additional help and assistance is being given to them in that area.

I will deal also with the issue of readmission procedures for oncology patients in University College Hospital Galway. I raised this issue during the summer and as we know, UCHG is a centre of excellence for cancer services but it has come to my attention, and it has received a good deal of attention in the media, that patients being readmitted are readmitted through the accident and emergency department. I am not happy about that. I have written to Professor Tom Keane and the hospital manager and received replies that I do not consider satisfactory. In a letter from Professor Tom Keane he states that his understanding is that this is the standard guideline in medical oncology nationally and that all patients with potential febrile neutropenia are given this advice whether they live in Castlebar or Dublin. Will Professor Drumm indicate if that is the national strategy and what will be done about it? In further correspondence I have been told that a bed utilisation study has been completed and that changes to the admission policy are being contemplated. What are those changes because I am sure Professor Drumm has heard of the people in this very vulnerable group spending up to 17 hours on a bed in accident and emergency? That is unacceptable when these patients' medical history is well known within the hospital and there is no need for that to take place.

In that regard and because I focused initially on the improvement of breast cancer services, I would like to make the witnesses aware of the position in Mayo General Hospital of people receiving chemotherapy and the overcrowding in that facility. I raise this because it is a national issue. When they rowed in with the centres of excellence project it was our understanding, and I am aware it is in the capital programme, that a new oncology unit would be built at Mayo General Hospital at a cost of €7 million. I am aware that project was going through the planning process in the past year but what is the current status of that project now? For a hospital that was rowed in with the national cancer strategy I am on record as saying, and my comments were repeated at the meeting of the Committee of Public Accounts, that this has worked well for people in County Mayo but there must be some level of payback and currently the service is overcrowded. I would like to know the exact position on that.

The Minister for Health and Children, at the start of her presentation, stated we face €800 million in cuts over the next year. Having been a member of the Western Health Board, I welcome the fact that decision making is being devolved to the four HSE centres. This will be positive because many of the issues I am raising today concern the west.

Why has a decision been taken by the HSE to move the ambulance control centre from Castlebar to Ballyshannon, at a loss of 12 jobs? I raise this because a call centre could equally be located on the Aran Islands or Inishturk. Why was the decision made, at a cost, when the service was located originally in the Sacred Heart Hospital? Money was invested to move it to the former St. Mary's Hospital, where it was working extremely well. It has top-of-the-range technology because the Western Health Board, while I was a member, contributed to a project called Camp West at a cost of €5 million. One third of the operational cost of Camp West is now being paid because of the technology that was installed. A decision was made, however, never to avail of Camp West. Camp West is an emergency call centre for all the emergency——

Will the Deputy conclude?

I will conclude on the issue of the lack of replacements for public health nurses when they go on leave from Inishturk. I raised this issue locally. Replacements are available on other islands. Why are the nurses not being replaced on Inishturk, thereby putting the islanders' health and safety at risk? Something needs to be done.

I welcome the Minister, Professor Drumm and their support team. One must acknowledge that medicine has moved on. It always will, irrespective of whether there is a structure in place to deliver it to the patient. There will always be medical advances and we all accept that.

What protocols are in place to deal with people who present themselves at psychiatric units with suicidal tendencies? Is there a procedure for contacting the families of psychiatric patients when they are being discharged from hospital? I got a very brief answer on this matter stating there is none because one must respect patient confidentiality. The last time I inquired into this — Deputy Neville will have something to say about it — I encountered several cases of people who committed suicide on being released from psychiatric units, on discharging themselves therefrom or on not being admitted thereto. If I met someone in a confused, suicidal state, patient confidentiality would be the last thing on my mind. I would contact the person's family and say I was very disturbed and worried and that the person needed help. The guidelines must be changed. It is unacceptable and outrageous that people hide behind the cloak of confidentiality. The families of patients are very worried. In most cases, the family that would be contacted would be the family that accompanied the patient to the psychiatric unit in the first instance. I do not understand the HSE's policy in this regard. It is misguided and should be put aside.

The reply in respect of the investigation into symphysiotomy by an outside expert is very detailed and long, yet it makes the same point as before, namely: "No, we are not going to do it." I appeal to the Minister in this regard. The women affected, who comprise a very small group, are not getting any younger. I am thankful the barbaric practice does not happen any more although I note in the reply that, in a rare event, the procedure may have to be carried out. However, given the geographical clustering of the procedure, its extent and its effects on the people on which it was performed, the matter warrants investigation. Those subject to the procedure deserve an investigation. I appeal to the Minister to re-examine this. The former Minister for Health and Children, Deputy Martin, actually agreed to an investigation but an expert could not be found.

The central issue I want to address concerns the moving of the breast care unit from the South Infirmary Victoria University Hospital to Cork University Hospital. Does a centre of excellence have to be within a certain structure or on a certain campus? Most people in the south believe the South Infirmary Victoria University Hospital breast care unit was and still is a centre of excellence. It is now proposed that the unit be moved to Cork University Hospital by 1 December. It will happen; it is a juggernaut that seems impossible to stop. Very worrying questions remain to be asked, one of which concerns information technology and access. The IT system in Cork University Hospital is not compatible with that in the other hospital. Therefore, if on 2 December one goes to Cork University Hospital with a breast-related condition that was already dealt with in the South Infirmary Victoria University Hospital, there will be no way for the consultant to compare mammograms or files. It is suggested that the files be photocopied.

Three consultants, including a radiologist and pathologist, are to be moved from the South Infirmary Victoria University Hospital to the new unit in Cork University Hospital without making provision for the general surgical list in the former hospital. One surgeon will be left there to deal with all the cases four surgeons dealt with heretofore. That is not the way to do business and it is very worrying.

I ask the Deputy to conclude.

We must not open the new unit on 1 December and we need further consultation on the matter. It is very worrying.

I welcome the Minister, Professor Drumm and their teams. It was particularly refreshing to hear their report this morning on outcomes and levels of activity in hospitals across the country. I remember the hard times in 2006 when there was a lot of pressure on the Minister. A lot of muck was being slung at her after setting up the HSE. A lot of muck was thrown in the meantime by those who believe it was wrong to set it up. This morning's report certainly demonstrates the move to establish it was correct.

It is heartening to hear that, in spite of constrained budgets, outcomes are improving and levels of activity in hospitals are increasing. It is heartening for me, as a representative from Donegal, to know this continues to be the case and that the delegation is more than hopeful that the trend will continue. It is great to hear considering the current economic circumstances.

I very much dispute Deputy Jan O'Sullivan's comments on the decentralisation of decision-making powers to the four regions. She stated she would like the powers returned to the hospitals. This is how problems arose in the first instance under the old health board set-up. The current thinking on hospitals' working practices and on the making of comparisons comprises one of the main reasons for the increases in levels of activity. The current plan to deliver the decision-making powers in the four regions is very good. It has been intimated that an endocrinologist and diabetologist is on the list for future consultant requirements for Letterkenny General Hospital. What is the timeframe for this?

I have two or three specific questions. I have inquired about the problems with the centralising of the processing of medical card applications; I raised the matter at the last meeting as well. I will quote from a letter — and say no more about it — to show how daft this decision is and how it is simply not working in favour of the people we should be helping. The letter states:

I am an old-age pensioner who is 86 years of age. Some weeks back I was at the HSE clinic on Sea Road in Galway. The lady in charge told me my card was out of date. She gave me a number to ring, which I did. I stayed on the phone for 20 minutes and all I got was an answering machine and no more. I found out my medical card is valid until 2010 but I have no medical card at the moment. I would be very grateful if you tried to help me.

That person has a card but she cannot prove she has it or find anybody to tell her how to get an updated card. If the Minister or Professor Drumm were 86 years old, would they like that to happen? I do not have to say any more.

I wish to raise another issue relating to inspections by HIQA, which I greatly welcome. I have said as much publicly many times. Who is to bear the cost of the inspections? Is it the HSE, the nursing homes or the patients in the homes? I am in receipt of a letter that was sent by at least one nursing home to patients indicating that because of this particular cost, the nursing homes would have to transfer an extra €6 to €8 per week to meet the cost of HIQA inspections. I wish to clarify today who is supposed to pay the cost of inspections. It would be ironic if the people for whom the inspections were intended to help would have to pay for them out of their own pockets.

I have said on many occasions that I welcome the introduction and implementation of the fair deal scheme. There are many aspects of the process which will find favour but there is also a big black cloud. It is totally biased against the rural communities and farming communities in particular. There is a three-year cap relating to the private dwelling where family members do not have sufficient resources to pay for a nursing home patient. I do not have time to go into that aspect but we know what it means.

The money would be reclaimed when the house is sold by the Revenue Commissioners and although there is a cap relating to the dwelling house, there is no cap on businesses or farm lands of any description, irrespective of how small a business is. That will create havoc as it has not been thought out at all. When the normal inheritance procedure happens, as it does, in rural Ireland, there will be significant legal problems. Unless something is done during implementation, these legal problems will affect families.

I compliment the Minister and Professor Drumm on the performance in the Euro health consumer index. The move from 28 to 13 shows that policies are working and we are moving in the right direction.

I also want to speak on the south east and the future of hospital services there. I am from Kilkenny and my colleague is from Clonmel. There should be a strategic alliance; we all realise that the four-hospital system we have in the south east will not continue because of financial constraints and improvements in services. The nuclear option of moving all acute services to Waterford is not on as we serve 500,000 people in the south east. There is no way one hospital could handle all the acute services for these people, so that proposal cannot go ahead.

In Kilkenny, Clonmel and Wexford, concerned groups have come together and want an input into future services in the south east. I am glad this is happening and I hope the HSE will listen to these concerns. We should get a good system whenever the decision is made and the report is published. There are specialist programmes such as cancer treatment, orthopaedics and ear, nose and throat procedures which must be centralised in a regional hospital. Other acute services for a population of 500,000 people cannot all be brought into such a centre. With all respect to Waterford Regional Hospital, it would not be able for it, as it is already bursting at the seams with the services operating there. A specialist cancer unit is also going in.

We need a two-tier system in that respect. I hold the hand of friendship out to Clonmel as we should proceed with a strategic alliance to serve the population. Waterford is at the bottom edge of the south east and to bring people over 60 to 100 miles to get to the hospital in Waterford in not viable. It would not be prudent for an emergency patient. We should proceed with a two-hospital strategic approach, with Kilkenny and Clonmel coming together, and perhaps Wexford and Waterford. Kilkenny is the geographical centre, and we serve Clonmel, Laois-Offaly and Carlow. That is the way it should go. The HSE should consider this two-tier system of hospitals.

There are concerns in rural Ireland and the farming community in particular about the fair deal scheme. I welcome the measure as it is a step in the right direction but there are concerns about family farms which have been around for generations. With the stipulations of the scheme and as a result of financial needs, part of something which has been left as inheritance for generations over the years could be taken away when a person dies. There is concern about this in the farming community.

It is great to see the building of such partnerships at this committee meeting.

I welcome the Minister and Professor Drumm. I will quickly deal with some issues. A Vision for Change proposes that the proceeds of sales of psychiatric lands and institutions would be retained within the psychiatric service for its development. St. Loman's and the Verville retreat in Clontarf were sold for €42 million and I understand that has been transferred to the Exchequer. What progress is being made to ensure that the money is discharged from the Exchequer to the psychiatric services for their development?

Will the Minister or Professor Drumm inform us on how the health and social care professionals council is developing, particularly with regard to psychotherapy and counselling? There is no regulation whatever for psychotherapy and counselling and I have come across some quite bizarre examples of how people who sought counselling were treated in a very unprofessional way. It will be three years in November since the relevant Act was signed into law.

I will take up Deputy Lynch's point regarding suicide and discharge from hospital. I do not want to classify psychiatrists. Some progressive psychiatrists decide that when a person is admitted to the psychiatric services, a recovery plan should be developed with his or her family. Under this process, all aspects of a person's recovery are discussed, including, if required, occupational or family therapy. I will not discuss the matter of multidisciplinary psychiatric teams because the Minister and Professor Drumm are probably blue in the face with me raising that issue.

The opposite of what I have outlined is happening in 70% of cases. I am aware of a case involving one person who was admitted to a psychiatric hospital following an attempt to hang himself. The psychiatrist involved was informed that the individual in question was persuasive and would try to have himself discharged. On the following day, when a different psychiatrist was on duty, the man was discharged and went home and hanged himself. I am also aware of the case of a woman who had attempted suicide on three occasions who, one day after being discharged, took some tablets and drank a bottle of vodka and died in hospital 48 hours later. The families of these people pleaded with the authorities to the effect that their loved ones were in serious danger but they were not communicated with following the patients' discharge from hospital.

What is the reaction of the Minister and Professor Drumm to the report of this committee — published in July — on suicide in Irish society? That report also examined the previous recommendations made by the committee on suicide.

I also wish to extend a warm welcome to the Minister and Professor Drumm and their officials. Everyone welcomes the fair deal. People were seeking this for a long period and are glad that it is finally being implemented. However, there are concerns abroad and it is important that people be provided with the necessary information in order that they might become familiar with the scheme.

With regard to HIQA, everyone welcomes the carrying out of inspections because for far too long there were no such inspections, particularly at residential care facilities. We know, to our cost, the results of that. However, I am concerned about public nursing homes which may not have the self-contained units that are necessary and which may have more beds in wards than should be the case but which are providing an excellent standard of care. Is it not the case that, outside the basic structures, the standard of care is most important? The management and staff of particular public nursing homes are extremely concerned about their future and that of their patients. If there were more of these facilities providing the level of care to which I refer, perhaps some of the past episodes about which we are now aware might not have occurred.

I welcome the roll-out of primary care teams under the primary continuing community care, PCCC, initiative. The committee visited a primary care facility in Cork. That facility is what I would term a centre of excellence. However, I do not know how primary care facilities can function properly if GPs are not on board. That is a major area of concern. If we are investing at a particular level but if the GPs are not on board, then it makes a mockery of the entire system. A meeting took place in Monaghan during the past week at which the roll-out of primary care facilities was discussed. I understand that not one GP from the north Monaghan area attended that meeting, which is objectionable. If patients are supposed to be at the centre of everything, why then did the relevant GPs not attend the meeting? It is time we called a spade a spade.

I share Deputy O'Hanlon's concerns regarding the number of people on trolleys in our hospitals, particularly as I was a victim of this myself. There is a need for proper and accurate figures to be provided. It is difficult to do anything about the negative spin that is being put on this matter in the media. People in Monaghan are exposed to more than their fair share of such spin. I read a newspaper article two weeks ago which stated that the ENT department is going to be moved out of Monaghan Hospital when the time is right. Nothing could be further from the truth. People are allowed to make such outrageous claims and we are seen to be either hiding or complicit because we do not react strongly enough. I have stated on numerous occasions that the ENT department is one of the most positive aspects of Monaghan Hospital at present and it will certainly not be moved. However, people make claims of the type to which I refer and there is little we can do about them except continue to highlight the good that is being done. These claims are causing huge anxiety for patients and other service users and are striking fear into the hearts of those who might like to avail of the service in the future. They are afraid that this is another service which will disappear on our watch.

In respect of today's good news, I wish to pay tribute to the HSE. We are quick to make criticisms and when one has a valid case, one is entitled to criticise. However, the HSE, which does not always get the credit it deserves, has done excellent work in the context of the information it provided on the swine flu pandemic. The information was clear, easy to understand and readily available. When children returned to school after the summer holidays, they all came home with the relevant information. Parents' minds were put at ease as a result because they knew what it was necessary to do.

I share Deputy O'Hanlon's view on low-grade, low-pathology cases at Monaghan Hospital. It is ludicrous that someone in a step-down facility who requires an intravenous drip must be transported 13 miles to the hospital in Cavan. We must do whatever we can to bring GPs on board. I accept that one can bring a horse to water but that one cannot make it drink. However, GPs are going to be obliged to take a long, hard look at themselves in the context of their providing better care for patients in the Monaghan region.

I apologise that I was absent from proceedings for a short period. Unfortunately, I was also obliged to attend this morning's meeting of the Joint Committee on Social and Family Affairs. I wish to be associated with the welcome extended to the Minister, Deputy Harney, Professor Drumm and their officials.

To save time, I wish to state that I am going to be parochial and refer to Tallaght for a moment.

Is the Deputy really going to do so? I have never heard him mention Tallaght before.

In light of the current economic climate, perhaps it might be better if I remain totally focused and stick to discussing matters relating to Tallaght. The Minister and Professor Drumm will be aware that I remain concerned and am interested in certain issues. I refer, for example, to the further delivery of cancer services in Tallaght. I pay tribute to Professor Tom Keane who has kept me and other colleagues up to date on particular issues. I am of the view that he is listening to the points I am making to him.

The community health report highlights a matter in which I am interested, namely, the further development of community services which would embrace the involvement of local GPs. The Minister and Professor Drumm will have noted that the report refers to the redevelopment of the Millbrook Lawns health centre, which I warmly welcome. The Minister and Professor Drumm would be welcome to visit that first-class facility. Tallaght can show the way in respect of how such facilities should be developed.

There has been a great deal of discussion locally with regard to the moving of the maternity unit in the Coombe Hospital to Tallaght Hospital. That development would be welcomed in the third largest population centre in the country in which many young people live. What progress has been made in respect of the proposed move?

There has also been much discussion regarding the delivery of paediatric services, particularly in the context of the future of the Mater Hospital site. There is quite a strong commitment in the reports before the committee in this regard. However, there is quite an amount of speculation to the effect that the economic situation will dictate that the relevant project will not proceed. I am, therefore, seeking further assurances from the Minister in respect of the matter. I am also seeking assurances that the proposed ambulatory urgent care centre at Tallaght will be completed and opened before the Eccles St. development is completed. I seek this important commitment on behalf of my local community because it forms part of the future.

How does Professor Drumm perceive the rate of progress of developments at Tallaght Hospital? He has made remarks recently about the good progress that has been made in respect of the management team and I note significant changes are afoot in this regard again. This should be good for the wider community. I remind members that Tallaght Hospital caters for both the local population and a wide catchment area that extends through parts of counties Kildare and Wicklow all the way to the border with County Wexford at Carnew. The hospital constitutes an important part of the health infrastructure and this point should continue to be taken into account. While I have no difficulty in supporting any colleague who raise parochial issues at times, my area is just as important and I believe the hospital plays a very important part in health service delivery.

First, I compliment the Minister and the Department on the introduction of the Fair Deal scheme. This is a great development for which one has waited for the past two years. It constitutes a significant development in the care of older people within Irish society and it is impossible to overestimate the significance of people no longer being obliged to worry. As the Minister noted previously, people will no longer be obliged to worry about selling their homes. Moreover, it will be customer orientated and patients' physical and emotional care will be at the core of the service provided by HIQA. I also compliment Professor Drumm on the improvement recorded by the HSE in the recent European health consumer index findings. It must be of great satisfaction to Professor Drumm to note the improvements in the health service have led to a jump of 15 places.

I seek an update from the Minister on the timeline for the delivery of the cervical cancer vaccine for 12-year olds, as well as an update on the status of the cystic fibrosis unit at St. Vincent's Hospital. On the first issue, 70 women die unnecessarily every year because they have not received the cervical cancer vaccine. While I acknowledge that free screening now is available, the introduction of the vaccine is an imperative. At the joint committee's previous meeting, I promised to keep up the pressure on this issue to ensure the roll-out of the vaccine as rapidly as possible. As for the cystic fibrosis unit in St. Vincent's Hospital, my experience is that families in the city with children who have cystic fibrosis are petrified. In particular, given the onset of swine flu, they worry that this unit will not be fully in operation and are petrified that their children will die. I cannot imagine what it must feel like to have a child with cystic fibrosis or the manner in which one must spend many hours each day keeping the child alive and retaining his or her health and mobility.

I was speaking on suicide to the ICA in Athboy, County Meath, the night before last. As I noted when I produced my document on suicide in the new Ireland, the establishment of a 24-hour, seven days per week freephone line is critical. Moreover, it should have a number that people can remember. At the aforementioned meeting, people made the point that everyone remembers that 999 is an emergency number, which is excellent. I do not accept the recent figures to the effect that the suicide rate is falling. As someone who has written a document on this issue, I hear anecdotal evidence on the subject every week. Given the rate of undetermined deaths recorded by coroners, such as the road deaths by single car accident, I do not accept those figures. As far as I am aware, the 3Ts organisation led by Professor Malone was sceptical in respect of those figures that show that rates have flattened out. In addition, there are far more deaths by suicide than through road accidents and I still believe this issue is not receiving the concerted attention that is required.

The Senator's time has expired.

I wish to make a further point. A good example in this regard is that of the 11,000 people who present at accident and emergency units, a total of 8,500 are repeat presentations. Moreover, Dr. Ella Arensmann has reported that 60,000 people self-harm every year, which is an indication that they are suicidal. When a person who has self-harmed presents at an accident and emergency unit, is a universal format in place as to the follow-up treatment? Second, if Dr. Arensmann's contention that 60,000 people, mainly under the age of 35, are self-harming is true, they need a telephone line to call. It is irresponsible not to have such a freephone line.

I wish to ask the Minister about one area in particular, namely, the H1N1 vaccine and its delivery. Can she inform members of the outcome of her discussions with the IMO and whether she expects that the general practitioners will be delivering the vaccine on their own or whether clinics also will be needed? She should clarify this point. I understand that no negotiations were held with the IMO until recently. Can the Minister explain the reason this was the case? As for the H1N1 virus, the Minister should comment on the Department's judgment as to how schools are coping at present and whether it is satisfied with the responses. Is there further advice or information that schools should receive at this point, given the recent closure of a school? She should comment on or make some general points in that regard.

I welcome the opportunity to raise some questions. The specific reply I received regarding the potential impact on the health services of the report by the special group on public service numbers and expenditure programmes, otherwise known as the McCarthy report or an bord snip nua report, must be one of the briefest responses I have ever seen come before this joint committee. I am not surprised because were these proposals to be implemented, it would amount to a body blow to the public health services and would gravely affect the most vulnerable and older people in particular.

I wish to raise one aspect of the McCarthy report recommendations, which pertains to older people. I refer to what I can only describe as the outrageous prospect of home care packages being means tested. The critical point is that the Minister has often referred to such care packages as being delivered in substitution for public hospital care. However, although one's entitlement to public hospital care is universal, this raises the prospect of home care packages being means tested. At no time did I ever accept that they could be in substitution for acute hospital services access. However, the prospect of such packages now being means tested constitutes a total contradiction in respect of one's universal entitlement to public hospital care. Will the Minister rule out this proposition here and now and be done with it? There is no equation and there can be no acceptance of it.

I refer to the response I received from the Minister regarding the loss by Monaghan General Hospital of acute hospital services as of 22 July and the position regarding the statistics produced subsequently in respect of Cavan General Hospital. The Minister indicates that, incredibly, there has been a decrease in the number of patients per day attending the emergency unit at Cavan General Hospital since the transfer of acute medical services from Monaghan hospital. She bases this information on a comparison of figures for the emergency unit over the seven weeks leading up to when Monaghan was taken off call, from 4 June to 22 July, and the seven weeks afterwards. With respect, anyone on the ground in County Monaghan will tell the Minister that the final seven weeks leading up to the loss of acute medical services was not the most appropriate time to present real figures of throughput. There was already great concern and a view presented in media commentary that the services were no longerin situ. This is not comparing two reasonable periods of time.

I refer to the situation concerning the medical assessment unit in Cavan. I note that the average number of patients waiting for admission to a bed from the emergency unit at 2 p.m. each day has increased slightly, from 0.5 to 1. That is a 100% increase from a half a person to a full person. The term increased slightly does not apply. A far more telling fact is the comparison between the number of patients on trolleys over the month of September 2008 and September 2009. I have the daily figures for those months in two successive years.

Will the Deputy conclude?

The percentage increase of patients on trolleys in Cavan General Hospital for September 2009 was 188% on September 2008. The truth should be faced. For patients and service providers this has been a bad day's work on the part of the HSE and the Department of Health and Children, with the Minister at the helm.

I want to add some questions to the many questions asked already. I thank the Minister and the witnesses for their submissions. I congratulate them on presenting the very positive achievements. It must be terribly demoralising for those working in the health service to be constantly bombarded by the shortcomings of the system. The Minister must be much more forceful in communicating the successes in the health system. Nothing is more successful than increased survival rates from illnesses. The public can expect to live longer in this country than previously.

I commend the Minister for listening to what this committee said in the past about paediatric services. I also commend her on appointing someone to take charge of that area, one in which this committee is very interested and which the public requires to see moved forward.

There is a broad welcome across the country for the fair deal scheme. Members have raised questions about the types of services covered. It is important to clarify that it is not a second-rate service. The range of services under the old system will be available under the fair deal.

Regarding the primary care strategy, some 127 teams meet and the objective is to get 210 teams in place by the end of the year. Will that target be achieved? One can have all the meetings one likes but what is important is how effective the teamwork is for people on the ground. This committee has a keen interest in the primary care strategy and its delivery. Setting up the centres is an essential next step but, given the economic difficulties we have, we must examine the means to incentivise delivery of those centres.

Some 25 minutes are available to the Minister and Professor Drumm but they should not feel that they have to use all that time. I invite the Minister to start.

I thank members of the committee for their contribution and the acknowledgement by some members that progress has been made. I will begin by responding to the questions from Deputy Reilly. It is not true to say that the number of women getting cervical screening has dropped off. Last year it was 15,000 per month, this year it is 28,000. The figure has almost doubled. The purpose of the call and recall is to remind women to go for their smear tests. It was always envisaged that women would receive a reminder, as they do with BreastCheck, and I will allow the CMO to explain this. It is a useful tool in reminding women to attend their GP. There is nothing sinister and is not true to say that there has been a fall-off.

It is not true to say that 200,000 people have cancelled their health insurance policies. Some 10% of that figure, or 20,000, policies have been cancelled. There has been much switching between VHI and other companies. This is understandable in the recession we are in, with many people losing their jobs. Many companies had paid for health insurance and it is to be expected that there would be a fall-off. The figure is 20,000, not 200,000.

Regarding the levy, we cannot have a community rated system where the sick and the elderly can get insurance at an affordable price without a form of transfer from younger to older people. In the model advanced by Deputy Reilly, based on the Dutch model where universal health insurance is provided, there is risk equalisation. The risk equalisation model legislated for in the 1990s was struck down by the Supreme Court and if we had done nothing older people would have exited health insurance in their thousands last year. The VHI has the majority of older people and those over 60 cost the company €170 million. There is no way an older person or a sick person who requires much hospital attention could afford health insurance if we did not do what we did. In the UK only 11% of people have health insurance because it is not affordable. I know an Irish couple who lived in the UK when in their 60s. Their health insurance premium was £20,000 but when they moved back to Ireland it was under €3,000. We must compare like with like. If we are to have a debate, we must base it on the data.

If I have missed some questions I will return to them. Others are operational questions that I will allow Professor Drumm address. Every health Minister wants to protect the biggest possible budget for the health system. We have seen major increases in health spending in Ireland over the past decade of economic prosperity. Health accounts for 27% of current spending. Mr. McCarthy referred to the gap of €400 million per week between revenue, what we are raising in taxes, and what we are spending but last week's Exchequer figures, published on Friday, show the gap at almost €500 million per week now. In that scenario, where the Government must reduce public spending by some €3-4 billion per year, the health system cannot escape just as the welfare system and all other areas must be examined. The Government is now beginning the Estimates process and I am not in a position to say what the outcome will be. The roadmap is the McCarthy report and it must be seriously considered.

Health Ministers all over Europe are faced with the same issues. I recently attended an EU Health Ministers meeting and every Minister, from Germany and Holland to the UK, is faced with the same challenges at a time of economic downturn. How do we continue to fund the public health system? That is why issues of flexibility and staff ratios are very important. The cost of delivering public health in Ireland is substantially higher than the cost across the Border in Northern Ireland, or in England, Scotland, Wales or any other European country. The margin is quite substantial. If the cost of delivering the service is substantially greater, the only way to get better treatment and more treatment of patients is to work on flexibility issues. The staffing bill for the health service is some €7 billion per year, of which €1.2 billion is non-core pay. We have spoken of the need for flexibility. If services move from one place to another, it is not unreasonable that people might move with the service within reasonable geographical distance. This is particularly true in the current environment.

That brings me to the issue of centralising medical cards. If 300 people are surplus to requirements in the administration of medical cards and we have a shortage of 300 people somewhere else to support frontline services of course it makes sense to move them from one to the other. We cannot justify having people that are superfluous to requirements anywhere in the health system at a time of great pressure. It is not about making anybody redundant, it is simply about asking people to work differently.

With regard to the fair deal, I consulted with the farming organisations and they were very supportive. We brought in changes on foot of their advice. The IFA and other farming organisations told me this will encourage early transfer which they have sought for years. Deputy Connaughton knows that I come from that background——

I am afraid the Minister has forgotten her background.

I grew up on a very small farm and I know the issues very well. We must remember that 70% of the cost of the care will continue to be paid by the taxpayers. Next year it will amount to more than €1 billion. The €97 million mentioned by Deputy Jan O'Sullivan is the additional money for the fair deal in a full year and I am confident that it will be forthcoming. We will spend more than €1 billion——

Is the Minister certain?

Yes. A total of 70% of the cost of care will continue to be met by the taxpayers. For the first time, we have a system that is fair, equitable and takes from people in accordance with their means. Prior to the fair deal, 90% of the cost of care in a public nursing home or a bed funded by the public health system was paid for. In a private nursing home families had to pay on average 60% of the cost of the care.

With regard to the €190 annual fee for inspection and registration, I answered a question from Deputy Connaughton last week and he knows the answer. On 23 September I told him it was not to be passed on but carried by the nursing home. The nursing homes pay €65 a year to their own association and they never suggest passing that on. It is not unreasonable to charge nursing homes €190 for a high-quality inspection regime. The reason for this is that we want to encourage nursing homes in the public and private sectors to be conscious of their responsibilities beyond the environment of nursing care to wider interests, including social activation and other issues mentioned.

I do not like Deputy Reilly's use of the phrase "warehousing the elderly". We are not warehousing the elderly, we will provide extremely high-quality care. We have standards of care now that are among the best in the world as far as nursing homes are concerned. Everybody who goes into a nursing home must have a care plan customised to the needs of the individual. I encourage members to read the first inspection report, which was published two weeks ago. They will find it very reassuring. Residents were spoken to at length, the inspectors sat down and dined with them and did not just ask them a question and walk away. That is the type of inspection regime we want to have because it will deliver high-quality care. It is not unreasonable to charge €190 a year for that, to be carried by the nursing homes, given that we will fund 70% of——

The patients should not pay it.

Of course not and I stated that to Deputy Connaughton in a reply to a question in the Dáil. There is no point in trying to go public here——

It does not seem to be coming across no matter what question the Minister answers.

Allow the Minister to conclude.

It will not come across if people such as Deputy Connaughton, when they are informed, continue the myth that it will passed on. All of us have a responsibility——

It is the patients who believe that.

Deputy Connaughton has a responsibility to tell patients the facts when he knows them and I gave him the facts on 23 September.

I have no doubt they will be back to the Minister.

With regard to the children's hospital, I am very encouraged by the comments made by Professor Drumm to the committee on Crumlin hospital. I salute the courage and leadership given by the boards of the three hospitals and many of the clinicians. The children's hospital is a key priority for capital funding for me and the Government because children deserve it.

The status quo is not an option. If we did not do this we would have to spend a large amount of money on Temple Street Hospital and Crumlin hospital. The option of no capital spend does not arise. We know that by bringing the three children's hospitals together in a single entity not only will we deliver better care for children but will also be able to eliminate a minimum of €25 million from costs. That minimum saving of €25 million multiplied by 25 years will more than pay the capital cost of building the hospital. That amount would be saved by removing 300 people from the three sites and no one would regard that as excessive. It is hoped that we can go much further and perhaps Professor Drumm will deal with that.

Deputy Lynch asked about the movement of services from the South Infirmary in Cork. Whatever about Sligo having a problem moving to Galway, one can see one hospital from the other in Cork. There should not be an issue for patients but perhaps it is an issue for some clinicians. The idea is that all cancer diagnosis and surgery will happen in a specialist cancer centre. We know from experience throughout the world — perhaps the chief medical officer would like to comment on this — that this provides the best results. With cancer it is most important that one is diagnosed properly and that one has the appropriate surgery. If these are not right nothing can make up for it. Capital works are going ahead in Cork University Hospital and the transition will happen at the end of November and start of December. It is the last move to be made.

Last week, I received a letter from a lady in Sligo who told me that her friend was being treated in Galway and that it was a great service. We have received good feedback from Mayo. When these things happen people forget about the difficulties and concentrate on the treatment. People are receiving outstanding treatment and it is to the great credit of the HSE, and particularly of Professor Keane, that the transition has happened ahead of time. The target was to complete 90% by the end of this year and the remainder next year but 100% will have been completed by the end of the year and 90% has already been completed. All breast surgeons in the country with the exception of one have signed off on this.

Whatever about being able to see one hospital from another, what about patients' records? What about the 2,000 women who will not have their mammograms because the machines are being removed?

Deputy Lynch should not fall for this type of talk because it is not true. The centre will be as good as one will get anywhere. That is a fact.

I do not doubt it.

I will let the chief medical officer comment on it because he is a clinician and I am not.

Unfortunately, in the health area we always see the problem. If we all concentrated more on the solution we would achieve much more. That includes everybody from politicians, Ministers, officials and clinicians. Professor Keane came here with very little extra money and found a solution even though many people felt he could not do so without a big budget. He has done an incredible job. I have no doubt that the last remaining transfer in Cork city will not inconvenience any patients and they will receive a standard of service which is the best that this country can offer and on a par with the rest of the world.

I met the Patients for Dignity group and I have undertaken to get back to it. I have had a number of meetings with the Attorney General and I am due to have another one shortly. As Deputy Reilly will acknowledge, major issues are raised, not least criminal prosecution. I gave an undertaking to get back to the group. I had hoped to have done so by now but I will do so shortly.

Many members raised issues with regard to service provision and I will let Professor Drumm answer them. With regard to health and social care professions the council has been in place for approximately three years. It is chaired by Margaret Hayes, a former Secretary General of a Department and I met her recently. I do not have the specific date for the counselling service mentioned by Deputy Neville but I will come back to him with it. We are making good advances in this area. Moving 12 health care professionals from a non-regulated environment to a regulated one involves a considerable amount of logistical work and that has been under way in consultation with all of the professional groups involved. I do not have the precise details and I will come back to Deputy Neville on this.

With regard to what happens in hospitals, Deputy Aylward mentioned the hand of friendship and I would like to extend the hand of friendship to the members of the Opposition with regard to health reform. Safe care is about the right person doing the right thing in the right place to get the right outcome whatever that is, and if one is sick or if one's loved one is ill that is what one would want. Every hospital has an important role to play in this regard. It is not about whether it is this place or that place. Different things can happen in different places centred around the idea that the right person delivers the right care in the right place at the right time. We know our public hospital system is very heavily dependent on junior doctors and with the new consultant contract there will be one-for-all access to diagnostics. This means that what happened to the late Susie Long, who was told if she had insurance she would be diagnosed tomorrow or next week and if she did not she would go on a list, cannot now happen. There is a one-for-all, universal access based on medical need — the way it should be — in the public hospital system funded by the taxpayer. The new consultants contract has a large role to play in this regard, particularly in the appointment of clinical directors. I attended the Irish Hospital Consultants Association annual meeting last Saturday and was encouraged by the level of clinical leadership that emerged. This makes a large difference between what might be possible and what will actually happen.

I would be delighted to take up Deputy O'Connor's invitation to visit the Millbrook Lawns health centre at an appropriate time.

I thank the Minister.

Senator White raised the issue of the cervical cancer vaccine. I have always been committed to introducing a vaccine programme as soon as possible. HIQA made a health technology assessment and is currently making one for colorectal screening. There are up to 1,000 deaths a year from colon and rectal cancer and 70 to 80 deaths a year from cervical cancer. Some 90% can be saved with a screening programme and we could do better with the vaccine. It is not, however, a question of "either or" but of "both". The Irish Cancer Society has stated colorectal screening should be the priority. It has generously offered some funding for this which I am happy to accept. However, I have to wait on HIQA's report and the budgetary process.

Senator Prendergast raised the matter of Clonmel hospital which I recently visited. I agree it is all about having a network of hospitals working together. There is much more we can do in places such as Clonmel that already happens in larger hospitals in Waterford and Cork.

What about the McCarthy report's recommendation that the home care package should be means-tested?

No decision has been made in that regard. Up to 10,000 people avail of a home care package. In a time of a shortage, one must ensure those with the greatest need receive the resources. The McCarthy report has not yet been decided upon by the Government. It also suggested changing the cap of 15% on the home for the fair deal package, an action I do not envisage taking. Everything must be examined and I cannot rule it in or out. As money is finite, if we are in a tight budgetary position, we must ensure those who need the service most receive it.

What about HIQA assessing home care standards and determining if value for money is being achieved?

I presume the Deputy is referring to private homes. We have not yet legislated for what happens in private homes. The Deputy's point, however, about whether people delivering care in a private home setting are screened by the Garda is valid. I was not aware this was an issue and will let the HSE delegation address it.

It must also be ensured the service they provide meets a certain standard.

Absolutely but that is an issue for the HSE and I would like its delegation to deal with it.

Ms Laverne McGuinness

Many HSE staff provide home care packages, including therapy. These would be screened as part of our normal protocols. HIQA has recently carried out an evaluation of home care packages and a report will be published soon. When it is, I will share some its outcomes with Deputy Reilly. It will show the level of care in home care packages is of a good standard.

Professor Brendan Drumm

The HSE never suggested the unions did not support the early retirement or career break schemes. They are 100% behind them. As the Minister alluded, we said that if one added an early retirement scheme and a moratorium on recruitment without flexibility on redeployment, the system would collapse. It is not within our control, unless there is flexibility on how we redeploy staff. I do not expect anyone to manage the system without this agreement.

Mr. Liam Woods

It is intended to put in place 30 swine flu clinics, one in each local health office area. The deadline of 19 October was set for this.

Will it go ahead in October?

Professor Brendan Drumm

One issue is the availability of vaccines as their yields have been low.

Dr. Tony Holohan

We have one licence for one vaccine we have purchased. It will be delivered in the latter part of this week. It will give us in excess of 100,000 doses which we intend to administer through the route of general practice, assuming general practitioners will agree to the offer made. The vaccine will be provided though GPs' surgeries for the young chronically sick for four weeks. At that point, the mass vaccination clinics will commence. Mr. Woods is referring to timelines in a situation where GPs might not be in a position to participate in the provision of a vaccine for the young chronically sick. If that were the case, the HSE would have to provide for it. It would be less than ideal but we have been assured these clinics will be ready to go from 19 October. I do not, however, have information on where exactly they will be located.

Professor Brendan Drumm

Most of them will not be in HSE facilities. We hope, however, we will not have to go down that route because it would affect other front-line services.

On spending €5 million a year on the new development board for the National Children's Hospital, it must be remembered that the rebuilding of Temple Street Hospital, which is essential, would cost over €200 million. Investing in the hospital in Crumlin, even to keep it running, will involve a sum well in excess of €150 million. This money must be spent and it would be a tremendous pity if it were spent on two sites with all the wrong outcomes and synergies wasted. I am reassured by the Minister's commitment to the one-site solution.

The issue of delayed discharges is constantly on our radar. It is somewhat ironic — I am not claiming it as a success — that the figure for delayed discharges today is lower than it was this day last year. That is because 250 long-care beds were put into the system in the past few weeks. The figure is down from 945 in August to 743 today. As we do not have the resources to keep doing this, I will not claim the figure will remain at that level. In general, for several years, delayed discharges have run between 600 and 900, approximately 6% of overall bed capacity.

We need to be careful that this is not used as an excuse for underperformance by hospitals. It is a problem but it is by no means the only solution to what goes on in hospitals. The figure varies across the country and in Dublin there is a bigger challenge than in most other areas. We know that 35% of patients in hospital do not need to be there. That is why we have focused on this issue. We have established medical assessment units, although it has been a slower roll-out in Dublin. We know we can reduce by 25% the number of accident and emergency department admissions by using medical assessment units. We know the community intervention teams we have put in place have been very successful. We are adding more, especially in the mid-west region, with our configuration in the next few months. We know that putting intervention teams into facilities which people attend for rehabilitation or a long stay can have a significant effect and we have begun to implement these programmes. Home care packages are a great success in that regard.

The second issue is that a system of integrated discharge planning is up and running. I must acknowledge the Irish Nurses Organisation which has co-operated significantly in this programme in the interests of patient care. This means that we are now focused on the early discharge of patients in the morning and taking down the average stay by half a day across the system. Getting someone home at 11 a.m. rather than at 5 p.m. would remove all our problems with beds. That is our focus and why we have been able to get through significantly more work with far fewer beds than we started out with three or four years ago. The discharge data initiative has been implemented across five pilot sites and will be spread across the system.

Planning access to diagnostics, early morning ward rounds and nurse-empowered discharges in order that a patient does not have to wait all day to go home because a consultant is busy elsewhere are simple things that have been difficult to negotiate, but with our constructive involvement with the different stakeholders we are putting them in place. That is why we have been able to increase activity levels with a lower bed stock. We said from the beginning that beds were not the solution but that the solution which was also better for patients was to use them more effectively. In response to Deputy O'Sullivan, there is no doubt that there will be serious pressures on the financial side. That is why the issues I have mentioned are absolutely critical because beds are very expensive and if we can redirect that money, we can get much more done with what we have. I am not saying this will be easy. It will be a major challenge which the Minister and everybody else accepts. These are very challenging times but we have to use resources more effectively.

There are four regions in the statute and we have gone with them. We have advanced greatly in clinical leadership. We have moved from a situation where nearly everybody was off-side to one where the clinical leaders are taking control all over the place to provide for change. What will evolve is that we will manage units in four regions but the functional units we deliver will, I suspect, devolve to approximately 20 because there are areas of cohesion that make a great deal of sense. There is not much point in trying to manage services in counties Mayo and Donegal as part of a single process but this can be done in day-to-day clinical management. That is where the critical decisions will be made, albeit across four regions. I would like to spend more time on that point but cannot do so today. I can speak off-line to anybody who wishes.

The figures for out-patient waiting times are available. We received them because they have not traditionally been counted and they are for our health staff programme. There are major problems in several areas, including dermatology, ear, nose and throat and orthopaedics. We are putting a process in place to try to deal with this. We have had significant success when we have focused on some of these in specific areas. This is the biggest challenge in the health system. At least, the figures are available on HealthStat and we are asking hospitals why they are not reducing the numbers of returns. Dr. O'Hanlon has mentioned that the number of patients coming back for a third appointment is unacceptable, blocking patients who need new appointments. We need to do a great deal of work on these figures.

I will ask Mr. O'Brien to respond to the question about Crumlin hospital at the end. The scoliosis issue has been resolved. The committee may be surprised that I wish to compliment its involvement in that issue because it focused us all across the system on the need to be more realistic. The issue was resolved rapidly after the committee's involvement.

Child and adolescent beds are being put in place rapidly. We have focussed on the performance of child and adolescent psychiatry services. Dr. Brendan Doody, a child and adolescent psychiatrist and a great clinical leader in that area, is examining how many children are being seen per member of team etc. across the country. There are resource issues in some cases and in others, a process issue. We are beginning to see significant improvements. The data will be available to everybody across the country on HealthStat when we include community data in a few months' time.

The figures for those on trolleys have constantly been a battleground for us and the INO. We count at 2 p.m., it counts at 8 a.m.

They are still going up.

Professor Brendan Drumm

I have just asked someone to give me yesterday's figures. Over 24 hours, across the country, there were only two people on trolleys, both in the Mater Hospital. Four or five years ago there were people on trolleys everywhere across the system, in Letterkenny, Castlebar, Limerick, which was not the worst, and Portlaoise. They have all disappeared off the radar due to the efforts of the local accident and emergency department and in-house medical staff.

That is not the reality on the ground.

What about Galway?

The Deputy should allow Professor Drumm to answer.

Professor Brendan Drumm

We can give the Deputies the absolute statistics to show this. If people are going to argue that the INO statistics etc. are the right ones, they can do so but I will use our statistics and give them to members. Any fair counting of the system and any approach to accident and emergency consultants will show that in the majority of centres around the country the figures have improved dramatically. Take Cavan for instance.

That is exactly the example I have cited.

Professor Brendan Drumm

The position has improved dramatically in three and even two years.

How can Professor Drumm say that when there is a 185% increase on the figures in September last year?

Professor Brendan Drumm

Yesterday in Cavan nobody waited between zero and six hours, from six to 12 hours, 12 to 24 hours or greater than 24 hours. The Deputy can check the figures.

Of course, I will but I want to know why the HSE takes a different amount of time from the INO to assess the reality in our hospitals? What is the professor's justification?

Professor Brendan Drumm

At the Department's request, which is very fair, there is live time recording right across the system which tells exactly when somebody arrived and left. That is available for 12 centres. I have no doubt that when it is available in Cavan hospital, the picture will be exactly the same — a dramatic improvement.

All too sadly I witnessed it recently and can tell Professor Drumm that he and the Minister should take the time and the opportunity to visit and see the situation in the hospital for themselves.

Professor Brendan Drumm

I have been in Cavan hospital several times.

One can argue about statistics——

Can we have order or we will not be able to hear the answers to the other members' questions?

If patients are discharged early in the day, is it not a futile exercise for the INO to check beds when patients are being discharged and patients being moved from trolleys into beds? Would it not make more sense to engage in the trolley watches in the afternoon?

Professor Brendan Drumm

The logic of doing them in the afternoon cannot be challenged. There will be arguments——

Perhaps we could move on to the other points made.

That position is not sustainable. We are talking about patients spending the night on trolleys, not at 2 p.m.

Professor Brendan Drumm

To follow up on Deputy O'Hanlon's point about comparative analyses between hospitals and outpatients, we have done this and have the figures up for the number of outpatients seen per whole-time equivalent, WTE, consultant. There are large variances which we are trying to manage at an individual level with the clinical directors. There have been areas, not least in County Mayo, where a clinical director has set about providing extra clinics and challenging the system to say this is not acceptable. In response to Deputy Flynn's question, her location is a good example. The clinical directors there are beginning to take up these challenges with individual teams. The variation for clinical performance at outpatient level is significant. There are significant variations in waiting lists, for example, for neurology services. We cannot explain them all but are beginning to challenge them.

We are establishing a pharmo-economic unit under Dr. Barry White within our clinical and quality care directorate. We will also establish agreed care plans involving agreements between general practitioners and the hospital system for many chronic illnesses. It will also involve a focus on the specific drugs used, as the cost of drugs is a major challenge.

I share Deputy Conlon's sense of frustration in respect of the IV lines. We are successfully doing this in situations that are not nearly as advanced as in Monaghan. We are doing this in long-stay facilities around the country, led by Brid McGoldrick, director of nursing in St. Joseph's Care Centre in Longford, but it requires GP co-operation. We will have to get to the bottom of this issue and perhaps I will return to it when I come to deal with Deputy Conlon's query on primary care teams.

Senator Prendergast, who has left, raised the issue of dermatology services in the south east. Certainly that one person should provide a service for 460,000 people is a huge challenge and an issue we need to revisit. Most recently the south east region has prioritised orthopaedics and vascular surgery for new appointments. It appears as if we should have been looking at dermatology services and perhaps that is one of the benefits of us appearing before the committee.

The issue of reconfiguration was raised by Senator Prendergast and Deputy Aylward. On the matter of overnight surgery, between Clonmel and Kilkenny there is significantly less than one overnight piece of surgery. In fact there is about one piece of surgery every three nights after 10 p.m., yet for surgery alone, we pay €100,000 per month in junior doctor overtime across those two units. While we are taking out homecare packages, etc., it is not sustainable to spend that amount of money. In addition, for the College of Surgeons it is not sustainable to continue to train people for workloads of that level. One may ask why surgery has changed. It has probably changed massively because of diagnostics becoming so advanced because of CAT scans, MRIs and so on. There must be a reality check on that type of spend. We are working locally with clinicians, directors of nursing and everybody to try to arrive at an agreed strategy. It is not for me to say what that strategy should be but certainly there will have to be change. The geography of the south east was not as blessed as the geography of the mid-west in terms of the location of Limerick and Waterford. We accept the challenge. I await the outcome from the local people on that issue.

Deputy Flynn referred to poor performances. We are getting the clinical director to sit down with colleagues to examine the individual figures. That is a very new approach but we think it is having a definite effect. We find that people like to get their performance data rather than being challenged. There was always the fear that people getting performance data would feel threatened but we find that because most clinicians do a very good job they want to be recognised and performance data allows one to do that. The Deputy raised the febrile neutropenia issue on a previous occasion. I will have to try again to get to the bottom of this because there is a real frustration that a patient, not only with cancer, but other patients who have a chronic association with a hospital need to go back to an accident and emergency department. I cannot say I will defend it here because I do not think it is——

Is it the national policy?

Professor Brendan Drumm

I suspect it is. I suspect that people have said it is. That does not mean it cannot be——

Professor Brendan Drumm

——looked at. It is something I need to take it away and come back on it.

If we could get an improvement on that——

Professor Brendan Drumm

It is probably a wider issue for patients who have a chronic disease other than cancer. As we move forward with the development of our programmes of care and chronic disease we will try to make direct contact between the patient and an in-hospital service rather than going through accident and emergency departments. I will try to come back on the specific issue, although I think I promised the Deputy that before and did not. In regard to chemotherapy, the capital plan has not yet been confirmed.

I ask Professor Drumm to keep it in mind as a priority in light of——

Professor Brendan Drumm

Okay. The other thing I would say about Mayo General Hospital — because I do not know where capital will go over the next year or two — is that it is a fabulous facility and if it cannot be done with the new capital we must look at how a facility which is so modern could——

Certainly we want an improvement in the present situation which is inadequate.

Professor Brendan Drumm

There may be something we could do with minor capital because it is such a modern facility. I gather the ambulance control centre is still operating there.

That is correct.

Professor Brendan Drumm

There will not be any reduction in staff but ambulance control centres across the country will be subject to major change because it is likely that there will be two ambulance control centres in the country. There is no justification for what we do at present. Therefore, there will be huge change across the country in ambulance control centres. My understanding is that the centre is Mayo will remain. Irrespective of whatever changes take place, it will not lead to a reduction in the number of staff but there will be redeployment of staff. As we develop a reconfiguration, for instance, ambulance staff are critical to it but probably we need them at the front line.

The only point I would make is that there has been such an investment in that particular control centre during the past couple of years and the CAMP-West facility has the technology. If there are to be two for the country, why not locate one in Castlebar?

Professor Brendan Drumm

I think there will be one in the west and one in the east. On the islands issue, I will come back to the Deputy regarding Inishturk.

Deputy Lynch and Deputy Neville asked about the protocols in regard to suicide. Perhaps Ms McGuinness will comment on it.

Ms Laverne McGuinness

In regard to protocols on suicide, there is a national standard approach. Both Deputies articulated that it is an issue. There are legal reasons, more so than reasons of confidentiality with the patient. As of yesterday, there are 13 mental health clinical directorsin situ who will be seeking to put national standards in place throughout the country for protocols such as this, for people presenting with suicide where there is a danger and a fear that they will make a further attempt. We will be working with the mental health clinical directors to put in place a national standard.

Professor Brendan Drumm

I will come back to the other issues raised by Deputy Neville. I thank Deputy Blaney for his acknowledgement of the changes. A good example of where change is taking place is in his locality with the opening last week of the first tranche of new primary care centres through a public private development. This is a state-of-the-art facility. At some stage we should invite the committee to visit a primary care centre. What is being put in place in Letterkenny — we have not had an official opening — is one of the most comprehensive of services which looks like a hospital development. Similar type centres will be in place in Mitchelstown and Mallow before the end of the year. This is the direction in which we need to go.

In regard to the post of consultant endrocrinologist in Letterkenny, because of the moratorium, consultants are excluded but only on the basis that we suppress junior hospital doctors to develop a post. It is an issue we can discuss with them in Letterkenny if that capacity is there. General physicians deal with the vast majority of diabetic care and we need to ensure that service is not lost. We will raise the issue of whether that post can be filled but those are the rules under which we now operate.

One minute remains.

Professor Brendan Drumm

Deputy Connaughton asked about the centralising of medical cards. I invite Ms McGuinness to respond.

Ms Laverne McGuinness

Centralisation of medical cards is for financial and efficiency reasons. Some €10 million can be saved by the centralisation of medical cards which will be used for front line services. That whole processing facility will be carried out by 100 staff, rather than 400 staff speckled throughout the country. The turnaround time for medical cards will be 15 days. At present, the processing centre for those over 70 is in Finglas. In regard to the lady who was in contact with the Deputy, all those over 70 were written to three, four and five times by our centre in Finglas. If the lady still experiences a difficulty I would be delighted to take the telephone numbers and get in contact with her. This does not prohibit anybody contacting their local health office to obtain information on medical cards. All we are doing is processing the medical cards and standardising the arrangement for the issuing of same from one centre in Finglas which makes sound economic and financial sense and will be more efficient.

That is not happening.

Is it true that the computers in the local health centre cannot access the information?

Ms Laverne McGuinness

That is a good thing because a centre in, say, Donegal or Kerry, could issue a medical card and that information would not be known. If somebody else applied for a medical card in Mayo, there could be a duplicate medical card. By centralising the process, the possibility of duplication would be eliminated which, in turn, would mean overpayments would not be made to the GP.

It is good bookkeeping as long the HSE does not hear from them.

Please allow Ms McGuinness to reply.

What the HSE is doing is ridiculous.

Ms Laverne McGuinness

There is one centralised ICT system on which the database for all medical cards will be held, which will eliminate duplication. Overpayments had been made in regard to some duplicate medical cards. They have been recalled, which means it is a much more efficient system. It is better for the taxpayer. Some €10 million in savings——

Is it better for the applicant?

Professor Brendan Drumm

Deputy Neville asked about money from the sale of lands. Mr. Gilroy will deal with that matter shortly.

With regard to psychiatric services, we now have clinical directors appointed in psychiatry, for whom standardisation of procedures will be a priority. This will give people such as the Deputy direct contact with a group of 13 clinicians who will have a huge role in standardising procedures. It will give the Deputy a voice where it could make a real difference. We can give him some insights into how that connection can be made.

Ms Laverne McGuinness

On the suicide report of the sub-committee, an assistant director for mental health will be appointed in the coming weeks. All the reports on national implementation strategies will be dealt with by him or her and the 13 clinical directors. The administrative arms and clinicians will be brought together to deal with serious issues mentioned in the reports.

Professor Brendan Drumm

They are in a good place and want to make a difference.

Deputy Conlon raised the primary care teams issue. If one looks at the position in Mallow, Letterkenny and across the country, we have made a lot of headway that we have not made in other areas. We need to seek more engagement and I welcome her noting of this point. We need to sit down and start to drive this process. However, there has been some progress in the north east.

Ms Laverne McGuinness

The first primary care team in the north east will be launched in the next two weeks. General practitioners have not embraced it as much as their colleagues in other parts of the country.

Professor Brendan Drumm

Once these teams start, we have seen——

Is the financial position okay to roll them out?

Professor Brendan Drumm

Yes. I will deal with the Chairman's contribution at the end.

In the political system issues such as Monaghan hospital have been very challenging. I acknowledge the hugely constructive way in which people have dealt with us on them but I am sure that is not always helpful to Deputy Conlon.

Deputy O'Connor asked about cancer services in Tallaght Hospital. Professor Tom Keane was in touch with him.

I acknowledge that; he is doing good work.

Professor Brendan Drumm

Mr. Gilroy will address the issue of the transfer of the Coombe Hospital service to Tallaght Hospital and the ambulatory centre. There has been significant progress on Tallaght Hospital. We have had our difficulties but there has been significant progress. The chairman of the hospital board, Mr. Lyndon McCann, has worked hugely constructively with us to bring about that progress. We are moving in a good direction and I hope we can continue along that road with the board of the hospital which is committed to the changes we need to make.

The Minister has dealt with most of the issues raised by Senator White. I will deal with the CF issue later.

With regard to the suicide call line, we have a GP out-of-hours service right across the country and practically every general practitioners has received mental health training. They probably have more expertise than anyone we can provide.

On the basis of my information and observations on the ground, general practitioners are not up to scratch in identifying serious cases of depression and providing the proper treatment.

Professor Brendan Drumm

It is a pity because we must accept the vast majority of general practitioners deal with cases of depression day in, day out in their practices; many of them have huge experience of dealing with it.

Dr. Reilly can answer that question.

It is an extraordinary statement by Senator White.

It is a vitally important issue which warrants discussion. However, we are under time constraints.

From my experience as a lay person, it is all about getting the right medical help to prevent a person from committing suicide.

Professor Brendan Drumm

With regard to issues such as how we deal with suicide presentations and the report, we have the capacity to standardise the response but need to take this forward with the new clinical directors.

Mr. Gilroy will deal with the issue raised by the Chairman. The issues of cardiac waiting lists and intensive care developments in Crumlin hospital were raised.

Concern was raised about public nursing homes. That issue has not been addressed.

Perhaps the outstanding matters can be dealt with through correspondence.

Ms Laverne McGuinness

With regard to public nursing homes, in getting ready for HIQA and knowing the homes had not been inspected previously, we carried out our independent audit and the vast majority not only provided excellent care, they scored highly. It is an independent audit, the findings of which we can make available. It is due for publication. We have made modifications to physical infrastructure. We have also engaged with HIQA, whose officials have inspected some of the homes. They might close one or two rooms but recognise capital investment is an issue. They have not rigorously imposed closures because the standard of care has been high.

Mr. Brian Gilroy

The development at St. Vincent's Hospital is not just a CF development. It is a much larger one. We have placed contracts for the preliminary works and site clearance has commenced. We expect it to go to the market within the next two weeks for the placing of a construction contract. However, there are two outstanding issues before we do this. We need to conclude the engagement with the NDFA in order that the agency can issue the value for money letter because of the value of the contract and all the indications are positive. We also need to conclude the protection of the State's interest for the capital development. Historically, there was an anomaly where we could grant €200 million to a voluntary group and it could close up shop and sell off the site the next day if it wished. The Mater Hospital signed off on the protection of the State's interest last year for its development, which gives an indefinite lien to the State on the assets. We are in the process of trying to conclude this with St. Vincent's Hospital.

A sum of 40 billion red cent is in the capital plan for the paediatric hospital. It is important that the committee visit the site and the paediatric development board because there are references to virtual projects. This is an enormous project. Huge co-operation has been received from consultants, therapists and nursing staffs across all three hospitals. A huge team has been based in my office on Parnell Square and working non-stop for the past two years. An announcement on the appointment of the design team is imminent. That exemplar design team has been accepted and, therefore, its scale could be displayed. A visit would be worthwhile to clear up some of the perceptions.

The development of the ambulatory centre in Tallaght Hospital will be completed in advance. We are working not only with the Coombe Hospital but also with Holles Street Hospital and the Rotunda Hospital on the implementation of the KPMG review which relates to the locations of the relevant hospitals and we are working on innovative funding proposals in conjunction with the Departments of Health and Children and Finance to make them happen. We are still engaged with both Departments, not just on the St. Loman's Hospital money but also on the future sale of mental health service lands, on which we are making good progress. I hope before the budget is announced we will have a positive conclusion.

There has been a lot in the media about the intensive care beds at Crumlin Hospital. There was a scheme in the hospital for a much larger build which did not include just intensive care beds. Ward accommodation, etc., was to be provided. In line with everything else, the level of cuts in capital funding meant that bar our current contractual commitments and four specific projects which include the paediatric hospital, radiation oncology, St. Vincent's Hospital development and Dooradoyle critical care unit the HSE cannot enter into new contracts with anyone until after 2012. However, that is the point at which we said to Crumlin we could not engage in that level of development and that we needed to go back and design to address the critical care issue. The solution we recommended was to accelerate it and bring it in more quickly by adding ten beds to the existing 13. We have worked with the hospital, despite what is stated in the media, and come up with a version whereby we will supply 17 new beds in the new development. We will close the old development but use it as a support service for the 17 beds and this comes in at the same cost as the original version. We have appointed design teams and we will be placing contracts for that shortly.

Mr. John O’Brien

Just to add to the information on the critical care area, equally as important as the physical facilities referred to by Mr. Gilroy would be the organisational issues around critical care and paediatrics. Going back to the DNB report we have picked out some of the more important recommendations and the most important one is the establishment of the paediatric critical care network with an independent chair and this has been put into position and has been working very effectively. It is headed by Dr. Des Bohan who is head of paediatric critical care in SickKids, the Hospital for Sick Children, in Toronto. He has visited here on a number of occasions.

The other organisational pieces which are quite important include increasing the workforce in critical care, in particular at consultant level. We have just recently approved three new intensivist posts for paediatric critical care, two of which will work across the city and one specifically in Crumlin. This is critical to increasing the professional capacity and quality of services delivered in this area. This will lead to a very different way of managing the critical care facilities within the city and bring much better utilisation of the existing facilities which in turn creates additional capacity in its own right. Not only are we looking at additional physical capacity, we are also looking at improved utilisation of existing capacity which will facilitate that process extensively. About €1.3 million has been spent on that and, in addition, another €800,000 has been spent on paediatric retrieval services over the course of this year. The DNB report is well under way in terms of progressing implementation with respect to critical care.

Professor Brendan Drumm

Dr. Des Bohan is a Dubliner and has made a huge effort for no recompense in trying to help us on the critical care agenda. It is not an easy task to come back and put in that effort in a difficult medico-political background and he has invested a huge effort and has done wonderful work for us which I wish to acknowledge. On the issue of primary care teams Mr. Gilroy will comment.

Mr. Brendan Gilroy

We have 90 centres. Some centres have two teams and some have three. A total of 90 centres accommodate on average about 180 primary care teams. We have 90 centres signed under the new initiative, eight of which are opening in 2009, 42 in 2010 and the balance through 2011 and 2012. We have met the Irish Banking Federation and met all the relevant banks who will be funding these centres for the GPs to clear up any issues outstanding with regard to head lease, etc. There has been significant progress. There was a slowdown in quarter one and quarter two with banking considerations and nothing was moving, so to speak, in the country. We have seen an uplift, as it were. In the past week, which is not included in these figures which were bottomed out about a week ago, we have concluded negotiations for four major primary care developments in Dublin and they have achieved banking support which they could not achieve previously.

I suggest the committee note the recommendation made by Mr. Gilroy in respect of meeting the development team for the paediatric services as that is a good idea. I propose we do so as soon as possible.

I offer my congratulations on the work being done. I invite the spokespersons to make a brief contribution.

I ask the Chairman to bear in mind that I purposely allowed the Minister to speak without any interruption so I have a number of issues. I also ask for clarity on the €400 million for the capital fund for the new hospital.

I will make some quick comments. Longevity has improved in this country and that is to be welcomed. I have no doubt that health has played its role but it is not the only predictor for longevity because housing and social issues also have a role. The improvement in cancer survival rates are very welcome but nobody should be under the impression that this is due to the cancer strategy because it could not be the case. Five-year survival is five-year survival and that is how it is measured whereas the cancer strategy has only begun. However, this is very welcome.

On the issue of health insurance, I may have given the wrong impression but I am saying that 200,000 people are predicted to leave the schemes by the end of the year and the beginning of next year and a 43% increase in insurance premia in a 12-month period is outrageous and unsustainable. The inflation is similar to that in South America.

The Minister claimed my figures are wrong and claimed as much also about my contention that cervical screening has been delayed by this obstructive practice. I challenge the Minister to produce the figures for the past two months since this programme was put in place rather than figures for the year when we know that there was huge activity for the first half to three-quarters of this year because people had unfettered access. This is diminishing access, controlling demand by limiting access.

Cork University Hospital receiving the biggest breast unit in the country from the South Infirmary strikes me as unnecessary and a case of moving around the deckchairs at a time of financial constraint, so to speak. Along with many others, I do not understand the benefit of moving the unit to Cork University Hospital.

The Minister stated that the new consultant contract will give universal health access to all based on illness. Will the Minister tell the committee when this will happen because it certainly is not happening now and the consultant contract has been with us for a year or nine months. It is clear from what Dr. Holohan said and from the response of Mr. Woods that the vaccine will be delivered by the GPs and not by the HSE.

Dr. Tony Holohan

I am happy to clarify that point.

I would like clarification because if that is the case the fact that the Department is heavily dependent upon general practitioners to deliver it and it has not negotiated with the representatives since last July does not strike me as terribly clever planning.

The increase in activity in our hospitals is obviously related to the increase in our population. The reality for people in this country, regardless of what we hear in this committee, is increased numbers of people on trolleys. Professor Drumm has told the committee this morning that there are no people on trolleys in some hospitals and that there has been a huge improvement. The INO figures are compared with its own figures from last year so it is not a case of comparing apples and oranges. What are the figures compiled by the accident and emergency consultants? They began compiling figures out of frustration from arriving every morning into an accident and emergency department full of people on trolleys and yet hearing the HSE state there were only two or three people on trolleys overnight. This is nonsense and this is the credibility problem. The reality on the ground for the population of this country is considerably different from the picture painted to this committee. When I was canvassing for the Lisbon treaty referendum I spoke to a woman who was furious because her mother lay on a trolley in a Dublin hospital from Saturday night until Wednesday morning. That is the reality.

I am pleased the Minister acknowledges it is not a case of either-or but both in the case of cervical screening and cancer vaccine. For the sort of money we have been able to find for other things, it still beggars belief that we have not done that and have not protected our children.

There have been 900 delayed discharges from hospital, reckoned at about 6% to 8% of beds by the Department.

Professor Brendan Drumm

It varies between 600 and 900. The figure is 740 delayed discharges.

The answer I was given the other day was nearer 900 and that was an official answer. It is 700 and another 700 being taken up with hospital-acquired infections. This is a huge volume and that is what is causing much of our trouble.

Is the new consultant contract being monitored? The Committee of Public Accounts is concerned that it is not being monitored. Mr. O'Brien referred to paediatric appointments and I hope one of those is the paediatric anaesthetist for neurosurgery in Beaumont. I welcome Mr. Gilroy's report on the ICU in Crumlin. A great deal of frustration is experienced by the average Irish patient. Outpatient waiting lists can extend to up to seven years, for example. A few weeks ago Deputy Bannon brought our attention to the fact that phantom appointments were being made. Many are being treated on trolleys. It is ridiculous that two weeks ago nine of the 13 ambulances in Dublin were tied up in hospitals because they were not allowed to leave with fresh trolleys. The reality is that people are being brought to hospital in fire engines. Nobody should leave this meeting with the idea that everything is hunky-dory because it certainly is not. There is a great deal of work to be done.

I will conclude by talking about the HSE's much-vaunted redundancy plans. I do not agree that we should throw our hands up in the air because it will not be possible to get co-operation from the unions. One of my colleagues asked what had happened to the 300 people who used to work on the centralisation of medical cards. Where are they working? What are they doing? There is a long way to go. I do not think we have had the real reform of the health service, from top to bottom, that is required. We need to change the way hospital budgets are structured in order that they operate on a "money follows the patient" basis. The budget should be structured in a way that ensures hospitals are paid every time they see a patient. They should not start the year with a lump of money and then have to wait until the end of the year for a determination to be made on whether it has been well or badly used.

I ask the Deputy to conclude.

I will do so by saying I am not happy with much of the information we are getting. I do not believe it is accurate. It does not reflect the reality on the ground.

I compliment the Chairman and the rest of the committee on the fact that the format is working well at this stage.

The point on which Deputy Reilly concluded is important. The Minister has said the issue is not how money is collected, but how it is spent. The development of a one-tier universal system was first proposed by the Labour Party in 2002. It has since been embraced by practically every party which has an opinion on it. I do not think Fianna Fáil has an opinion on it but practically every other party has adopted it. The proposal relates not only to how money is collected, but also to how one offers incentives within the system. We have proposed that the same payment system apply to private and public patients. There are perverse incentives in the system. Public and private patients are paid for differently at primary and acute hospital level. That is one of the reasons the Minister was correct when she said the cost of delivery was much higher here than in other countries. The budget for the health service has increased threefold since 2002. If this system had been changed in 2002, as proposed by the Labour Party at the time, the additional money could have been used in an effective way. I reject the Minister's point that it is simply a question of how one collects money from the public. It is also about how one uses the money in the system. The current system continues to encourage the waste of money in certain areas because of the way it pays hospitals and doctors, etc.

The Minister and Professor Drumm both spoke about the importance of flexibility in the challenging times ahead. I agree that the health service will face significant difficulties in the budget and when it negotiates with the unions om flexibility, etc. It would be helpful if we could be given an assurance that neither bonuses nor top-up pensions will be paid to those at the top of the system next year. A recent report in theSunday Independent mentioned that the Ministers for Health and Children and Finance had signed off on top-up pensions within the health service. If the Minister can give us an assurance that sweet deals will not be offered to people at the top, ordinary staff will be much more likely to show flexibility when they are asked to take redundancy or move around within the system.

I welcome the information we received from Mr. Gilroy on developments at Our Lady's children's hospital in Crumlin. Has a timeframe been agreed for the 17 new beds?

I would like Ms McGuinness to clarify the point she made about the centralisation of medical cards. Will local health centre staff who deal with people like those mentioned by Deputy Conlon and me be able to access information on the status of medical card applications? As I understand it, such persons were initially unable to access such information on their computers and transmit it to the public.

I wish to speak about regionalisation. I agree with Professor Drumm that it is good that a greater level of clinical leadership is evident. However, the point is that clinical leaders are operating within networks, rather than within the four regions. Is it possible to re-examine the possibility of devolving the structures to those levels at which there are effective systems in place? Very few are operating at regional level in the four regions. When I tabled a parliamentary question about who was actually working at regional level in the western region, I was informed that the number of staff was small. Most of their work is done with the regional committees. There may be a need for totally new structures. It would be much more effective to allow each network to manage its allocated budget while keeping patients in the community, where possible. If patients had to go into acute hospitals, that would be fair enough as long as the budget was being managed. That would be a really effective way of making progress. When Professor Drumm and some of his officials told us a few months ago that they were moving to a regional system, I thought there would be a bigger number of smaller regions. Is it possible for that matter to be examined again?

I will conclude by asking about the role of general practitioners in providing vaccinations. Is it intended to move to what is known as a "single patient identifier" system, whereby every patient has an identification number? That would be very useful when it comes to dealing with vaccinations and many other aspects of the system. When I had a child in Canada 32 years ago, my daughter was given a number that would have followed her through the system if she had stayed in Canada. As far as I know, we still do not have such a system in Ireland, which is a major failing.

At a time when we often hear about the many problems in the health service, it is commendable that the Minister has been able to say Professor Tom Keane will exceed his targets and that the delivery of services will be ahead of schedule. We should be singing that from the rooftops. I welcome the appointment of Mr. John O'Brien and his team, which is something I called for at a meeting of the committee some months ago. I suggested someone should be appointed to lead a paediatric team, just as Professor Keane leads his team. The input of the committee is much more important when its sensible and logical suggestions can be listened to. I welcome the appointment of a team to manage the relationship between the HSE and the paediatric community.

I would like to respond to the comments made about public nursing homes. I continue to have huge concerns for those who are delivering an excellent service. I will contact Ms McGuinness to talk about the challenges they will face. They do not have the money for the huge capital outlay required if they are to meet the standards set. It needs to borne in mind that such investment will not make a bit of difference to the standard of care they are providing. I know people who are very worried about the future of their nursing homes.

I am glad progress has been made with IVs in residential facilities. I hope this issue can be considered in Monaghan.

I accept that the HSE faces challenges as it engages with general practitioners. I have heard about the matter at first hand. I have spoken to patients who are very upset — they feel hard done by — because in other parts of the country, there are GPs who are engaging and primary care centres which are up and running. When the country faced bigger challenges and crises, we solved them by talking. There must continue to be engagement. I have no difficulty in saying that if people have another agenda, they need to make this clear. The time has come for people to step up to the plate and ensure the patient remains the central focus in every action they undertake.

Perhaps the Minister and Professor Drumm might take five or six minutes each to respond and wrap up.

I am disappointed Deputy Reilly has chosen to engage in a rant. When we give answers, he tells us we are not telling the truth. He started by saying 200,000 people had dropped out of the health insurance system, but now he is saying that was just a prediction. I cannot predict the future and neither can the Deputy. We have to deal with the facts. It is a fact that 20,000 people have switched from VHI to its competitors. Quinn Healthcare's share of the market has increased to 22% while that of Hibernian has increased to 9%.

We did not do what we did by way of the levy. A couple of hundred thousand people aged over 60 and sick people would have dropped out of the private health insurance system as it would have become unaffordable.

I will ask the chief medical officer to address a number of the other issues raised, including swine flu, general practitioners and the screening programme for cervical cancer.

Dr. Tony Holohan

I will run through some of the issues. It is correct that one half of the increase in life expectancy is attributable to a better impact of the health services, while the other half is attributable to the factors which have been referred to. Among the key health indicators are cancer and cardiovascular survival. As the Minister noted, both of these rates have been improving dramatically.

Deputy Reilly is correct on the issue of cancer survival rates, particularly on attributing improvements to reform under the cancer programme. Most of the improvement has been the result of better access to chemotherapy, early diagnosis and so forth. We know from some of the patterns of care work done by the cancer registry — three such works have been completed to date — that our poor performance at national level was, for the most part, due to a disparity in regional performance. Dublin did well, in the main, because most of the hospitals providing cancer care were delivering it in the manner described and patients in these centres were securing better access to chemotherapy. The cancer programme is introducing a mechanism to ensure this level of service becomes a standard achievable on a national basis. We can expect the improvements we are currently observing in cancer survival rates to be consolidated and enhanced through the cancer programme.

On the swine flu vaccination administered by general practitioners, the Health Service Executive wants to launch the vaccination plan once we know where we stand with GPs. For this reason, I do not wish to give all the details but I will, broadly speaking, outline what is provided for under the plan. We have a whole population which at this point requires two doses of vaccination. Contracts are in place with two companies. As I noted, we have a licence for one company and expect to have a licence for the second next week. We have not yet received the vaccine from the company for which we have a licence, while we have some vaccine from the company for which we do not yet have a licence.

We want young, chronically ill people who, as Professor Drumm noted, are well known to their general practitioners in terms of their dependencies, medications and so on, to be immunised through general practice. This group of approximately 400,000 people accounts for about 10% of the population. We know general practice does not have the capacity or scale to deliver two doses of vaccine to the entire population as we have worked out what this would entail. It would effectively mean 40 man days of vaccinations in one year for each general practitioner, which would be excessive, particularly in the context of the possibility that GPs could also be required to deal with the impact of the pandemic as well as a range of other pressures. For this reason, it would not be prudent to plan on the basis of general practitioners vaccinating the whole population. However, we would like them to vaccinate the group to which I referred, which accounts for 10% of the population. That is the reason we have made the offer.

Once one has removed health care workers who would be vaccinated in occupational settings, the remainder of the population would be vaccinated through mass vaccination clinics. We have been assured by the Health Service Executive that these are beginning to be put in place and members have been given details on dates and timelines.

Professor Brendan Drumm

I will address some of Deputy Reilly's questions. On neurosurgery and the issue of paediatric intensivists, I understand an appointment has been made. The position has been put into the system, advertised or whatever. In the past couple of months we have appointed two new paediatric neurosurgeons to add to two existing paediatric neurosurgeons. The service has increased from one to four people over a two-year period. A clinical leader and anaesthetist have also been appointed. We are also appointing three critical care intensivists to paediatrics which will free up a large amount of paediatric anaesthetic time. These are massive developments in the paediatric services which need to be recognised as such.

On the overall issue of reform and money following patients, etc., no one would deny that this is the ideal. The Minister has established a group to examine overall funding to the health service. We are operationally very interested in having money follow patients and are working with some of the leaders in Germany, probably the world leader in using case mix systems, to achieve this. We believe they will give us access to much of their technical expertise to try to develop this further. However, the change system involved is massive. As I said a number of years ago, efforts to change health systems by flicking a light switch constantly fail.

The HSE could start by working on it.

Professor Brendan Drumm

We are engaged in a fully planned restructuring. A couple of years ago we were told to build six more hospitals. I wonder where they would be now. We have completely restructured the system and have got clinical leaders to refocus on doing things completely differently, rather than arguing for more of the same. If anyone wants to have an independent evaluation carried out on what the HSE has done over the past three to four years, I would have no fear as I believe that, using any international parameters, it would give a very positive review of what has been achieved in health care reform.

I have confused Deputy O'Sullivan on the issue of clinical leadership. The Deputy is correct. When it comes to how the health service will function operationally, we will probably have 18 to 20 units. We are setting catchment areas for hospitals and that work is nearly completed. As a result, Beaumont Hospital will know exactly what primary care team areas it is responsible for. It will also know that by dealing with the waiting list in these areas, it will not have to worry about people coming at it from all angles. That clarity will be of great assistance. We will end up operationally with clinical leadership at 18 to 20 justifiable units across the country. How services are provided will ultimately be the most critical issue. The issue of how we operate at the ground level is still in the process of design. The process will be completed over the next month or two and will bring some reassurance to those who believe that Donegal and west Limerick have nothing in common.

On critical care beds in Crumlin children's hospital, the timeline is approximately 18 months, which is one and a half years ahead of what could have been delivered with the initial proposal. I am pleased to note there is agreement on this matter because those involved in Crumlin children's hospital believe they require 17 new beds. Even within the confines of what we deal with, I acknowledge that issues such as scoliosis have been dealt without additional money but by bringing focus. The Department is addressing the issue of the unique identifier.

The health information Bill, which is almost ready, will legislate for this issue.

It is very difficult for general practitioners to identify their patients.

I accept there is a major deficit in that regard.

Professor Brendan Drumm

The new national system for imaging will be a significant step forward as it will ensure X-rays and other information can be easily transferred between hospitals. The system also depends on a unique identifier. This major capital programme has proceeded to tender.

Deputy Conlon raised the issue of leadership in paediatrics. I have no doubt we can make significant progress with this type of approach in this and many other areas.

As the Chairman noted, morale is extremely important. As I repeatedly point out, if we keep beating up on people, they will not perform. We are seeing, with the clinical leadership approach and at a wider level in the health service, a much greater determination to try to get the information out that people are doing a good job. As the Chairman noted, this raises performance to a different level. While times are difficult, if we can do this we will continue to make progress.

On behalf of the joint committee, I thank the Minister, Professor Drumm and their officials for coming before us and making direct and informative contributions. The next meeting of the joint committee will be on 21 October when Professor Tom Keane will update members on cancer service issues. If members wish to raise specific issues, they should signal them in advance.

The joint committee adjourned at 1.40 p.m. until 10.30 a.m. on Wednesday, 21 October 2009.