Quarterly Update on Health Issues: Discussion with Minister for Health and Children and HSE.

This meeting is for the purposes of a discussion with the Minister for Health and Children, Deputy Mary Harney, and the chief executive officer of the Health Service Executive, Professor Brendan Drumm. I also welcome the Minister of State at the Department of Health and Children, Deputy John Moloney, a regular visitor to this committee. Before we begin, I draw witnesses' attention to the fact that while members of the joint committee have absolute privilege this privilege does not apply to them. Members are reminded of the long-standing parliamentary practice to the effect that Members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. I ask the Minister to make her opening remarks for approximately five minutes, in accordance with the standard protocol which has worked effectively in the past few months.

I will keep my opening remarks as brief as possible to allow for dialogue with members of the committee. I am happy to be present today in the company of the Minister of State at the Department of Health and Children with responsibility for mental health services and disability, Deputy John Moloney. That area featured strongly in the questions submitted by the joint committee in advance of this meeting. I am also happy to be accompanied by Professor Drumm and his team from the HSE, as well as the chief medical officer and officials from my Department.

The challenge for everybody in the provision of health services, particularly those in leadership positions, is to deliver best outcomes for patients within the resources that can be made available in our country. That is at the heart of the reform agenda that has been under way for a number of years. Patient safety and best outcomes for children were at the heart of the reorganisation of cancer services into eight designated centres and one outreach centre at Letterkenny. They are at the heart of the reconfiguration of our acute hospital system in the north east, the south, the mid-west and elsewhere.

All of us recognise that at a time of financial constraint, we have a particular responsibility to ensure we get the best possible value for the money taxpayers can provide for our health service. Very often the debate in Ireland centres on how we raise the money but how we allocate the money is much more significant and I recently appointed a group, chaired by Professor Frances Ruane, which is due to report in April 2010 on how we allocate resources in the health service.

Our national income for 2010 is €130 billion, €15 billion of which will be spent on the health services. That amounts to 11.5% of our national income and, while international comparisons are often complex, that is a high percentage of our national income, particularly given the age profile of our population. Our population is, on average, substantially younger than that of many other European countries and substantially younger than the average in the OECD.

I have said on many occasions that, rather than concentrate on the number of inputs such as the number of drugs prescribed, the number of scans we carry out, the number of in-hospital beds or the number of patients who receive services in hospital beds, we need to concentrate on outcomes and how we can deliver the best possible outcome for patients.

Professor Drumm will talk about the service plan for 2010, which continues the reform agenda to provide services in the most effective way for patients. The most effective change comes when one gets a buy-in from those responsible for the delivery of change and we have empowered clinicians at every level. Nurse-prescribing has been a feature of our health service for only two and a half years and more and more nurses are now doing the course to enable them to prescribe medication in certain health settings and to arrange X-rays.

With empowerment, however, comes responsibility as they are two sides of the same coin. The reform of the hospital system throughout the country is being led by clinicians who are putting their heads above the parapet and leading their communities. In the mid-west, this is exemplified by Dr. Paul Burke and Dr. O'Donnell; in the south, by Professor John Higgins; and in the north east by Dr. Ó Brannagáin, whom members may have heard this morning, and Dr. Colm Quigley. I salute that clinical leadership because that is what makes the difference in convincing the public that what we are doing is in the interests of patient care. At national level, Dr. Barry White is head of clinical responsibility for the HSE as director of clinical care. It is his intention to put in place a number of clinical care leaders across the country in order to make sure we have the appropriate pathways for patients, whether in respiratory conditions and other chronic illnesses such as diabetes, stroke, etc.

In regard to the allocation of resources, next year the HSE will have to live within a budget that, comparing like with like, is €1 billion less than for 2009. Approximately €400 million will be saved by efficiencies including a reduction in the cost of drugs of some €240 million as compared with 2009, taking into account the fact that the figure continues to grow as a result of the rising numbers who are being prescribed medication. We are also changing the manner in which we remunerate pharmacists and have entered into a new agreement with the producers of pharmaceutical products, which will deliver some €240 million. We will also introduce prescription charges and legislation is being prepared in this regard, to be taken in the Oireachtas shortly.

The third element is reference pricing. The total market for generic products in Ireland is approximately €250 million. These are generally sold at approximately 90% of the cost of the branded product and we believe the introduction of reference pricing will drive competition. The irony is that, as a result of the new agreement we have reached with pharmaceutical producers, some generic products will now be more expensive than the products that come off patent. That is, by any standards, a very strange situation to be in and I appeal to the manufacturers concerned to reduce their price in accordance with the reductions we have been able to agree with the producers of medication.

The big issue concerns how we get the best outcomes, equity of access and cost-effective health care. At a time of financial constraint the overriding question is how we provide the maximum number of services for the patients we have with the resources that are available. Notwithstanding the financial pressures we are experiencing, we have been able to provide an extra €20 million for cancer in 2010. That will allow us to begin the process of rolling out cervical screening and the vaccine for every girl in first year of secondary school. We are also providing €10 million extra for home care packages, €70 million for issues relating to demographic pressures, such as renal treatment, some €230 million for more medical cards and €15 million for the implementation of the recommendations of the Ryan commission. These are among the new areas of expenditure the HSE will have in 2010. In addition, an extra €97 million is being provided for the fair deal, bringing the annual expenditure to some €152 million.

I have probably exhausted my five minutes but I look forward to answering any questions members may have.

The Minister was very concise. Professor Drumm also has five minutes.

Professor Brendan Drumm

A number of questions on specific issues were put to us and we have circulated written replies. I will spend a few minutes updating members on the service plan for 2010. From our perspective as a delivery organisation, what has been foremost in our mind is that we can continue to focus on our transformation programme and we will use the resources provided to us to the maximum to make it easier for people to access the care they need. Our challenge is to continue to enhance the quality of the services we provide. We can only do this by improving our effectiveness and, in so doing, reducing our costs.

Thanks to the commitment and co-operation of staff we have achieved, as the Minister pointed out, considerable success in savings during the past few years. We can take up this challenge again this year. During 2008-09 we delivered approximately €500 in efficiency savings and exceeded many service targets.

From a service point of view, we will continue to reorient services away from bringing people into hospital and this remains central to our transformation programme. We remain focused on the fact that people do not want to be and should not be forced to come into hospital for services that they should rightly get in their community or outside the hospital walls.

A high hospital admission rate has been considered in the past, for some reason, to be a measure of performance in our health care system, but it is exactly the opposite. A high hospital admission rate is a measure of how ineffective is our performance. Given the worry and inconvenience hospitalisation can create for patients and their families, we need to continue to lower admission rates and only admit patients where there is no alternative.

I am particularly pleased that during the year we will be completing the development of 1,200 very high-quality residential beds for older people and new primary care centres for 47 primary care teams across the country. I recommend that anybody who has not seen these modern developments for older people to try to see them in the places in which they are developed because they are a state-of-the-art development.

In terms of day cases, in line with international best practice we plan to carry out more procedures on a day-case basis. Last year we exceeded our day-case target by more than 28,000. This year we will provide 14,000 more day-case treatments than we did last year and, as a result, reduce inpatient admissions.

The development of medical assessment units, which provide a comprehensive day-case medical review for urgent GP referrals within 24 hours, is central to our transformation. These are available in many parts of the country but not within the Dublin area. There is often confusion about what is an acute medical admissions unit, which is for short-term admissions, and a medical assessment unit which, essentially, is a point where patients can be sent directly by GPs for a consultant-provided opinion within 24 hours of being referred. This would greatly reduce the number of people in our accident and emergency departments who go there to see medical physicians and are, therefore, not in the right place. Several successful units are now up and running. It is unfair on patients to have to wait long periods in emergency departments until a medical assessment is provided or they are admitted to hospital when all they require could be provided in a medical assessment unit without admission.

While the number of people who will visit emergency departments this year is expected to remain constant, we plan to continue to reduce the number of people admitted. This can be achieved in one area, for instance, by improving access to diagnostic facilities. Remarkably, 17% of patients who were admitted through our emergency departments in 2009 spent fewer than 24 hours in hospital and 30% spent fewer than 48 hours in hospital. Many of these admissions could clearly have been avoided, if we could have senior frontline decision-making in place through structures such as medical assessment units. We wish to continue to reduce that figure this year.

A significant number of people who visit emergency departments do so for treatment associated with chronic illness. As the Minister stated, Dr. Barry White is now focused on developing chronic disease management pathways for these major conditions which will, we hope, greatly reduce the need to admit patients.

During the year we will implement a number of such projects. The initial concentration will be on diabetes, heart failure, acute coronary syndrome — essentially, a heart attack patient — stroke, asthma and chronic obstructive pulmonary disease. We also hope in the mental health area to be able to bring a focus on a more standardised approach to the management of depression, on which a large number of presentations are made each year. The aim is to provide an effective bridge between community care and hospital care, which will reduce the inconvenience for patients and take pressure off emergency departments. Chronic illnesses absorb substantial resources and while this new approach will not necessarily impact on budgets immediately, it will improve access and quality of care in the short term.

From audits carried out in 2007 and repeated in several hospitals in subsequent years, we know that up to 40% of patients in acute hospitals on a particular day do not need to be there, 43% of them were there because they were waiting to see a doctor or another clinician such as a physiotherapist. We know that people can, for no explanation, spend much longer in some hospitals than in others for the same procedure. We also know that there is a huge variation in the day-case rate for the same elective procedure across hospitals. This is something on which we are very focused, through our HealthStat process, in terms of bringing this into line across all hospitals.

During 2010 we will continue to seek greater uniformity in the length of time that people stay in hospital across all hospitals. This will involve better co-ordination of the hospital and community services that patients need through a more intensive discharge planning process. The national discharge planning code of practice was piloted in five hospitals during 2009 with positive results and will now be applied nationally. This will be better for patients who can get home sooner and will free up beds for those who need them.

Since 2007 the number of people waiting more than six months for a day-case procedure has decreased by almost 50% and those waiting for day-cases has decreased by 40%. While these reductions are welcome there are still approximately 1,000 patients waiting more than 12 months to receive their treatment at this time. We look after 25,000 patients each day. Therefore, those who are more than 12 months on the waiting list account for 20% of one day's work. This is something we have to and will address this year.

During the year we will continue with our drive to increase the number of new patients seen in outpatient clinics. The number of new patients last year increased by 5%. We will also ensure there is a reduction in the high number of return patients — which will allow for more new patients to be seen — by ensuring they are seen in their primary care structures.

In terms of older people, an additional €10 million will be allocated to provide for homecare packages this year. The community services provided to older people will include 12 million home help hours for 54,000 people, 9,600 will benefit from homecare packages and there will be 21,000 day-care places.

In terms of disability services, additional funding of €19.5 million will be available for 100 more residential places, 400 more day places and 140,000 additional personal assistant hours.

With regard to mental health services, €6 million has been made available to staff two new 20-bedded child and adolescent units in Cork and Galway, which have been long awaited. The reconfiguration of mental health services, in line with A Vision for Change, will also create opportunities for efficiency improvements.

In terms of children and families, we are committed to improving our protection and safeguarding of children in the community. The key priorities are to deliver better outcomes for children through structural changes. With the additional allocation of €6 million this year, we hope to be in a position to recruit the additional social workers required and this is being prioritised.

Demographic funding of €14.5 million has been provided to improve a range of services in our acute hospitals, including haemodialysis, for which there is a constant increase in demand, transplant services, critical care, paediatric, neurosurgery and paediatric immunology, a service which this country has not had to date.

In terms of the national cancer control programme, the proposed work programme for 2010 will include additional medical oncology appointments where there are medical oncologists operating single-handedly, a reduction in the number of hospitals carrying out rectal cancer surgery and the bringing back of the programme of ocular cancer surgery from Liverpool in the UK. The national plan for radiation oncology, which forms part of the cancer control programme, will continue to develop. It is expected that the first of the new facilities for radiation oncology will open at St. James's Hospital and Beaumont Hospital before the end of the year.

In terms of the financial challenges we face, this is a hugely demanding service plan, but we believe the organisation — as has been proven to be the case in the past — is up to delivering on its targets.

I welcome the Minister, Professor Drumm and their extensive team. In the HSE Vote for 2010 there is a decrease of €668 million on the 2009 outturn. Professor Drumm has set out how the HSE will deliver the same level of service with fewer resources. He claimed there will be no reduction in access to our public services. However, we can see from the plan that there will be a reduction of 33,313 emergency admissions, a reduction of 54,000 inpatient procedures and yet an increase of only 10,569 day-case procedures. He might explain to those of us who are mathematically challenged by this, how that will out.

Professor Drumm said the level of service we delivered as admissions and procedures is being reduced. Reducing inpatient procedures will lead to longer waiting lists, a greater reliance on the NTPF and surely will negatively affect patient care which will ultimately put more pressure on accident and emergency services, now known as ED. Has the Minister made any progress on the money follows the patient issue? Professor Drumm mentioned it in the past and I have outlined it in our fair care policy. How many beds will be closed as a result of this reduction in funding and where are these beds?

On primary care, Professor Drumm said the HSE is on target to have 530 teams in operation by the end of 2011 and everyone in the country should ultimately be able to access up to 95% of the care they need in the local community. The budget allocation for primary care is being reduced from €351 million in 2009 to €327 million. How can the services in primary care be increased whilst suffering a reduction in budget? How can the HSE recruit new staff given the recruitment embargo and the unions' refusal to transfer staff to primary care and community care? How many fully-staffed teams are in place? I read Professor Drumm's document, the appendix on primary care teams, which is helpful. Having done a quick tot, it appears we are a long way from the numbers that need to be achieved. In regard to this area I have a direct question for Mr. Gilroy which I asked the Minister in the Chamber earlier in the year or last year. How many contracts have been signed for primary care centres with general practitioners during the past 18 months and where are they?

While I want to leave the issue of mental health services to my colleague, Deputy Dan Neville, I am interested to know how those services will be maintained given the reduction of €53 million. Professor Drumm predicts a drop in the cost of demand-led services and demand-led schemes of more than €100 million. That is generally an area that increases in cost because he does not have control over it. Perhaps it has to do with drugs or fees.

Given that the Minister of State, Deputy John Moloney, is present I have a specific question for him on Beaumont Hospital and the psychiatric unit. We know the co-located hospital impinges on the site of the psychiatric unit for which planning permission was sought in 2004 and has since been bumped down the line and as a matter of preference it has fallen behind. Will the Minister give an undertaking today that moneys will be made available to apply for planning permission for the hospital on a new site? I would prefer if the co-located hospital was moved elsewhere and the psychiatric unit went ahead given the dire conditions patients are suffering in St. Ita's Hospital, which was built as a temporary measure 50 years ago. That not being the case, surely a few thousand euro can be put aside to apply for planning permission, using the same design.

We have a statement on the HSE national service plan from the Minister in which she said a target of €106 million in non-pay savings has been set for the HSE in 2010. A statement from the HSE on the plan outlines a commitment to maximise available resources in order to deliver services at the same level as in 2009, except in the case of acute hospitals. It is also stated that further efficiencies of approximately €200 million are required to enable the HSE to deliver the level of services outlined in the plan as well as dealing with the impact of a €103 million retraction of funding. There is the €106 million with which the Minister and the HSE agree and another €200 million is required but it is not clear from the documents before us where that €200 million will come from. Perhaps the Minister or Professor Drumm could throw some light on that issue.

I welcome the Minister, Professor Drumm, the Minister of State, Deputy John Moloney, and their teams. My overall concern reflects Deputy Reilly's concern which is how the service can be delivered given the substantial reduction in the budget for the coming year. I think I am correct in saying Professor Drumm indicated last year that it would be very difficult, if not impossible, to deliver the same level of service if the cuts which had been projected at that time took place. I note it is proposed to reduce by 33,313 the number of admissions through emergency departments. I ask the Minister and Professor Drumm to be precise in regard to how exactly that will be done. It has been stated that more people will be treated in the primary care setting. As Deputy Reilly said there has been a reduction in the primary care budget from €351 million to €327 million. We all agree that more people should be treated in the community, that more diagnostics should be available outside the acute hospital setting and that people should not have to go into hospital for diagnostics. How will that be done? How can Professor Drumm facilitate more diagnosis without people going into hospital? Can the committee have precise information on how that will happen within the constraints of the budget? Where will the medical and surgical assessment units be located and how will they be resourced? Will extra resources be provided to those units already in existence?

The trolley-watch figures for yesterday, from the Irish Nurses and Midwives Organisation, which I know the witnesses will dispute, were 396. That number increased to 500 during the Christmas period. There are particular hospitals that feature at the top of the list all the time, such as Beaumont, Cork and the Mid-Western Regional Hospital in Dooradoyle in my constituency. I would like to focus for a moment on the Mid-Western Regional Hospital because I know it better than the other hospitals. It used to be one of the good hospitals and did not have people waiting on trolleys. It did very well in the 100-plus on how it moved people out of its accident and emergency department but now it is at the bottom of the list in terms of efficiency with regard to moving people out of that department. There has to be a reason for this as the personnel has not changed hugely. What has happened is that more patients have been shifted into that hospital from Ennis and Nenagh. I have a specific question around resources for hospitals such as the Mid-Western Regional Hospital, and Drogheda Hospital which featured in the news yesterday and will now get patients from County Meath. I agree that it is probably right to move trauma patients into more high-tech accident and emergency departments but the resources must be put in place. I am aware there are huge problems with the hospital in my constituency because it does not have the resources.

I ask the Minister and Professor Drumm to comment on the issue of trolleys being put into wards which is a cause of dispute in the Mid-Western Regional Hospital between the nurses organisation and the clinicians. Is that appropriate in an acute hospital? Are there consequences in regard to patient care and possible hospital borne infections? Do we have enough acute hospital beds? I appreciate that is a question in dispute. Do we need the co-located beds? Professor Drumm seems to suggest we have enough beds. I would like a direct answer to that question.

In regard to people who are in hospital beds and do not need to be there, how many have been moved out of acute hospital beds as a result of the introduction of the fair deal? Is there, as I have been told, a real problem with regard to the financial assessment of patients in hospitals and the delays caused by same? Does that mean patients are left in acute hospitals who could be discharged and, if so, what is the solution?

The waiting times for colonoscopies have increased over a three-month period. The numbers waiting longer than three months for colonoscopies have been a major issue particularly following the death of Susie Long. That the plan for bowel cancer screening is to be rolled out in two years' time is welcome but I understand it will be done in the hospitals. How will that affect the delivery of the service in existing hospitals and will extra resources be provided for that? Are facilities being built up within those hospitals with a view to introducing the bowel cancer screening programme?

The centralised medical card system is causing chaos for people over 70 throughout the country. I am told by my colleagues in Dublin that it is causing huge difficulties in the Dublin areas which have already been transferred. There is an overload on staff and a great difficulty in getting information. What level of staffing will be provided in the centralised unit? I ask the Minister to reconsider this system. There is a real concern among people of all parties that the human decision making process, which is needed, for example, in deciding borderline cases, will not be available under the centralised system. People tell me they cannot get through to the centralised unit on the phone and that the people who answer the phones are overloaded with work. I am concerned about this.

My colleagues will raise other issues. Deputy Lynch will raise some matters with the Minister of State, Deputy Moloney. I have one question about the child and adolescent psychiatric services. No civilised society should have children or adolescents in adult psychiatric beds. When will that practice end? What progress has been made? When will we reach the target envisioned for change with regard to the child and adolescent teams in the community?

May I be associated with the warm welcome extended to the Minister and Minister of State and to Professor Drumm and his colleagues? I thank Professor Drumm for his answers to the questions about issues of local priority. I had tabled three questions. The issues of the children's hospital and maternity services would draw considerable interest, both from the greater Dublin region and the country as a whole. My third question relates specifically to my constituency.

I am pleased that we took Professor Drumm's advice to visit the children's hospital project team. That was a very worthwhile meeting. It gave a clear impression that work is ongoing and that the project can be delivered. Professor Drumm knows I have concerns about the ambulatory and urgent care centre at Tallaght hospital. I had not intended saying much about Tallaght because I thought Deputy Reilly would continue his tradition of covering the needs of Tallaght. As he has not done so, I must take up the matter myself. There is a demand for this centre and Professor Drumm's reply does not leave me confident that it will be operational before the Eccles Street development. I need Professor Drumm to give me that assurance. The announcement that the Coombe hospital and maternity services are going south would be welcomed, not only in Tallaght but throughout the region. I hope the Minister or Professor Drumm will make reference to this issue today.

I lament the recent departure of Professor Tom Keane and I wish him well. He was always very helpful to me and to my colleagues. However, I have concerns about the national cancer control programme and there has been criticism of it. On the morning he left his position Professor Keane gave me very good information. Where patients are referred to central hospitals will resources be made available in those hospitals? We need assurances in that regard.

I support what has been said on the medical card issue. My jury is still out on this issue, and I am not simply reporting what I hear in my own local office. There is a difficulty and some confidence building is required. I hope Professor Drumm can give assurances on this issue.

The Minister referred to the pharmacy situation. What contacts are being maintained with the Irish Pharmacy Union on those issues? Is the Minister confident that the matter has been dealt with?

The presence of Deputy Dan Neville and Senators Mary White and Phil Prendergast reminds me that the four of us were members of a sub-committee of this committee which dealt with suicide. I welcome the Minister of State, Deputy Moloney, because I know he has an interest in this subject. We need to know what is being done about this issue, which this all-party committee saw as a priority.

I wish to mention Tallaght for one second.

The Deputy has mentioned Tallaght already.

Yes, but I really want to mention Tallaght now.

There can be no finality with Tallaght.

Local Deputies in Tallaght had the opportunity to meet Professor Conlon of Tallaght hospital yesterday. He gave an impressive presentation and clear assurances of what he saw as performance management evidence. We were very pleased about that. There are continuing issues in Tallaght. There are difficulties in the hospital's accident and emergency department, as there are in every hospital. I am looking at Professor Drumm as I ask about the HSE process of examining the case mix and fining hospitals. He has my support in his effort to get the performance right and look after the patients. However, when a hospital is fined and resources taken from it because of what is seen as a failure to do the job, that affects patients in a big way. What will be done to correct that situation? I do not object to the HSE putting pressure on a hospital and ensuring that the job is done. However, patients should not suffer if fewer resources are made available. I hope Professor Drumm can explain this difficulty to me.

I wish to be associated with the warm welcome extended to the Minister, the Minister of State and Professor Drumm.

My questions are directed to the Minister of State, Deputy Moloney. In south Tipperary, we were shocked by the announcement on 15 January that the 29 bed acute psychiatric unit which is part of the general hospital complement was to close. Why did consultation not take place? At meetings with the Minister of State it was indicated to me that the decision was made by the HSE and not by the Department of Health and Children. When and how often were the Minister and Minister of State briefed on this issue? Why do they require another month to apprise themselves of a decision which has already been made?

The construction schedule of the project contradicts what the Minister of State told me in the Seanad, when he said all facilities and services would be in place before St. Michael's closed. This answer indicates that some of the capital expenditure is aspirational and that other facilities would not be up and running by the end of 2010. This is clearly outlined in the answer. There is a contradiction here.

With regard to South Tipperary General Hospital, I have been told that the steering group is advised by the speciality advisory groups in general medicine, general surgery and women and children's health, and that the steering group's decision making process is also supported by pre-hospital care, the primary continuing and community care reference groups and business analysis of activity, capacity, staffing and finance, which is provided by a business analysis group. Why was the same process not undergone in relation to St. Michael's unit in South Tipperary General Hospital?

St. Michael's unit also serves adolescent patients from north Tipperary. The current inpatient capacities in the relevant units affected by the proposals are already overstretched. The number of beds in Limerick, which is operating at approximately 100% capacity, is insufficient. Ennis General Hospital has 14 patient beds at present. If the plan is to close the latter and send its patients to Limerick and 20 from north Tipperary who currently attend St. Michael's, Limerick will be expected to cater for the equivalent of 110 inpatients — comprising those at the Limerick, Ennis and Clonmel facilities — in a 50-bed unit. That unit is already operating 100% of capacity. It is also planned to send 30 patients from south Tipperary to Kilkenny, which is also operating at 100% capacity.

Will the Minister indicate what this is intended to achieve? What savings are expected to be made in the context of implementing the closure plan relating to St. Michael's? I have already referred to a cost-analysis in respect of that proposal. Would it be possible for the Minister to consider suspending the decision relating to the closure of this unit, particularly in view of the fact that she has not been fully apprised of the plan?

I am aware that some confusion arose in respect of this matter yesterday. An answer I received in respect of a query on the development of community services indicates that crisis houses in the community to support the home-based treatment team by providing low-support accommodation for people in crisis and that a timeframe of having this in place by the end of 2010 is envisaged. However, the Minister's interpretation of what constitutes a crisis house and that of Dr. Frank Kelly are completely at variance. Dr. Kelly's interpretation suggests that such houses are high-support units. This would have implications in respect of staffing, increased costs and home-based treatment teams.

I met representatives of the PNA last night. The Minister met them prior to that and I believe she was of the view that the PNA supports the closure of St. Michael's. She is now aware that it does not support the closure and that an element of difference exists with regard to how A Vision for Change has been interpreted. Parts of A Vision for Change have been ignored in the context of the answer provided to the query I tabled. It was stated, for example, that the development of a new day hospital and a community mental health centre in Clonmel is dependent on capital funding.

The Senator should conclude.

I am moving towards a conclusion. It is a case of definitely maybe. If the development of a new day hospital and a community mental health centre in Clonmel is dependent on capital funding, this suggests that the money may or may not be available. This gives rise to major concerns on the part of the people of south Tipperary. The way this announcement was made came as a major shock to the consultants, stakeholders, care-givers and patients involved. There are many implications in respect of how the care of people in south Tipperary will be managed in the future. I again ask if this decision relating to this matter might be deferred until the Minister is fully apprised of the position and provided with the requisite information.

I also welcome the Minister, Deputy Harney, the Minister of State, Deputy Moloney, and the members of their team. The questions I wish to ask are specific in nature.

My first point relates to waiting times. Many people make a common remark to the effect that the system is very good once one obtains access to it. They also state that the standard of care is very good in the majority of cases. The difficulty arises in the context of obtaining access. I spoke to a mother in recent weeks whose child was obliged to wait one year before being given an initial consultation, the outcome of which was that surgery would be required. The woman in question has been informed that it will be 12 weeks at least before the surgery is carried out. A great deal of time has passed in this case and the child is suffering at school as a result. A satisfactory resolution has not been forthcoming for these people. The major problem is the length of time people are obliged to wait before being assessed.

My second question relates to the fair deal. There is major concern that the €117 million provided will not be sufficient. Is the Minister of the opinion that this amount is sufficient in order to allow the fair deal system to operate in a full year and that there will not be any gaps that will give rise to concern among patients and their families?

I compliment the Minister on the cervical vaccination programme. The committee discussed this on numerous occasions and the Minister always indicated that it was her intention to introduce such a programme when the money was available. People must realise that, particularly in such straitened economic times, there is a major difference between the original cost of €16 million and the new cost of €3 million. I am concerned about girls who are no longer in first year in secondary school but who have moved on to second and subsequent years. Will arrangements be made to provide these girls with a once-off vaccination in order to ensure that they will be protected?

Deputies Reilly, Kathleen Lynch and I attended the cancer summit held in Brussels last week. At that conference the point was made that while the vaccination is extremely important, it must be used in conjunction with screening. It is vital that we do not lose sight of the importance of having people screened on a regular basis. What is the position in this regard?

Will the Minister provide clarity in respect of the position of GPs? I understand we are training increasing numbers of GPs. A number of existing GPs are retiring but there appears to be a logjam in the context of bringing the newly trained members of the profession in the system. Would it be possible to indicate why this is the case? If more GPs are being trained, they must be allowed into the system in order that they might deliver better care to the patients who need it.

One of the matters about which I feel strongly — I have mentioned this on numerous occasions — is the stigma attaching to mental illness. It was stated at a previous meeting of the committee that mental illness is similar to any other illness. One receives treatment, one comes out the other side and one lives a perfectly healthy, normal life and is able to do everyday things with more confidence. I do not wish to place a halo over the head of the Minister of State, Deputy Moloney. However, the interviews he gave in recent weeks have done an enormous amount of good in the context of humanising this illness and removing the stigma that attaches to it. We must continue his work in this regard because people who feel low should be in a position to realise that they require help, that they should know where to find it and that, following treatment, they will be fine. We must redouble our efforts in order that people might receive appropriate treatment in appropriate settings. This may not always have been the case in the past but it is the way to move forward.

My main question relates to the subject to which I am continually obliged to return, namely, the need for a rehabilitation service — similar that provided at the National Rehabilitation Hospital in Dún Laoghaire — for the south. I accept that a consultant has been put in place but such a service is still not being provided. The information supplied to me by Cork University Hospital, CUH, is that 2,000 bed days are lost every year. The cost in this regard — in my view it is extremely conservative — is €1,110 per day or approximately €2.2 million per year. These lost bed days relate to those people to whom those in the media refer as "bed blockers". However, they are just people who need to be moved on into appropriate services. The savings that could accrue to both them and the State by their being moved on cannot be quantified. What is the position with regard to lost bed days?

I understand the extension project relating to the National Rehabilitation Hospital has been put on hold. Will the Minister clarify the position in that regard? Is the project on hold? Will it not proceed in 2010? If it is not to proceed this year, then matters will only get worse.

Last year, some 338 people had operations to remove lower limbs. That number represents 50% of all the amputations that were carried out throughout the country. The individuals in question all have diabetes and the fact that they lost limbs is directly linked to the lack of a podiatry service. People with diabetes are not receiving the care they require in order that they might not be obliged to have limbs amputated.

We should think about this in terms of the follow-up costs to the State in services and support for want of very little outlay for podiatry care. I recently tabled a parliamentary question on hearing tests in the southern region. People in their 80s have to wait for up to 18 months for a hearing test. I cannot understand why the service has not been privatised and a person cannot walk go to a service provider and have a hearing test.

I am delighted that Deputy Lynch said that and not me.

Clearly the HSE is not able to deliver this service. I have not come to the end of my tether. I can have my sight tested, have glasses fitted and have the cost refunded by the State. Why should an elderly person not be able to go to Specsavers or any of the places that offer hearing tests and have this done without having to wait in a confused state for anything up to two years?

Will the Minister of State, Deputy Moloney, outline his response to the people with an intellectual disability who are placed in inappropriate institutions? There are 335 people with an intellectual disability who are in disability accessible and fit for purpose units. However, 25% of residents in long-stay mental health accommodation are inappropriately placed. Of these, 20% would benefit from a lower level of support — they do not need to be there — and 6% could live independently. People with an intellectual disability are living in units that are not fit for purpose when in fact 20% of them need a lower level of support and some could live perfectly well in the community. I know that the proceeds from the sale of lands that were part of psychiatric hospital will give rise to questions, but this is entirely different. The country is awash with houses which cannot be sold or given away and which we will very soon own. Why are we not taking this on board and considering the options for people in long-stay units who should not be there?

Will the Minister respond to the call for the extension of BreastCheck to women aged over 65? I am sure the Minister has the statistics that women aged over 65 are seven times more likely to get breast cancer probably because these women are out of the workforce, there are not the normal checks and the condition is not picked up early enough.

It is mentioned that there are 20 primary care units in the north Cork area, but apart from the unit in Fermoy, I do not know of any. I do not know where the primary care unit is located in the north Lee-Blackpool area. What services are provided in that primary care unit? Is there a general practitioner, a community nurse and so on?

I am sure that will be dealt with in the Minister's response.

I acknowledge all the improvements that have been made in the delivery of care, new procedures, cancer treatment, the fair deal package and mental health services since the Minister last attended a meeting of the joint committee. I compliment the Minister and the HSE on how they dealt with the swine flu pandemic. The chief medical officer, Dr. Tony Holohan, did an excellent job in communicating with the public through the mass media during this very worrying time.

I agree fully with the Minister and the HSE that the more we develop primary care, the less pressure will come on hospital beds. I note in some of the replies to parliamentary questions that Dublin North-East is not faring very well in the number of primary care teams. There are only 26, which is less than half the number in the west and even less than the number for the other regions.

I compliment the HSE on the new agreement with the IMO on general practitioners and extending the age limit for GPs. In areas where there is no GP in private practice and there is a shortage of GPs, is action being taken to ensure GPs are appointed? Is it possible to get a new agreement with the IMO so that GPs can be appointed? There are problems in a number of towns in my county. The waiting time for appointments has already been referred to by my colleague, Deputy Conlon. I share her concern. Is there a case for co-ordination and integration of records, perhaps through information technology, to ensure patients can get an appointment in whatever hospital can provide it in the shortest time? Most patients in the north east are in the catchment area of three or four different hospitals. While it is a disadvantage to have records in three or four different hospitals and to be attending them for different illnesses, it is important that people have early access to treatment. Is it possible to integrate medical records with hospital appointments?

Deputy Jan O'Sullivan raised the issue of the number of patients in a ward. That question must be addressed. In an ideal world everybody would have a room, but we are realistic and know that is not and will not be possible. If I were ill, I would be quite happy to be on a trolley in a ward. If I were a patient in a ward, I would be quite happy that patients on trolleys were put into wards rather than being sent home. In some instances, the number of elderly patients in HSE hospitals is being reduced. I am aware of one hospital for the elderly that is state of the art and I would be quite happy to be in it if I ever needed to be admitted to hospital. It is a matter of concern that facilities are being taken out. I know that, ideally, the fewer patients one has the better, but one has to balance one risk against another. While the risk of infection is a significant one, I cannot stress strongly enough that everybody who goes through the door of a hospital — staff, patients, visitors and anybody else — has a role to play in eliminating infection. Rather than reducing the number of spaces available for patients, I would prefer to see us eliminate infection and make available the extra places.

I have had complaints about head shops. Young persons of 15 years bought substances in some of these head shops and were hallucinating after them. One of the young people did himself damage, but fortunately not seriously. What is being done to ensure the ingredients in these products are investigated and banned where necessary?

I join in extending a welcome to the Minister, Minister of State, officials from the Department of Health and Children and to Professor Drumm and his team.

I welcome the forthcoming announcement on 1 March of the sale of assets and use of the proceeds for capital development in the mental health services. I congratulate the Minister on moving in that direction. I want to clarify the figure for the 2010 allocation to the mental health services and compare it with the figure for 2009. I understood there were to be no cutbacks in the mental health services allocation for 2010 relative to 2009. Will the Minister clarify whether there will be a reduction of €53 million in the allocation to mental health and psychiatric services in 2010?

Is there any change from 2009 in the direct budget of the national suicide prevention office for 2010? I am not talking about the budget the HSE has in various areas going back ten to 15 years from the time of the national task force on suicide but about the specific budget of the national suicide prevention office because it allocates moneys to the voluntary organisations throughout the country which do excellent work in this area. If there is a cutback in the budget of the national suicide prevention office, inevitably there will be a cutback in the work of the office and the voluntary organisations such as Console which the office supports. One can put all types of spin on the increase in suicide statistics for the first half of last year. The Minister of State, Deputy Moloney, spoke from the heart on the matter in an Adjournment debate in the Dáil. I welcome this fresh approach to answering questions in the House.

Bearing in mind that the psychiatric services have not been developed and have been under pressure to deliver a service, what is the effect of the recruitment embargo on the front-line staff of the mental health services? There is an opportunity to handle recruitment for mental health services in a different way from the general health services. What is the approach of the HSE to front-line staff providing mental health services?

There was a recommendation in the 1984 policy document, Planning for the Future, that we would have community-based psychiatric teams, and the more recent document, A Vision for Change, recommended it as well. The Mental Health Coalition maintains that there is no fully multidisciplinary team anywhere in Ireland. What are the specific plans to develop community-based, multidisciplinary psychiatric teams?

I wish to reiterate the point made by Deputy O'Hanlon on head shops. We know from British research that drug abusers, similar to alcoholics, are five times more likely to take their lives than the normal population. What are the implications of head shops for increasing the incidence of suicide in those who use the goods of head shops consistently or casually? There is a great deal of discussion of head shops but there has been no discussion of the psychological and emotional difficulties the use of goods in the head shops may cause.

Of the 577 planned community care teams, I understand 222 have been rolled out already and 34 will be rolled out this year. On the basis of what is being rolled out this year, it would take more than seven years to complete the full programme. Is my interpretation of the figures correct?

I join Deputy O'Hanlon in complimenting the Minister, Ministers of State and the HSE on the significant progress that has been made in the health services and also on the manner in which the swine flu pandemic has been and is continuing to be dealt with.

I wish to question Professor Drumm on the €500 million efficiency savings that were made last year and which he proposes to continue throughout 2010, with an additional €100 million being saved by value for money efficiencies. Will he detail where he sees those savings and efficiencies being made? What role will district hospitals play in the future? Obviously, I am concerned about the district hospitals in my constituency. Where does he see them fitting in and developing as part of the overall care for people in the community?

I welcome Professor Drumm's remarks on medical assessment units and would like him to say where they are located and specify the location of units that will open in 2010. I welcome his reassurance in the written reply that there will be no cutbacks in the opening hours of the accident and emergency department in Mayo General Hospital. I welcome that and it has been greatly reassuring because there have been a great many rumours circulating on that. When a problem arises in an accident and emergency department, and it has been the case before that there has been a problem in Mayo General Hospital, the manner of dealing with those problems is a management issue for the hospital, whether that is a problem with an individual or how they are doing their business. It would cause me great concern if there was an alteration to opening hours just because there was a particular problem that was not being dealt with. I am seeking reassurance that when a problem is identified, it will be dealt with through managing the situation and that a cutback in the service would not happen just because of a failure in management.

At a recent meeting of the Committee of Public Accounts during the discussion of the National Treatment Purchase Fund, it came to light that children in Crumlin children's hospital had been left on the waiting list for a longer period than they should have been. Is Professor Drumm critical of the failure of that hospital to use the National Treatment Purchase Fund, thus causing children unnecessary waiting times?

I have a particular problem with the timely renewal of medical cards for the over 70s. A facility has been put in place whereby Oireachtas Members can avail of a certain telephone line to get information, but that is not working for me and I do not know how it is working for my colleagues. I have many constituents aged over 70 who are entitled to a medical card but have been left without it since last August. I can give at least five examples of this which illustrate this point. It is difficult to get an answer to our queries. In his written response, Professor Drumm stated that the centralisation of medical cards generated a €4.9 million saving last year. While that is obviously a very welcome development, it is not satisfactory if it is not possible to contact and get answers from the people providing this service.

At a previous meeting I raised the issue of ambulance control centres and Professor Drumm stated that the plan was to have two for the country. At that time, I suggested that one of those might be located in my region and that created some mirth in the Visitors Gallery, but I am quite serious about that suggestion. Was a feasibility study carried out as to where those control centres should be located? How were decisions made? The number of calls that the current centres are getting would indicate that the control centre that is located in Castlebar would be busier, have more staff and would not be at any disadvantage from the technology and infrastructure point of view. Why was the decision taken in the manner in which it was? Is there an agreed policy between the HSE and unions that staff will not be redeployed more than 60 km from where they are located?

I have one query for the Minister and Professor Drumm. I thank the Minister for answering the question about the National Rehabilitation Hospital in Dún Laoghaire. At meetings in recent years an absolute commitment was given that the hospital would start to operate almost immediately. Many young victims of dreadful accidents are lying in beds in hospitals throughout the country which can do nothing for them. It is impossible for them to get into the National Rehabilitation Hospital in Dún Laoghaire except as a priority case, one of the criteria being one's age. The extension of the hospital was mooted in 2002 and much was said about its importance for alleviating the trauma caused to many families. However, the reply states:

The view of HSE Estates is that the preferred option may not be the most economically advantageous option and does not address all the options. HSE Estates will continue to engage with the hospital to progress this project. The completion of the national service review would assist in clarifying the role the NRH will play in the provision of this service nationally.

If ever I saw a message that was code for doing nothing, it is in that paragraph.

I welcome the Minister and thank her for the introduction of the vaccination for cervical cancer. The last time she was before the committee she promised she would introduce it as soon as she could. I am heartily delighted for all the young people involved and the lives that will be saved. I congratulate Professor Drumm on the successful introduction of the centres of excellence for cancer, which is a wonderful achievement. It was a pleasure to listen to Dr. Holohan, who was very clear and interesting. For an official from the Department of Health and Children, he is a very impressive communicator.

Senator White should not allow herself to be distracted.

I wish to raise three issues. One is on ageism and breast cancer while the other two relate to suicide. Professor Des O'Neill, the prominent Irish gerontologist, says that a woman is seven times more likely to contract and die from breast cancer after the age of 65, yet screening stops at 65. Currently, more than 1 million people over the age of 65 live on this island, which reflects a great achievement on the part of the authorities, North and South. However, as I said in my policy document on ageing and ageism, age discrimination is rampant in our society. This widespread ageism is simply another form of bigotry and means that old age is often represented in negative terms such as "health care burden" or "pensions time-bomb". Some people may be shocked that I use the word "bigotry" for ageism but that is what it is. It is bigoted and ignorant.

Age related illnesses, such as stroke and dementia, are not catered for in the same way as cancer or cardiac diseases. In this regard, it is vital we identify what rehabilitation services and supports will be provided for the 30,000 people with disabilities as a result of stroke, two thirds of whom are over the age of 65. I ask the Minister to introduce breast cancer screening for women over 65. It is an equality issue and has been raised by other members of the committee in this meeting.

The Senator has less than a minute.

Suicide is a very serious issue.

I appreciate that.

At the end of 2009, Dr. Paul Corcoran of the National Suicide Research Foundation published a paper on widowhood. The research showed that widowhood was an increased risk to mortality from suicides and accidents. This finding, referred to as the "widowhood effect", is well established and has been found to be greater on men than women, and on young and middle aged adults rather than the elderly. Dr. Corcoran found that widowhood was associated with a doubling of the suicide rate among Irish men. The study shows that widowhood affects people in many ways. I am on a mission in respect of this issue and I will continue to be so until it is addressed. There is no reason on earth a district or community nurse cannot seek out and visit the person who is left behind when a person dies to assess their mental state.

Thank you very much, Senator.

I must mention my final point.

The Senator must be fair to other members.

My final point relates to suicide and the recession. It is recognised internationally that recession, unemployment and job insecurity increase the rate of stress in people's lives. In 2008 there was a 6% increase on the previous year in the incidence of deliberate self harm. Can the Minister and the Minister of State with responsibility for mental health services and disability, Deputy John Moloney, say what is being done to address this problem in the context of people losing their jobs? What is being done to help the 465,000 who have lost their jobs by creating new jobs for them?

I welcome the fact that we can address the Minister, Professor Drumm and their colleagues once every quarter. I am informed the reduction in the cost of prescription drugs is not being passed on by pharmacists. Is the onus on the patient or the pharmacist to ensure the reduction is given? I am told that some pharmacists are pocketing the money.

Deputy Flynn asked about the centralisation of the medical card system. I am finding it very difficult to make representations on behalf of constituents now that the system is being centralised to Dublin. I am aware there is a big demand on the system because of the downturn and more people are looking for medical cards, but I cannot seem to get an answer when I make a telephone call on a case. When the service was localised, I was always able to get a reply from the people who ran it in Kilkenny. It removes the personal and the local touches to a centralised unit in Dublin where they do not even know where Kilkenny is. It is a pity and should be re-examined.

I did not hear the programme but someone from the HSE appeared on "Today with Pat Kenny" to talk about the consultation currently under way into the future of hospitals in the south east. During the interview, Pat Kenny stated it was his view that St. Luke's Hospital in Kilkenny would be downgraded and services would be sent to Clonmel. He later had to apologise for saying that but it must be clarified. We are trying to retain the best services for the south east. The main regional hospital is in Waterford, with three more in Wexford, Clonmel and Kilkenny. The sooner the consultation process is complete, the sooner we will know the situation. I will be wearing my Kilkenny hat because we are always being praised about the efficiency of the service we have. I do not want to see any downgrading of services. I say that wearing my personal Kilkenny hat.

We have a print out here that I presume is about Caredoc services in Carlow, Kilkenny and Waterford. What is the position with centres in Callan, Thomastown and Ferrybank?

I agree with Senator White about breast cancer screening. Could the Minister send a briefing note to advise us of the cost of extending breast cancer screening to women over 65? I also congratulate the Minister on the introduction of the cervical cancer vaccine and for the management of the H1N1 threat.

I welcome the priority for mental health services in A Vision for Change for children and young people. The figures last year for children admitted to adult mental health wards increased, a sign that we are not making progress. What is the explanation for that? When does the Minister expect this practice to stop? If improving mental health services for young people and children is a priority, the figures went in the wrong direction.

The money ring-fenced from the sale of psychiatric facilities and properties throughout the country led to €42 million going to the Exchequer, with €25 million going back to mental health facilities. Where did the other €17 million go? Did it go to the general budget? Why did this happen when there was an agreement that money from the sale of such properties would be reserved for mental health investment?

I have come in to raise a specific issue that is of increasing concern to me and that will be of increasing concern to other Members in future.

The processing of medical card applications and the renewal of cards has been referred to. At some time in the past year, all of the over-70s applications were moved to the primary care reimbursement scheme in Finglas and, in recent months, all medical card applications and renewals from my constituency were moved to that location. It is, however, an absolute and utter disaster. If people think it is bad now, they have not seen anything yet. When the under-70s apply there for a card, they are driven to distraction. As a public service, it is the worst possible example. It is totally dysfunctional. It is one of the few new services being provided at community level by the HSE and we must ask that if it cannot get this basic public service right, what hope is there for other areas?

Applications are getting lost on two or three occasions and simply cannot be located within the office. On a regular basis mistakes are made with assessments. There is a complete overlooking of the medical evidence, something that never happened before. Previously, if a person had a serious medical condition he was given a medical card, even if he was over the income limit. There is now no consideration of that at all. People are not being informed of decisions, even after three or four months. They might be told verbally but they cannot get decisions in writing from the section.

Children with severe disabilities are not being shown any consideration. Everything is done by the book, with the parents' income being assessed irrespective of the costs involved in catering for a child with a severe disability. These are life and death situations for families but there is no appreciation of the fact that people on low incomes, families and pensioners, regard the medical card as a lifeline. It is as if the HSE sees it as acceptable that this lifeline is cut off or are left for months on end waiting for a decision. The HSE must wake up to the damage being done to people's well-being by this contemptuous attitude to people. That is the only way to describe the attitude of those in the section.

There have been several cases recently where people have applied in plenty of time for a renewal of their medical cards but two or three months later there has still not been any decision. As a result, the medical cards have run out and they are pleading with their GPs and pharmacists to extend their cover until the HSE gets its act together.

In the PCRS system in Finglas, it is impossible to meet anyone in the unit. There have been occasions in recent months where there have been extremely unpleasant scenes where clients have arrived in absolute desperation, submitting documents for the second or third time. I had an 85 year old man who had gone to a great deal of trouble gathering the documents being demanded. Those documents were lost on two occasions. Each time he had to gather them up again at huge expense and difficulty and catch a taxi to Finglas to submit them only to meet this contemptuous attitude.

It is not possible to speak to anyone there. On a recent occasion gardaí had to be called because people became so irate with the bureaucracy they faced. The public cannot contact anyone on the telephone. I have dealt with people recently who set aside an hour and a half every day to make contact with the HSE. They would spend days on ending trying and failing to make contact.

Recently the Minister set up an arrangement whereby a designated person can take calls from public representatives but it is still not possible for us to get through. I object to the Minister setting up a supposed speedy service for Members of these Houses while she is incapable of setting up an adequate telephone line for the public. We hear many complaints about clientelism and Deputies spending time running after basic services. I object to the fact my constituents are unable to access a basic, decent, compassionate and professional public service from the HSE. I strenuously object to having to spend increasing amounts of time daily trying to get answers from the HSE for constituents who are entitled to a medical card because the HSE is incapable of providing such a service.

The Deputy has made the point very effectively.

I welcome the opportunity to contribute once again. Going through the responses that have been presented in relation to health cuts, my question about whether the Department and the HSE were carrying out an impact assessment of the budget cuts and all the other statements that have issued prior to and since the budget at the beginning of December has not been answered. There has been barely an acknowledgment that these cuts are having an impact on patients, never mind a commitment for an assessment. The reply from the Minister refers to the HSE national service plan which, at the time the responses were prepared, did not exist in real terms because she only approved it yesterday, yet we have these responses going back at least to last week.

Can the Minister confirm the number of beds that will be taken out of the public health system arising from that new national service plan? A figure of 1,100 beds has been suggested. Is the Minister in a position to advise if that is the number involved? We are told there are to be some 33,000 fewer admissions. How can that be squared against the fact that we have an absolutely under-resourced, under-developed primary care service across the State, but at the same time she is proposing to cut back admissions to acute hospital facilities by some 33,000? I find this very difficult to follow.

How can one possibly reduce the numbers of patients on trolleys in accident and emergency departments that reached a record number of 500 in one day in January? We do not have to go over the HSE versus the IMO figures again but those are the figures I am following. How will the Minister reduce the numbers of people in inappropriate settings within hospitals while at the same time reducing the number of inpatient beds? She is also reducing the number of staff and reducing staff pay. I find it incredible and I do not know how the HSE and the Department of Health and Children propose to arrive at the results they allegedly expect.

I also asked about the cuts to dental services. In her reply, the Minister only referred to the dental treatment services scheme for medical card holders. I wanted to know as well the cuts to dental benefits for PRSI workers. We have to understand that PRSI payers make a contribution directly out of their wages and salaries on an ongoing basis and have an entitlement. We are aware the McCarthy report recommended the slashing of the dental benefits altogether. The Minister has not gone that far, but nevertheless a serious situation now applies in that it will only cover dental examinations.

Surely this is a serious short-changing measure of people who are continuing to pay pay-related social insurance into the system with the expectation that the service access they have previously enjoyed would continue. What can the Minister say about the current situation and will it be taken into account in respect of any assessment of the impact in regard to patient need and patient care? What is the position of the dental treatment services scheme? The very brief response the Minister has given does not indicate the number of patients who would be affected, yet the Irish Dental Association has estimated that funding for this scheme will dry up mid-way through the course of 2010. What can the Minister say that would give us any better expectation than the Irish Dental Association's own estimate?

In regard to prescription charges, the Minister did not answer my question in respect of medical card patients. I had asked if this was a temporary measures or if the charge will grow year on year, budget after budget, in terms of current costs of the order of 50 cent and up to a maximum per household of €10 per month. What is the situation? Is this a temporary measure? Will she indicate if this is something we can hope will be removed at the earliest opportunity?

While I welcome the announcement of the agreement reached between the pharmaceutical manufacturers and distributors and the Department and the HSE that will result in savings of the order of some €94 million over the course of a single year, does the Minister believe that is the area we should concentrate on? There has to be even greater savings achievable rather than penalising those on the lowest level of economic condition within society, medical card holders, who have to make a contribution towards the cost of prescriptions issues. Surely that should be abolished.

The Deputy will have to conclude.

I am not sure if my last point has been raised by others. In regard to the decision announced today to further reduce the level of accident and emergency access and service at Our Lady's Hospital in Navan, does the Minister appreciate the serious impact this will have on real access and public confidence in terms of acute service provision in County Meath and across the north east and against the backdrop of the closure already of all acute services from Monaghan General Hospital only last year?

There has been quite a variety of questions from the 15 members who contributed. I commend Professor Drumm on his achievements since he last presented to the committee. There is no doubt that his programme for change is grinding inexorably forward. We can see that in the excellent work done by Dr. Holohan in terms of the swine flu, the increased home care packages, the hugely effective work in the cancer control programme and in many other areas. A number of members have alluded to the situation in accident and emergency departments. I hold the strong view that public confidence in the health services is being undermined unnecessarily because of the publicity surrounding the accident and emergency crisis which is continual in some hospitals, but obviously not in all hospitals.

I have been in various accident and emergency departments over the years, some of which work very efficiently. One can see them working efficiently but the word lethargy might be more appropriate than emergency in some other departments and they seem to be the same hospitals that continually appear in the media. What type of radical initiatives does Professor Drumm have to solve that problem because in solving it he will restore public confidence in how the health service is operating?

I wish to raise three brief questions. Members have alluded to the headshop phenomenon which has been developing during the past year; they are now in most towns across the country. Amendments to the Misuse of Drugs Act may be appropriate. Does Professor Drumm agree that other Departments should be involved, such as the Departments of Justice, Equality and Law Reform, Community, Rural and Gaeltacht Affairs and the Environment, Heritage and Local Government, to examine planning permissions to restrict these shops which are causing major damage to people, young and not so young? Our intention must be to eradicate them completely.

What can Professor Drumm tell the committee about developments in terms of cystic fibrosis services? He has an ambitious programme and is committed to it. What progress has been achieved?

I know members will want me to refer to the issue of symphysiotomies which has arisen here on a number of occasions. As a committee we have strongly recommended to the Minister and her Department that an independent review of that practice should be carried out. We would like to hear if any progress has been made in that regard.

The Minister has 25 minutes in which to respond and Professor Drumm has 25 minutes in which to respond. I appreciate some of the questions may be responded to in writing afterwards. Perhaps they could deal with the principal points that have been raised. The Minister of State, Deputy John Moloney, will have additional time to deal with the mental health aspects.

I will try to deal with individual queries. If I fail to do so, I apologise in advance. However, some queries were repeated so I will make some broad brush responses first.

With regard to the €53 million reduction in spending on mental health services and spending on demand-led schemes, we are reducing the cost of pay in the health service by €630 million in 2010. That will be spread across the different headings. A general pay reduction of €630 million will account for €53 million in the staff costs of mental health services and likewise in the fees for general practitioners in the general medical scheme. The other substantial saving in the GMS is in spending on drugs, which is €240 million. The domiciliary care allowance has moved from the Department of Health and Children to the Department of Social and Family Affairs, which accounts for the reduction in spending in that area.

Deputy Reilly continually mentions the importance of money following the patient. Of course activity and money must go hand in hand. However, the best health care systems in the world, such as Kaiser and the Vets — Veterans Administration Health Care System — and other systems I have looked at, do not make payments on a fee-per-item basis. Both insurers and public health care systems consider it an inefficient way of allocating resources. The preferred system is one which encompasses an overall package based on the particular requirements of groups of patients rather than the individual piece for every patient, which encourages over-prescription of diagnostics. This is a big issue in the United States.

One of the big issues being addressed by President Obama in bringing in his health reforms is the fee-per-item system, with its encouragement of over-prescribing. I am also having this discussion with private health insurers to try to move to best practice, which is preventing or managing chronic illness in a non-hospital environment rather than associating all the benefits with hospital attendance, either on a day-case or in-patient basis. The VHI has interesting pioneer work under way at present with diabetic patients in a community-based setting. That is the future.

The resource allocation group, which will report in April, has been asked to look at how the resources the country can provide, whether we raise them from insurance or taxation, can be allocated to deliver the best outcome for the patients. I have no doubt a larger proportion of that resource must continue to be provided in a non-hospital environment in a primary care setting. That is at the heart of the service plan for 2010, about which Professor Drumm will talk.

If we focus on best outcomes for patients and patient safety we should not then be obsessed with what I call inputs, such as the numbers of beds or scans. What is important is how we do the best for the patient. That is not always about admitting the patient when he or she comes to the accident and emergency unit. As Professor Drumm said in his opening comments, 30% of those patients are in hospital for less than 48 hours and need not have been admitted in the first place. It is about continuing to do things differently, which is at the heart of the reform process.

The HSE will speak about the non-pay savings of more than €300 million. Many of them are on the procurement side. Savings have been made in legal services and other items which the HSE procure on an ongoing basis. We must continue to drive costs down. If there had never been a recession or a property bust or if Lehman Brothers had not collapsed, we would still have needed to drive the cost of health care down, as every health Minister in Europe is trying to do. That means reducing staff costs, which we have had to do last year and this year. It also means reducing the unitary cost of treatment.

Reference has been made to extending BreastCheck to people over 65, and I would love to see that. I share the view of members of the committee that we need to make this happen as quickly as possible. The HIQA evaluation has shown that our unitary costs do not compare favourably to other countries, particularly with our nearest neighbour. It is three times more expensive here than across the water. I have asked the National Cancer Screening Service to examine the HIQA report and to evaluate how we could extend the BreastCheck service to people up to 70 without necessarily increasing the cost. To do this on a same-case basis would be 40% more expensive. We do not have the money to do that at present.

We had an extra €20 million for our cancer budget this year. In that context, we were able to provide the cervical cancer vaccine because the drugs companies reduced the price. The programme would have cost €16 million last year and will cost €3 million this year. I called in both companies before the budget and explained the tight financial situation to them. I told them we remained committed to providing the programme as quickly as possible but that unless they came in with a price which was close to that offered in the United Kingdom, we would not be able to start it this year. I am pleased they responded, making it possible to begin the programme this year. Unfortunately, with the resources we have we can only provide the vaccine to first-year girls. Last year, we planned to vaccinate girls in 6th class in primary schools, because we have a track record of providing vaccination programmes in primary schools. Since we want to catch the same girls we would have caught last year, we will vaccinate girls in the first year of secondary school. It is new for the HSE to do an immunisation programme in secondary schools but I am certain it is up to the task. It will begin before the summer of this year.

Deputy O'Sullivan raised the issue of extra resources and asked how services can be provided without more money. We were asked that question when we began the reform of cancer services. Professor Keane came to Ireland and we planned eight designated centres. People asked where was the budget. It is not always a question of extra money or additionality which, quite honestly, does not exist in current circumstances. It is a question of re-allocation and re-prioritisation of the resources we have. That is being done successfully in the cancer service. That reform has happened with a small amount of additional money, relative to what might have been spent in the past.

It has not been done in the acute hospitals.

It has. The eight centres are now in place.

I am not talking about cancer. I am talking about reconfiguration in the general services.

There are two big cost drivers in health. One is staff costs, which are expensive. Public sector salaries rose in the last decade. The other is the volume of activity in demand-led schemes. The volume of treatments, particularly on the drugs side, has led the drugs bill to increase by more than 105% in a matter of four years. However, if we move to more day-case activity, if we do not have 24-7 wards, with all their associated staff costs, and if people come for diagnostics on an ambulatory basis, service can be provided on a much more cost-effective way than on an inpatient basis.

A new accident and emergency unit will open in the north east in March. There are also 48 acute beds there. The additional staff requirement will have to be factored in in the context of the recruitment moratorium. The HSE is required to reduce its staff complement by 1,600 during 2010 but the moratorium allows for exceptions. The reform programme in the north east is a priority. Approximately 140 additional staff will be required, both on the hospital side and in community services and home-care packages. We remain committed to making that happen.

With regard to patients going to Drogheda and not to Navan, patients already go to Drogheda. They simply go on a staged basis, having first been admitted to Navan hospital. As the clinical director for the region said this morning, those patients already go into Drogheda, having first been taken to Navan. All the advice says that is not safe care. The change is being made to deliver better outcomes and better results for trauma patients. The same applies to moving trolleys up to wards. I will leave it to Dr. Holohan to speak about this. It is what happens in all the best health care systems in the world. There is trade union opposition to it in some places but all the advice to us is that it is best practice for the patients.

Has the Minister seen what is like in the wards in the Mid-Western Regional Hospital in Limerick?

I have been in the Mid-Western Regional Hospital.

Has she seen the overcrowding there at present and the number of trolleys all over the place?

I will allow Professor Drumm to address the specifics of the Mid-Western Regional Hospital.

It sounds lovely sitting here in this room.

Deputy O'Sullivan asked a specific question——

The Minister is describing something which is not the case.

Deputy O'Sullivan asked was it safer for a patient to be in an accident and emergency unit on a trolley or in a ward on a trolley. The evidence from the chief medical officer and other medics is that being in a ward is the preferred option.

The fair deal system is a completely new system of funding care. There is a legal process, particularly for those who have diminished responsibility, which requires court approval. There are time factors involved in that regard. I do not know how many applications under the fair deal scheme have been approved. However, based on the data provided by the Central Statistics Office and our experience within the health service in recent years. I am satisfied that €152 million is the appropriate amount for 2010.

In respect of urgent colonoscopies — these are colonoscopies where it is recommended that the procedure be carried out within 28 days — at the end of November, 151 people or 18% of those referred were awaiting procedures. At the end of December, the figure was 48 or 8%. I understand that figure has fallen again in the interim and perhaps our colleagues from the HSE might comment in that regard.

I am aware of the issues surrounding the centralisation of medical cards. Perhaps Professor Drumm will deal with that matter. Deputy Shortall brought a particular example to my attention last week. I pursued the matter to which she referred and discovered that what she stated in respect of it could not be borne out. In the first instance, the person involved had a long-term illness card. In addition, the family was €1,000 per week over the income limit. By no means could it be stated that this was a borderline case. I accept that response, time and industrial relations issues arise. However, in the instance in question the family involved was not being obliged to pay €800 per month for drugs, which were covered by the long-term illness card. Unfortunately, the family's income was €50,000 over the limit.

I accept that many of those present favour people having free access to their general practitioners. We do not have such a system in place at present and at a time of financial constraint, we must prioritise around income and also the special needs of individuals with particular illnesses. The latter will continue to be the case. Notwithstanding the centralisation process, discretionary medical cards will still be provided. I acknowledge that issues arise in the context of that centralisation process and I spoke to Professor Drumm regarding that matter very recently.

Deputy O'Connor referred to ambulatory care services at Tallaght. These are an integral part of the new children's hospital and the two will be developed together. Perhaps Mr. Gilroy will deal future with that matter and comment on a number of other capital projects.

The examination of maternity services in Dublin recommended that such services be co-located on acute hospital sites. As a result, the service provided at the Coombe Hospital will go to Tallaght and that provided at Holles St. will go to St. Vincent's Hospital. We remain committed to making these two projects happen as quickly as possible. Mr. Gilroy may have something to say with regard to the proposal to transfer the Coombe service to Tallaght, which, we hope, will be part of a PPP arrangement.

Deputy O'Connor also inquired whether the issues relating to the Irish Pharmacy Union have been put to bed. I do not believe the Irish Pharmacy Union or its members would be happy with the changes that were made. In respect of the medical card scheme, the Government is reimbursing just the dispensing fee. In the case of the DPS, we are reimbursing that fee plus a mark-up of 30% rather than 50%. I am aware that many pharmacists are still charging their private patients a mark-up of 50%. There are many issues that arise in this regard. Given that more information is available with regard to the cost of drugs, I hope that consumers of medication will be more vigilant. We have no way of controlling the price of drugs other than through the price we pay to pharmacists in respect of the dispensing of medication on Government schemes. Issues may also arise for the Competition Authority, particularly if everyone is charging the same price.

Senator Prendergast raised a number of issues in respect of Clonmel. The Minister of State, Deputy John Moloney, will deal with these. All I want to say is that we have all signed up to A Vision for Change. As it is rolled out at local level, which is what is happening at Clonmel, it must be borne in mind that we are committed to the strategy. I am not a psychiatrist and cannot deal with all the aspects of the matter to which the Senator referred. However, what is happening at Clonmel, particularly in the context of moving psychiatric patients to more appropriate community facilities and, where appropriate, to acute services co-located with acute hospitals, is in line with the strategy outlined in A Vision for Change.

We recently made a number of changes to the GMS, including increasing the retirement age of doctors on the scheme from 65 to 70. In the short term, this will increase the number of doctors on the scheme. I am conscious of the fact that there is a shortage of such doctors. We are currently training approximately 120 doctors for the GMS but this number must be increased. We are involved in discussions with the Irish College of General Practitioners in respect of training programmes. The Competition Authority recently made a number of recommendations, particularly with regard to those doctors who have extensive experience as locums or in hospital settings.

It has always been a bone of contention — I dealt with an instance of this recently in my constituency — that a doctor who has been in practice for many years with another doctor who has a GMS list is not eligible to apply for that list unless he or she undergoes a particular training programme. We must address the issues identified in the report of the Competition Authority and increase the number of doctors throughout the country. There are 2,600 GPs with GMS lists, 300 locums and a number of other doctors engaged exclusively in private practice at present.

A review of rehabilitation services was completed recently and is due to be submitted to Professor Drumm in the near future. As I understand it, the review will not recommend a centralised model whereby there is one hospital in Dublin to which everyone must come. A member of my family had an accident and was admitted to the National Rehabilitation Hospital in Dún Laoghaire. Every Friday evening the relative in question was obliged to travel home by taxi to east Galway and then return on the following Monday. That is not a very effective way to provide rehabilitation services.

I understand the review will recommend a smaller number of beds at the centre. We must have a centre but we need a much more devolved model of care. Budgetary constraints have meant that we have not been able to proceed as quickly as we might like with this and other projects. However, the need to do as I have outlined is also a factor.

I dealt with the issue of headshops in the Seanad last week. If we could ban products such as "Snow", "Ice", "Charge Plus" and "Blow", the matter would be dealt with overnight. Unfortunately, it is not possible to do so. Instead we must consider the composition of the chemical compounds involved. Some of the derivatives of, for example, BZP have legitimate uses within the pharmaceuticals or plastics industries. Four regulations are required to deal with this matter and they will be ready this month. These regulations must be notified to the EU and the waiting period in that regard is three months. Questions were posed in respect of whether we need to notify the Union. I consulted the Attorney General and discovered that if we do not notify it and if there are prosecutions on foot of the regulations, they could become invalid. We must follow the law, as advised, in respect of this issue. The regulations will, perhaps, be ready by the end of February and it will then be a further three months before they become valid.

I acknowledge the comments made by previous speakers. We will not be able to deal with headshops simply by banning certain of their products through legislation. We will never be able to keep up with the ingenuity and creativity of these people who call a product "Bath Salts" and sell it for €30. It is impossible for the law to keep up with such behaviour and, therefore, a much more multifaceted approach is required. Such an approach must include developments in the areas of product liability legislation, public liability insurance, the planning laws, etc. I have appointed a group of officials to consider the matter from a multifaceted perspective.

All countries throughout the EU are attempting to grapple with this matter. Officials from my Department attend a high-level group in Europe. The matter has been on the agenda for many months but no country has been able to get ahead of those who create these substances which are designed literally to blow the minds of vulnerable people, particularly those who are very young. Extremely unscrupulous individuals are making a fortune from selling these products to vulnerable people within society.

I wish to acknowledge and agree with the comments made in respect of the chief medical officer and his handling of the swine flu crisis. I am sure he is well able to speak for himself but I wish to echo those comments.

Deputy Kathleen Lynch referred to privatising the system relating to hearing tests. I am in favour of anything that delivers effective services for patients. Perhaps Professor Drumm will comment on that matter. If outsourcing such tests to private providers can ensure that people are treated with a more rapid response, I will certainly not stand in the way. If patient services are at the centre of what we wish to achieve, then we must focus on how best to provide such services.

I am sure a privatised service would mean that people would not be obliged to wait two years for a test.

To be fair to the health service, it is often obliged to take up the task of dealing with every problem in society. I accept that people who are lonely and vulnerable are particularly prone to depression. I also accept the comments made in that regard. However, the health service cannot solve every problem. I had a meeting last week with the director of the suicide prevention office who informed me that there are over 100 organisations operating in the area of suicide prevention. I would love it if we could bring some of those organisations together. There are some 600 organisations operating in the area of disability services. When one is dealing with such a large number of organisations, one incurs a high level of overhead costs.

The Minister of State, Deputy Moloney, is focused on this issue and has established a group chaired by Mr. Laurence Crowley to examine how we can achieve greater co-ordination and cohesion between the different service providers to ensure as much as possible of the money we provide is used in service provision.

What I said was that the research indicated double the rate of suicide for men.

I accept that.

It is not alone mental illness but suicide.

Yes, depression leading to suicide, I accept that. I have visited many community clinics around the country. Last year, I visited a community mental health facility in which all of the patients present on the day were men between the ages of 55 and 70 years. The nurses made the point to me that this was their only outlet of contact as they did not have families and lived in rural parts of the country. Without those community based services, they would have had no human contact. I am trying to make the point that the health service cannot deal with all of the problems that arise in society.

I will conclude with this point as I believe I have dealt with all the issues raised. As regards dental services, the Department of Social and Family Affairs has responsibility for the PRSI service, which has been curtailed to an examination only service. That decision was made by Government in light of the budgetary situation in which the Department found itself.

On the public dental service, the HSE has a capped budget for 2010 but that cap is based on the cost of the service in 2008. I understand the HSE will not run out of money in July as the budget will be capped month by month. Professor Drumm may wish to elaborate further on that point.

I asked about podiatry services.

I share the Deputy's view in regard to podiatry services and services generally in respect of diabetes. As I stated in my opening comments, Dr. Barry White, the new clinical affairs director for the HSE, is currently in the process of appointing a clinical team to lead on appropriate care paths, in particular in cases of chronic illness such as diabetes. This will ensure services required for the patient will be provided in a non-acute setting. I do not have a specific answer to the Deputy's question on podiatry services. Perhaps Professor Drumm will answer that question.

Perhaps the Minister will respond to my question regarding an assessment of the impact of cuts on patients. The written reply did not provide me with an answer. Given the deep cuts that have taken place and the fact there is broad awareness across all political opinion that this is impacting severely on individuals and families, would it not be the responsible thing to carry out an assessment to understand and inform at least remedial action in the short-term and, it is hoped, the reversal of most if not all of the cuts at the earliest opportunity?

The Deputy has made his point.

As I stated in my opening comments, whatever sum of money the Government, regardless of what party is in Government, can provide in any one year it must result in the provision of the maximum amount of services for patients. For this reason the emphasis in the service plan for 2010 is on services to patients. Deputy Ó Caoláin appears to believe that if a person is not in a hospital bed and the service is not provided there, he or she is not getting the service. The biggest cut is in respect of staff costs. Of the €1 billion being taken out of the service in 2010 as compared to 2009 when comparing like for like and factoring in additional money for new services, €630 million will be taken from staff costs. We are not seeking to reduce staff numbers rather we are reducing the cost of existing staff. Approximately €250 million has been cut from the spend on drugs. A major effort was made to minimise the impact on patient care and to maximise cuts in procurement costs, unitary costs and delivery of service, drug costs and so on.

Perhaps the Minister of State, Deputy Moloney, will deal with the questions in respect of mental health issues, following which we will move on to Professor Drumm.

I will try to address the nine questions posed. I will deal first with the question posed by Deputy Reilly in regard to funding for mental health, an issue also raised by Deputy Neville and to which I hope to return later. Deputy Reilly asked specifically about Beaumont Hospital. I welcome this opportunity to advise the Deputy of the situation. Before I do, I wish to state that I support the Government's co-location proposals notwithstanding that the Beaumont site has been approved and the project has been put out to tender.

I can confirm that it is a 60-bed unit and that the tender process in respect of a design and build took place last June. In a nutshell, we intend to go to tender and to begin the construction phase some time this year. The site is not the previously chosen one which was near the carpark.

The Department has not yet obtained planning permission.

I am confirming that the site is located at Beaumont Hospital. I expect the planning application will go through. I will be in a position to fund the Beaumont acute centre this year.

By way of background information, the unit will be a 60-bed unit comprising of two wards with 27 beds, plus six beds designated for psychiatric care of the elderly. This will replace facilities at St. Ita's in Portrane.

Deputy Jan O'Sullivan raised the issue of child and adolescent facilities on the last occasion I attended this committee. I had hoped to devote a full session to this issue, but am constrained by time. A clear commitment to provide 100 beds was give in A Vision for Change. I am pleased to say that the number of beds in 2007 has been doubled, and we now have 30 beds. We are committed to the provision of 50 beds by year end. Quite obviously, the issue concerning the following 50 beds remains within the timeframe of A Vision for Change, which is a work in progress. We are committed to delivering on that programme. I have already provided information on the location of the beds and on our commitment to the delivery of a further 20 beds in Cork and Galway before year end.

I will address the points raised by Deputy Charlie O'Connor and others. The issue of suicide crosses all the areas of mental health supports. I am pleased to hear Deputy Neville's contribution. I had hoped to explain further our strategy in March when I was due to appear before the committee, but not until then.

It is intended that the Minister of State will come before us again in March to deal with these matters in detail.

I will try to provide a middle ground appraisal between now and March. In the past 20 months I have gone around the country meeting various groups and other groups came to my Department with proposals on how to reduce the number of suicides. The main thrust of our policy is to reduce the number of suicides.

In that context a representative group came together to consider ways to deal with the stigma of mental health issues. I asked Mr. John Saunders who chairs Schizophrenia Ireland to chair this group, Seachange. I am satisfied this group will have specific proposals and targets for reducing the number of suicides. We are taking a county by county approach and are involving local service users and providers. I will announce further details in April as to how we intend to fund these proposals. I hope to be able to commit myself to explaining how we will involve the sector providers. I acknowledge that the many groups I have met are well intentioned and very interested in providing support. The policy is a draft proposal at present and I intend to clear and approve the policy document some time in the next three or four weeks. I hope I will be able to provide more detail to the joint committee at the March meeting. It is a draft proposal at present and I intend to clear and approve the policy document some time in the next three or four weeks.

South Tipperary is part of the A Vision for Change programme and is no different from any other area in that regard. I was in the area yesterday and met Senator Prendergast and her colleagues so I wonder why I was asked why I was taking a further month to make the decision. I thought the purpose of going to Tipperary yesterday was to hear both sides of the debate but I did not think I had to make a decision there and then.

The decision was already announced.

I want to finish because the story has moved on from yesterday. I went to hear both sides — the consultants who opposed the proposals for Clonmel and those in the management team who supported the proposals. During a two-hour meeting I listened to the complaints from the consultants who felt they were not involved in the thought processes of the proposals or the conclusions. They also challenged the make-up of the management team but I thought I was very fair. Their criticism was that Deputies and Ministers tended to come down to an area in such cases and dictate the pace of the discussion. Having heard both sides, I said I would go back and reflect on both cases. However, I made it very clear that the funding for A Vision for Change was limited and that a catchment area of Clonmel, Kilkenny and Carlow, with 300,000 people, could be served by the acute beds in Kilkenny, bearing in mind the fact that there are 44 of them and the requirement is for 34.

I am surprised that when I mention capital programmes and ring-fencing, people think I make it up as I go along. A contract for €20 million was signed yesterday as part of the capital programme. A correspondent suggested some time ago that I was left red faced when I pointed out the proposals but I am not in the slightest bit red faced. The commitment is clear and the contract was signed in the presence of many public representatives, including HSE officials. The €20 million is for the modernisation and reform of mental health services in south Tipperary.

I set a date of 1 March for an appraisal so that I could publicly state it was not my intention either to delay the timeframe involved in A Vision for Change or to reduce the cost commitments. Last week I spoke about a spend of €43 million each year but, following today's Cabinet meeting, the figure is now €50 million. People may be cynical about the project but it is the first time there has ever been a multi-annual capital programme for mental health. I intend to go to the meeting on 1 March in the company of Mr. Brian Gilroy who will be able to publicly confirm the commitments for each year for A Vision for Change. The director of mental health, Mr. Martin Rogan, will be at the same public conference, where we will explain how we will deliver on the non-capital commitments. Mr. Rogan has worked with the 14 clinical directors and will come forward with an implementation plan in this regard. I ask people not to be sceptical because the improvements we are hoping to deliver in mental health services are based on the capital programme.

I am not totally relying on a capital programme to fund the developments. Deputy Kathleen Lynch asked about intellectual disability but A Vision for Change is not totally reliant on the capital programme. We will fund and deliver on the commitments by a combination of things. The Irish Council for Social Housing has already agreed how we intend to accommodate people living in old institutions. A commitment to close the psychiatric hospitals within three years remains in place and I hope to come before the joint committee at some time before 1 March to explain the commitments in detail.

I want to make it clear that in south Tipperary there is absolute, 100% support for A Vision for Change and the closure of St Luke's. I was seeking clarity as to how many times and by whom the Minister of State was briefed about the shock closure of the 49 acute beds which are part of the general hospital complement. This has an impact on the reconfiguration in the south east and is causing great concern. Government Deputies are on record as saying that they are totally opposed to any downgrading of our general hospital services. The Minister of State has not answered that point. I appreciate that he has been very facilitating and has met us to discuss the issues, but there appears to be a lot of misinformation.

Whether one accepts my clarification or still feels the decision was rushed depends on what side of the debate one stands. I will give more time to the issue at a later date, as I promised earlier.

Members need to realise that we have scheduled a special meeting with the Minister of State to deal with mental health and disability issues.

I do not want to be at cross purposes with Senator Prendergast but I gave a commitment to sit down with the consultants again once we had decided what the proposals were to be, rather than simply making a telephone call. I met the PNA and told its representatives the very same thing.

Does the Minister of State wish to respond to any other specific questions?

Deputy Kathleen Lynch asked an important question but I will respond to Deputy Conlon first. I do not see any issue regarding the support of the mental health services and we should end the nonsensical suggestion that there is an issue. I will emphasise that point when we launch the anti-stigma campaign. As well as the capital programme, the main challenge is to enable people to continue their daily work without any hindrance.

Deputy Neville suggested there was a contradiction in what I said, a point of view shared by Deputy Reilly. There has been a reduction in pay across the board and mental health has suffered in line with other areas. The Deputy also referred to reductions in the budget for direct support for the National Office for Suicide Prevention. It is far more important to fund suicide prevention by means of advertising campaigns at national and local level so, while we took back €100,000 with one hand, we gave back €1 million with the other to progress new thinking about the issue. This involves bringing all the various groups together who have campaigned for a suicide prevention policy.

Senator Frances Fitzgerald asked a relevant question about the capital side. She referred to the €42 million from the sale of lands at St. Loman's in Dublin. I have received €25 million in return and can let members know where that money was spent. We have secured a capital programme of €50 million each year and the HSE is aware that we have only received €25 million of the €42 million from the sale. The money is still outstanding and I will be putting in further proposals out of next year's spend in respect of that money.

As long as A Vision for Change is a Government programme it will be the responsibility of the relevant Minister to say what the spend has been and what any shortfall might be. The fact that the HSE has appointed a director with full responsibility for delivering the recommendations under A Vision for Change, with procurement manager, Mr. Brian Gilroy, having responsibility for the capital side, means we should be able to meet our targets within the time limits. I have already talked about turning the sod on child and adolescent facilities and by the end of the year the additional 20 beds will be in place.

Is the €17 million the Minister of State wants back from the HSE in addition to the €50 million?

Yes it is. There is a certain ambiguity about this but there are no cloak and daggers or mirrors involved in this. It is open and transparent.

Deputy Reilly asked me in November what would happen if we did not secure the funding. In response I said that if there was no capital programme in place there would be no point talking about the reforms in A Vision for Change. The capital programme is there and although we should not gloat about it, it is the only way it can be funded.

To answer Senator Fitzgerald directly, the €50 million is in addition to what we will claim back from the sale of land in St. Loman's. Brian Gilroy has knowledge of capital assets and how they can be transferred into realising the commitments in A Vision for Change.

I said at the last meeting that whatever was raised in each county would go back to each county. I erred in my rush to show that we approved of that. Whatever is secured from the sale of assets remains in mental health. It might not happen for every county because some counties have no assets to realise.

I will say how we will fund A Vision for Change in more detail when we make the presentation on 1 March.

There was an increase in the number of young children being admitted to inpatient units last year. When can we expect an end to that practice according to current plans?

Deputy Fitzgerald asked about revisiting the mental health Bill in the Seanad some time ago. I hope to be in a position to clarify that sometime before the end of the year. Our commitment is that the practice will end before the end of 2011.

We acknowledge the progress being made and look forward to the detailed meeting in March.

Mr. Brian Gilroy

It has been picked up that the money from St. Loman's must come back from the HSE. To be clear, there are two different St. Loman's, one in Mullingar and one in Dublin. The land sale of St. Loman's in Dublin yielded €31 million. During that period we also sold other lands, including houses in Clontarf and elsewhere, and that is what makes up the original claim for the €40 million plus; it is the €31 million plus additional sales. We got back the money from St. Loman's last year and we are still pursuing the balance of money. All the money was surrendered to the Exchequer, as is required under the law.

What is Mr. Gilroy's position?

Mr. Brian Gilroy

One role I have is estates director, although I have other responsibilities in the HSE. I am responsible for the capital programme and property.

Mr. Gilroy will join us at the meeting on 1 March.

Professor Brendan Drumm

Deputy Reilly mentioned the decrease of 32,000 cases. In my introductory comments, I alluded to a couple of areas where that decrease will be brought around that will not balance out against day cases. We know from our auditing that a significant number of people in hospital are simply waiting for diagnostic tests. We now plan for such tests to be done without those people having to come in as day cases. In the mid-west we have put in place five new CAT scanners. There are areas where we must now stop admitting people for diagnostics.

Almost 17% of patients now come in for less than 24 hours. Everyone accepts the vast majority of those people do not need to be in hospital. That relates to senior decision making in accident and emergency departments. The Chairman referred to accident and emergency services as a barometer but we should point out that a person is twice as likely to be admitted to hospital if he presents to accident and emergency in Cork or Waterford than if he presents to primary care. Senior decision making and medical assessment units are critical to bringing down numbers by 32,000.

The bed closures associated with the plan will number around 1,100. That is in line with the reductions in admissions.

The primary care budgets and mental health budget were mentioned repeatedly. The Minister stated this is not a reductionper se to us, it is a reduction in the pay costs related to decisions the Government has made about public sector pay.

The €200 million is an added adjustment that we must make for retirement. It is often misunderstood that the HSE is responsible for its own pensions. We pay over €400 million per year but that is in our annual budget. There has been an increase in retirements, for many reasons, some of which are related to the fact it is more beneficial to retire under the current tax system. We have had to make provision for the extra €200 million for lump sum and pension payments to those who leave the service over the next year.

It is best to answer the question on the number of contracts signed for primary care teams on a year by year basis.

Mr. Brian Gilroy

Up to December 2008, seven centres were built and opened under traditional procurement. In 2009, we have opened another 15, eight of them built the traditional way. Those are Dundrum, Millbrook, Pearse Street, Irishtown, Strokestown, Inis Oírr, Clonbur and Westbury.

Under the new scheme we have signed leases for another seven. The process we have followed for contractual commitment is one where we have advertised all the locations. Once there were meaningful expressions of interest from those who possessed a site that could be built upon and that GPs were interested in, we engaged in discussions, identifying a preferred bidder, having worked with sealed bids. At that stage we wanted further evidence of bankability and "planability" of the scheme and the presence of GPs. Then we issue a letter of intent. So far 95 such letters have been issued, outlining that if planning is achieved and the GPs stay on board, we will sign a lease the day the building opens. That progresses to a point at which the design is completed and planning permission is achieved or is in the process of being achieved. At that point it progresses to an agreement to lease. The day the door opens, we sign the lease. Those are the different stages.

Overall, we expect 26 to open this year at a minimum. In 2011 there will be 37 and 25 in 2012. To put that in context, 26 centres in 2010 is the equivalent of €140 million worth of capital investment, more than a third of the entire capital vote for the HSE. They are spread throughout the State.

There is confusion about the lists.

Perhaps that was deliberate, to confuse us.

Mr. Brian Gilroy

There are two different lists, one that outlines the centres and there is a list on page 3 of the 35 pages.

Professor Brendan Drumm

If the Deputy looks at the list of primary care teams, which was circulated with my opening statement, she will see the list of primary care centres that are opening in Cork in 2010. She knows the areas better than I do — Knocknaheeny, Macroom, Bishopstown has a couple, Bandon, Passage West, Mitchelstown and Mallow.

There are two in Cork city so far.

Let us not get into all these centres.

Professor Brendan Drumm

Let us be clear in terms of what Mr. Brian Gilroy has done. This is an innovative approach. I would point out that primary care centres does not equal primary care teams. There will be primary care centres such as the one in Mallow which will cover 30,000 people and it will have three primary care teams. Therefore, the entire primary care centre bill is providing approximately 200 centres or thereabouts which will incorporate the 500 teams. This may be confusing for the Deputy but Mallow will have three primary care teams, each of which will cover 10,000 people, based on coalescence of general practitioners. They have all decided to put their structures——

Professor Brendan Drumm

Yes, full teams. Mallow has one of the most impressive team structures in the country.

Is there a full team in Cork?

Professor Brendan Drumm

I will have to get the information on Cork city for the Deputy. I have visited the centre in Mallow. That is the reason I can tell her it has a superb structure with all members of the team in place.

A Member

Are any of them in Cork city?

Professor Brendan Drumm

There are primary care teams in Cork city.

Are there entire teams?

Let us not get lured entirely into what is going on in Cork.

Mr. Brian Gilroy

The places are outlined in the country.

Professor Brendan Drumm

You see——

Sorry, Chairman.

Professor Brendan Drumm

Deputy Jan O'Sullivan asked how we would deliver given the reduced budget, etc. The bottom line is that we have to be much more efficient about what we do. She also mentioned the mid-west. The mid-west is a good example of what we have to do. I was interested in the comments on Navan because there was a prediction when the changes were introduced at Ennis and Nenagh accident and emergency services that there would be a collapse of the service. In fact the attendances at accident and emergency department of the Mid-Western Regional Hospital in Limerick are less than 2% higher since that happened. We need to reflect back and see where the panic was at the time and how the position can change. The reconfiguration has resulted in the freeing up of services. CT scanning is now commissioned in Ennis, Nenagh, St. John's and a second CT scanner has been provided in Limerick. We have been able to appoint three new radiologists. We can now advertise for new consultants in areas such as dermatology, rheumatology, gastroenterology. Patients who travel out of that area regularly——

They were promised for a long time.

Professor Brendan Drumm

Those advertisements are there.

They were promised for a long time.

Professor Brendan Drumm

They are on the way.

We were supposed to get under a previous——

Professor Brendan Drumm

Absolutely, but the point——

Are the advertisements there as we speak?

Professor Brendan Drumm

They are there. This is the point.

Professor Brendan Drumm

There is a time lag in respect of the radiologists. They were appointed and are coming in from other centres. The bottom line is they are appointed.

Are they moving or are they new?

Professor Brendan Drumm

They are new.

They are additional.

Professor Brendan Drumm

Yes. We have got new appointments in radiology, dermatology, rheumatology, gastroenterology and haematology.

That would have amounted to €100 million plus about three years ago.

Professor Brendan Drumm

Sometimes, one wonders what we do. We simply——

Professor Drumm may as well be honest about it.

Professor Brendan Drumm

What else do we do in the mid-west? Let me keep going. I am sure there will not be——

There is a budget for the Mid-Western Regional Hospital even though Leinster House——

Please, please.

Professor Brendan Drumm

In addition, a unit was being built, a new intensive care unit, a new critical care centre in general with cardiology, new community intervention teams have been put in place, an increased number of staff has been put into the ambulance services, a medical assessment unit is open. That is what reconfiguration has allowed to happen in the mid-west and that is what it leads to, which is a far better and more comprehensive service going forward. The new capital unit will not be completed for probably two years but it has to be built. The money is available and is committed to it as a result of reconfiguration. It is a challenge to get it all right at once. People on the ground have been hugely committed to this work across the clinical and management structures and are delivering.

The issue of colonoscopies was raised. I have to acknowledge the pressure came from the Minister to us to deal with colonoscopies right across the system. Those awaiting colonoscopies for more than four weeks was 24 on the last count, that is down from almost 400 when this project was started. The pressure on the system has delivered. That colonoscopies are down to that level anywhere in the world is a huge success but we now have to deal with the 24. That will be a huge success for the Minister's programme in that area.

Perhaps I can leave the issue of centralised medical cards until I deal with them for everybody. Deputy O'Connor's questions on the ambulatory and urgent care centre at Tallaght and the maternity services were dealt with. We should acknowledge there has been positive engagement with Coombe Hospital with a view to coming up with innovative ways in which its budget could be altered and bring more efficiencies by moving to Tallaght and using that money to drive the capital development.

Deputy Conlon raised the issue of the child who was obliged to wait for one year for a surgical consultation. That should not happen. We need to get information on why that would happen. Certainly for general surgery, there should not be such a delay in respect of paediatric appointments. I think most of the other questions were for the Minister. Deputy Conlon and somebody else raised the issue of training for general practitioners and asked what will happen to those general practitioners. At present that continues to be a challenge. We are increasing our numbers but there are historic agreements with the IMO which have to be complied with before one can be set up with a GMS No. in practice. Agreement has to be reached with the IMO before that can happen. Those agreements are still in place.

Deputy Kathleen Lynch raised the issue of diabetes. Podiatry has presented a challenge even when money was available. A school in Galway is beginning to produce graduates. They are an exempt group under the moratorium. In a short period we will announce our interim clinical need because these have to be interim appointments for diabetes. They will take our expert advisory work on diabetes and begin to implement that right across the system. There is a significant buy into that from the clinicians across the system. That will be focused on a significant movement of that work back to the community where there is a great deal of evidence from general practitioners, such as Dr. Velma Harkins in the midlands, that much of the work done for diabetics in hospitals should be done through primary care.

Can Professor Drumm give the committee the expected number of additional podiatrists who will come into service, specifically for diabetes, over the next period?

Professor Brendan Drumm

They will not be appointed for diabetes. They will be appointed to the primary care teams to deal with all podiatry problems. Obviously diabetes will be a big part of their work. I will have to come back to the Deputy on the actual number.

Will they specifically specialise in the area of diabetes?

Professor Brendan Drumm

No, not for just diabetes but diabetes will be a huge part of their work. One could not include podiatry and exclude other people with significant problems from access to them. Deputy Rory O'Hanlon's questions were answered. He mentioned appointments for hospitals and access. There has been much confusion in regard to access to hospital appointments but this is often based on the lack of any application of catchment areas. We are in the process of implementing integrated service areas, the mid west is one such area, where hospitals are clear on their catchment areas, based on the primary care teams because that structure is mapped. Hospitals will be clear on where their responsibility lies in terms of providing appointments and for what population. That will be critical for the Irish health system. We have always had the problem that highly efficient units — the Chairman has mentioned how units can vary in their efficiencies — were often overrun with work coming from areas where, perhaps, the system was not as efficient.

I think Deputy Neville's questions were answered by the Minister of State, Deputy Moloney. Deputy Flynn asked where the efficiencies of €500 million were made. I can give her listings. The HSE claims to have one of the most efficient public service procurement services in this country and internationally. We are highly competitive in how we put out our contracts. We set up a highly professional centralised procurement structure when we started out four or five years ago. Savings are made on everything, from bedding and clothing through catering, furniture and crockery to a huge reduction in our travel expenses.

Against whom is Professor Drumm benchmarking the HSE, given the size of the organisation?

Professor Brendan Drumm

I am not talking about size. I am talking about how we do our business and set about procuring at a national level. It does not matter whether we are tiny or huge. It has to do with the processes we have set in place. Procurement is now centralised. It is not done at every turn on the road where individuals control the procurement process. We are now highly competitive in procuring nationally and will be more so as we go forward. We focus all our business for scanners, for example, on a single procurement process. Category management is a big step forward. Anyone in the country who is dealing with the HSE will confirm how our procurement function has changed. The proof of that is that we have taken €500 million out of the system without hitting front-line services. I do not think that has been done before.

I have been trying to listen to Professor Drumm's reply. Would it be possible for him to send a report, rather than reading a list of areas where savings have been made?

Professor Brendan Drumm

I can send the Deputy considerable detail on that.

When Deputy Flynn spoke about the role of district hospitals I presume she referred to hospitals in places such as Belmullet. In developing primary care team structures we are also grouping teams. We will see three teams forming a network, especially in rural areas. We cannot justify each team having a psychologist, for example. We see district hospitals as having huge potential in that area. We would also like to see much more involvement of general practitioners in district hospitals. In some areas, such as Belmullet and Donegal, where there are several good district hospitals, the general practitioners are very involved in those services. We see them as having a very important role, especially in the area of step-down from acute units.

Will their operations be enhanced rather than scaled down?

Professor Brendan Drumm

Absolutely. We see district hospitals as having a broader future rather than less so.

That is very positive.

Professor Brendan Drumm

With regard to accident and emergency services, especially in County Mayo, I have never made a secret of the fact that we have found them challenging at times. The service in County Mayo has done much better in the last couple of years than before that but it continues to be a problem intermittently. The Chairman mentioned some of these issues earlier. We need huge support for Dr. O'Neill, who is the clinical director there and is trying to take on some of those challenges. Without that support it is difficult for him to deliver on the ground. This is a classic example of where we need to bring focus to our processes, continue to improve them and support the staff on the ground, many of whom are excellent people who are often frustrated when those processes are not applied fully across the workforce.

Can we reinforce the commitment to the continuation of the provision of an accident and emergency service in Mayo?

Professor Brendan Drumm

I am not aware of any proposal to reduce the service. That would not be practical at present.

That is excellent. I thank Professor Drumm.

Professor Brendan Drumm

I have no idea what will happen in 20 or 30 years.

We will worry about it then. I am happy to wait until then.

Professor Brendan Drumm

If the National Treatment Purchase Fund is not used it is a frustration for us. The NTPF has been a huge success in terms of long waiters. However, it cannot solve our problem of waiting in general. Waiting lists are down by between 40% and 50% but we must remember that the entire NTPF workload is little more than 1% of the HSE workload. While the NTPF has been a huge help to us, the responsibility for controlling waiting lists rests within the HSE. Equally, the reductions have largely been brought about by the staff of the HSE putting in the effort in localities. We continue to work with the NTPF and we are frustrated when we find people not referring long waiters to the NTPF.

We also want people to work together. A number of months ago I discussed the question of scoliosis with the committee. We did not have any money but we were able to validate the waiting list. Perhaps it was not as long as we had thought. By people working together in a number of institutions and through the Minister's good offices that waiting list has been successfully dealt with. Working together can be hugely successful.

Does Professor Drumm ever step in and encourage the use of the NTPF when it is not being availed of? Does he ever contact hospitals to do that?

Professor Brendan Drumm

We do. We constantly challenge hospitals about failure to use the NTPF. However we only manage statutory hospitals. We do not manage voluntary hospitals. That fact is sometimes lost.

What about the seamless service we were promised?

Professor Brendan Drumm

In relation to the NTPF?

We thought we would no longer hear the excuse that something was not the responsibility of the HSE.

Professor Brendan Drumm

If someone wants to change the law with regard to how voluntary agencies work that is not my responsibility.

We are once again hearing the excuse of matters falling between the stools of different institutions.

Professor Brendan Drumm

That is something which should be dealt with by legislators.

The Minister should deal with it.

Is there any possibility that the NTPF would be used to deal with non-surgical waiting lists?

Professor Brendan Drumm

There is a good point to be made with regard to out-patient waiting lists. We now have good data on out-patient waiting lists and we are beginning to target activity levels on them. Deputy Lynch's point is absolutely right. The NTPF has built up an expertise in dealing with waiting lists and we have had discussions with its representatives. We should look at that again. I will take Deputy Lynch's suggestion on board. The NTPF has considerable experience and expertise in dealing with waiting lists, probably more than any agency in the State.

I will ask Ms Laverne McGuinness to deal with the centralisation of medical cards.

Ms Laverne McGuinness

Deputy Shortall raised a specific issue. If she will bear with me I will deal with the general issues first. The overall centralisation of the medical card in the primary care reimbursement service, PCRS, deals with medical card holders over 70, of whom there are 72,000. There is a difficulty in getting through on the phone. The PCRS office is clearly taking calls which are not connected with medical cards. In the past week, for example, 25,000 calls were received, which would indicate that in three weeks every single medical card holder over 70 had called the service. The 32 local health offices are still in existence. Each of them has full access to the over 70s medical cards data, can deal with queries from people living within its area and is obliged to do so.

Staff in those offices cannot get through to the PCRS.

Ms Laverne McGuinness

They do not need to get through to the centralised office in Finglas. Each office has access to the national over 70s medical card system.

People are being told to telephone Dublin.

Ms Laverne McGuinness

That is the issue. I understand that. People are being told to ring Dublin when that is not necessary. Local offices can deal with queries.

Is Ms McGuinness sure the local offices can access the information on computer?

It is nonsense to talk about ringing an office to get information if that office is not processing the medical cards.

Ms Laverne McGuinness

I will deal with Deputy Shortall's query in a moment. Two areas from Deputy Shortall's region have moved over to the PCRS central office. In respect of those over 70, there are two routes of access. A person can make an inquiry at his or her local health office, where access to the over-70s medical card can be obtained. Staff at these offices will be able to provide all the information people require. The primary care reimbursement service, PCRS, will also have details on its system of applications relating to those over 70.

That is not the case. Will Ms McGuinness listen to what is being stated? People are submitting applications and four weeks later these are still not registered, let alone being subject to decision.

Ms Laverne McGuinness

Approximately 90% of the cases are completed in time.

With regard to Deputy Shortall's area, Dublin North and Dublin North-Central have been centralised——

Ms McGuinness referred to those over 70.

Ms Laverne McGuinness


The statement she made in respect of these people is not true.

Ms Laverne McGuinness

Applications are dealt with within 30 days.

Why then are people complaining about this matter?

Ms Laverne McGuinness

They are dealt with within 30 days. There was a backlog of 6,000 cards in Dublin North and Dublin North-Central. As a result, people in the PCRS who would have been manning the phones were diverted to deal with this backlog. At present, only eight people are manning the telephones.

Professor Brendan Drumm

This was on the old system. There was a backlog of 6,000 cards on the old system, which we will now remove.

Ms Laverne McGuinness

That was the old system which will be removed and the backlog will be dealt with. Additional members of staff are manning the phones in order that people's queries might be dealt with. I have the data relating to that matter in my possession.

Deputies were given the names and numbers of people they could contact.

Ms Laverne McGuinness


I can only speak for myself, but my office has tried to contact the person in my area for many months. In desperation I contacted the Minister's office and informed her that I could not get through on the number we were given. Between 1 p.m. and 2 p.m. — lunchtime — on the same day, the individual involved telephoned my secretary. We have not been able to contact her since. That is not acceptable.

The position is the same throughout the country. Members cannot obtain information relating to those over 70 from their local offices.

Ms Laverne McGuinness

There are two issues with which we must deal in this regard. The Minister sent out a letter in respect of medical cards which contained contact names. We telephoned around the offices and were informed that we should contact the central office. Incorrect information was being given but part of this was due to the non-cooperation with the centralisation of the medical card system.

We are referring to data relating to the period prior to that.

Ms Laverne McGuinness

This has been an ongoing issue in the context of non-cooperation with the centralisation of the medical card system. It is being addressed with each of the four regional directors of operations, who have all been in contact with their officials and informed them that each of the local health offices must take people's calls and deal with their queries.

From our point of view, it is a waste of time to contact one's local health office in order to seek information which the PCRS in Finglas does not possess. This will merely create more work and add to people's frustration. We should be able to speak directly to staff of the PCRS in Finglas in order to discover the position with regard to people's applications for medical cards. In fact, applicants themselves should be able to telephone the PCRS in Finglas and be provided with the information. Ms McGuinness is stating that we must contact other HSE offices and speak to members of staff who know nothing about this matter. These staff will then be obliged to try to contact the PCRS in Finglas. That is nonsense.

Ms Laverne McGuinness

I am not saying that. What I am saying is that in respect of the over-70s medical cards, the relevant information is available to both the PCRS office and local health offices. The latter have access to the information.

Much of the time such information is not available.

Members are concerned with regard to this matter. Will our guests consider this matter urgently and provide the committee with written advice in respect of it? This is an important matter.

Professor Brendan Drumm

There is an issue with our local health offices in the context of co-operation with responding to the committee's questions. It is clear Members are not getting the responses they require. We have become aware of that fact and we need to deal with it.

We are not getting the responses because the process is not working.

Professor Brendan Drumm


Applications are not being entered into the system or they are being lost. It seems there are people——

Professor Brendan Drumm

The Deputy provided one example, which was completely inaccurate.

I beg Professor Drumm's pardon.

Deputy Shortall, please.

I let the Minister away with such behaviour earlier. In the first instance, it is inappropriate for members to raise individual cases before a committee. I am adhering to the rules in this regard. I could provide Professor Drumm with information relating to 30 cases. It is in my office. I have already used all of the mechanisms open to me as a public representative. It is completely unacceptable that I am obliged to intervene on behalf of members of the public who are trying to have their medical cards, to which they are entitled, renewed.

The Deputy has made her point.

It is not acceptable for Professor Drumm to say "give me the details".

The Deputy has made her point in very clear terms.

That is not an acceptable way to run a modern service.

Professor Brendan Drumm

We have stated that we will communicate further with the Deputy. We will deal with the issues locally that have frustrated her attempts to obtain information. She can take it from us that not all of those issues relate to a lack of information. There are other issues involved, particularly those relating to resistance to the centralisation of the medical card process.

Those matters are Professor Drumm's concern and he should get his act together in respect of them.

Professor Brendan Drumm

To be clear, we have to do the best we can to resolve these matters.

The position, as it stands, is not acceptable.

Deputy Shortall has made her point.

Professor Brendan Drumm

The Deputy made the point in respect of a specific case——

I did not refer to a specific case.

I will be forced to adjourn proceedings if the Deputy continues to interrupt Professor Drumm.

I did not refer to a specific case. Professor Drumm should not try that one on me.

I wish to clarify that, of course, it would be inappropriate to raise an individual case. However, the Deputy brought to my attention the case of a disabled person who has had a medical card all their life and who has now lost it.

I am not saying that. However, I am saying that disability, serious illness and terminal illness are not taken into consideration when medical card applications are being processed.

That is not true.

Professor Brendan Drumm

We are clear, from the information provided to us today and from that supplied to us in the past by the Minister — who is extremely frustrated with regard to this matter — that there is a problem in the system at present. Some of that problem relates to information which should be available from people's local health offices. By April, and accepting that we have IR issues, the 140 people required to do this work will be posted to the new centralised facility. This will mean that loads of people will be available to answer telephones.

Unfortunately, when we attempted to centralise cards from the local systems — again, this is our responsibility — we discovered a huge backlog of cards in those systems of which we were not previously aware. Those cards must also now be dealt with. It is amazing that those cards have not come to members' attention prior to now, particularly in view of the fact that there was a significant backlog.

Once we get into April, it is fair to state that, barring huge industrial relations resistance, this system should be functioning extremely well. In the short term, in respect of the issues the Deputy raised, we will try to ensure that local health offices, etc., provide the information we believe they should be providing now.

I thank Professor Drumm.

Professor Drumm took copious notes when I referred to it but he did not comment on the case mix at Tallaght Hospital. If he wants to come back to me on that at a later date, that is fine. However, he must understand that this is a serious issue.

Professor Brendan Drumm

Case mix adjusted funding has been in place for years. There are various arguments with regard to the accuracy of the Irish case mix measures. However, it is standard across the system and, therefore, its inaccuracies apply equally across that system. During the next 12 to 18 months we hope to put in place a much more accurate and fair case mix system. That is all I can say on the matter at present. The focus is on introducing that system but I am not certain whether it will benefit one hospital over another.

I thank Professor Drumm.

I ask Deputies Reilly and Jan O'Sullivan to——

I did not obtain an answer to my question on the ambulance control centre. Would it be possible for Professor Drumm to send me a detailed response in respect of that matter if he does not have one to hand now? Was a feasibility study carried out in respect of this matter? Why did the HSE arrive at its eventual decision? Why did it determine that the centre will be located in a place that is not where I believe it should be located?

I call Deputy Reilly. He has five minutes.

I hope the Chairman will indulge me in the way he has indulged everyone else. I wish to be sure with regard to what Mr. Gilroy told me, namely, that there were seven centres up to 2009, that 18 opened in 2009 and that seven contracts have already been sighed this year. Is that correct?

Mr. Brian Gilroy

Some 15 centres opened in 2009. Of these, eight were built under the old scheme and seven under the new leases. A total of 26 will open this year.

How many contracts will be signed this year?

Mr. Brian Gilroy

When one is defining a contract, there are 95——

Mr. Gilroy and I both know that letters of intent mean nothing. I am referring to the type of contracts that people who propose to proceed with developments can present to their banks in order that they might arrange finance.

Mr. Brian Gilroy

The Deputy is referring to agreements to lease. At the point of which it is designed, there are seven leases signed and we currently have six agreements to lease. An agreement to lease cannot be produced or signed by us until the design is complete.

Will Mr. Gilroy be in position to produce a list of these centres and their locations at a later date?

Mr. Brian Gilroy


In the context of the discussion which took placed earlier — I resisted the urge to become involved in it — I put it to Professor Drumm and Ms McGuinness that there is a serious issuevis-à-vis the medical card system and its centralisation. Professor Drumm is nodding. In such circumstances, I am glad the HSE accepts that such an issue exists and that it is going to deal with it. If Deputies are encountering difficulties obtaining information, patients are having nightmares in that regard. I am aware of several instances of patients producing medical cards which are not included on any list. I do not know what is happening but the problem must be resolved.

The increase in the number of people on trolleys in hospitals is a matter of serious concern. While there might be a study that shows it is safer to have trolleys on wards than in accident and emergency departments, neither situation is safe. I wonder if the Health and Safety Authority would pass a hospital with trolleys in the middle of wards and on corridors as a safe working place. I doubt it very much.

I am glad something will be done to address the low number of GPs. I ask the Minister and the HSE to expedite the fast-tracking of experienced people, who would not have to undergo a full four years' training and that this process be moved along.

The medical card income threshold, which is just a little more than half the average industrial wage, is outrageously low. This has caused ferocious hardship for people and this is still a problem. The approach is sometimes perceived to be very callous, particularly for the terminally ill, as has been pointed out.

I note the Minister has made savings with drugs companies but generic drugs are still a major issue. Why they cost nearly 27 times as much in the South in some instances than they do up the road in Newry is still a matter of major concern. This is an area where more savings could be made.

The committee will launch its primary care document tomorrow and I hope the Minister will take cognisance of many of the recommendations in it. This will help expedite the rollout of the primary care centres, which is happening very slowly, although this has improved under the auspices of Mr. Gilroy.

The strategy providing for the national cancer centres has been successfully implemented, but are they a success yet in hospitals that have the highest number of patients on trolleys, etc? We will only know that in five years' time when we examine the five-year survival figures.

We need a national transplant authority, a proposal that was raised previously. The Minister must accept that the number of heart and lung transplants carried out in this country, having regard to the amount of money invested is these programmes, is abysmally low. Outcomes will not improve until a proper transplant authority is in place to co-ordinate matters.

I put it to Professor Drumm that the fact that 30% of people are in hospital for fewer than 48 hours does not mean that those 30% did not need to be admitted.

Professor Drumm mentioned the Coombe Hospital and Holles Street Hospital. Being a northsider, I would like to know what is happening with the Rotunda Hospital. The situation in all three hospitals is serious.

Can the Minister advise which company won the cervical cancer contract vaccine?

I welcome the Minister's initiative to deal with "head shops". The regulations proposed are fine, but legislation covering product liability insurance and planning is required and it should be expedited.

The cost of hearing aids was mentioned and I had intended to raise this matter previously. Has an investigation being carried out into the cost of hearing aids and the mark up on them in this country? They are extraordinarily expensive. The mark up was more than 100% many years ago. We need to examine the cost of them and perhaps we could do that through the committee.

The Minister of State, Deputy Moloney, has given an undertaking here to open a unit in Beaumont. I hope this does not turn out to be another false dawn because there have been too many of those in the past. His first port of call is to get planning permission for it.

Professor Drumm mentioned that there is an issue concerning retirement but there is a further related issue. Staff who have retired have been re-employed while young nurses, in particular, are emigrating because they cannot get jobs here. That is a big issue that needs to be addressed. I know of such incidents and people have written to me about this. I am concerned that people who have retired have been re-employed while other people have to leave the country because they cannot get a job here.

Professor Drumm mentioned that he has good information on outpatients. When Mr. Michael Scanlan, Secretary General of the Department, appeared before the Committee of Public Accounts he was not sure about the figures. He mentioned a figure of possibly 175,000. The cynic in me asks if the figure for inpatients is decreasing because the figure for outpatients is rising. If one cannot get past the barrier to get an outpatient appointment, one will never get on to a waiting list; one must see the consultant first.

I have two issues concerning the National Treatment Purchase Fund. Professor Drumm mentioned scoliosis and cardiology treatments. Scoliosis treatments have improved and that is welcome but cardiology treatments seem to have fallen back as a consequence. Those treatments do not appear to be carried out under the NTPF in any particular number, although many circumcisions are carried out under it.

I wish to raise another question about the NTPF, which was brought to the notice of a constituent of mine when he worked out the cost of his mother's care who has been in a nursing home for a number of years. He could not figure out the sums until he challenged the nursing home about the cost of his mother's care. It transpires the nursing home gets €200 more a week for caring for his mother than it got from him when he paid for it directly under the NTPF. Professor Drumm might raise that matter with the NTPF in terms of the securing of value for money for the taxpayer.

I wish to raise the issue of ambulances queuing up at accident and emergency departments in Dublin and being left there for five, six or seven hours. It seems that putting trolleys on wards and keeping ambulances outside those departments to stop more patients being brought into them is another method of reducing numbers in accident and emergency departments. It is not a methodology of which anybody here would approve. We need to have the few ambulances we have out on the road providing a service.

I thank the Minister, her team and Professor Drumm. Admittedly, some progress has been made but the treatment of patients on trolleys, the waiting times for patients and the centralisation of services, without putting in place the necessary resources to allow that happen safely, is having a negative effect on patients. We have yet to see real improvements on the ground in terms of people's experience. There was a time when we heard anecdotally that a patient was on a trolley for two days but I get reports of that happening virtually every day of the week. I heard a report yesterday of a lady in a southside hospital who had been on a trolley for eight days.

I welcome the commitment of the Minister of State, Deputy Moloney, that by the end of 2011 there will be no children in adult psychiatric wards. We will monitor that and I hope that commitment will be fulfilled.

I thank Mr. Gilroy for the progress that has been made regarding the maternity hospital in Limerick, which needs to be relocated to the grounds of the acute hospital. I note in the service plan that some progress has been made in that respect and I welcome that.

With regard to the centralisation of the processing of medical cards, we did not have the problems that have now arisen prior to the centralisation of this service. We could get answers to questions concerning medical cards. More importantly, the people concerned could get answers to their questions and they did not have to contact their public representatives. There is much talk about TDs doing work that they should not be doing in the context of George Lee's resignation, but if he had not gone already, he would have gone after today. The people concerned should be able to get the information they need. If the problems in the two Dublin areas, clearly articulated by Deputy Shortall who spoke to me at length about this last week, cannot be ironed out before the planned date to centralise this service throughout the rest of the country, this service should not be centralised and should continue to be provided in the regions.

In the context of the cancer strategy the Minister spoke about the reconfiguration of work and that resources were moved into the eight centres and so on. I cannot see any evidence of that. I have looked through the figures in the back of the service plan and I cannot see evidence that the Mid-West Regional Hospital received extra financial resources to address the transfer to it of acute surgery from Nenagh General Hospital and Ennis General Hospital as well as the closure of its 24-hour accident and emergency department. Services have been closed in those smaller hospitals but extra resources have not been provided in the big hospital. I am concerned about the delivery of hospital services in the north east as well.

A major part of the savings shown in the service plan are based on fewer people being admitted to hospital through accident and emergency departments, but for some reason no statistics on that are available for this year. According to page 49 of the service plan, such statistics will be available for next year. No information is available on the average time for registration to discharge all patients, or on the percentage of patients discharged within six hours of ED registration for 2009. Why is that the case? Presumably the HSE is basing its proposals on some kinds of figures.

The Minister, Deputy Harney, made the interesting point that instead of money following the patient for every item of care, there is a basket of provision. I read somewhere that Professor Drumm went to Germany to examine its system. I encourage the Minister in that regard because it is important that we find a way to pay our hospitals for the service they provide in accordance with the standard and efficiency of service they deliver. I hope she will continue in that regard.

Legislation to deal with "head shops" is needed sooner rather than later because the lives of children and young adults are being put in danger.

I support what my colleagues said about extending the BreastCheck programme to older women. However, I have not been called for a BreastCheck examination in my area even though the programme has been rolled out to every city and county in the country. It has still not been provided for every sector in these counties. The current age bracket must be served before the programme is expanded, although I support the idea of expanding the scheme.

I did not receive an answer to my question on the number of patients discharged to the fair deal scheme.

These are important meetings and sometimes they can be difficult but people are entitled to make their points. It is often assumed that those on the Government side do not have the same concerns — we do. I was glad to hear Professor Drumm acknowledge that there were difficulties. I referred to medical cards and someone said I would make a better Opposition Deputy.

Certainly not.

It does not matter what side I am on. It is important that we hear the responses to concerns raised. These meetings are important in that regard. Deputy Flynn suggested others in the Department and the HSE responded to the points raised and would correspond with the committee in due course.

I thank the Minister, the Minister of State and Professor Drumm's team. I also thank the Chairman.

The Minister might take five minutes to wrap up.

I will ask the chief medical officer to comment on the medical issues raised. There are logjams in respect of the centralisation of the medical card scheme and there is often a resentment towards change. Members said they had never received a complaint when the scheme was dealt with locally but now receive many and claim this shows centralisation does not work. I do not accept this. If 6,000 or 7,000 medical cards are just handed over when they should be dealt with locally, it presents a challenge, as it would for any system. The medical card division is headed by a wonderful man, Mr. Paddy Burke, but without co-operation, he cannot do the job alone. I have no doubt Professor Drumm and Ms McGuinness will deal with the concerns of Deputies. We need information; we do not want Deputies to be involved in this space. If constituents have a problem, they should be able to access public service information. Every change raises transitional issues.

Deputy Shortall mentioned a particular case but I did not mention any names. She said a medical card was suddenly withdrawn from a disabled individual. As I was concerned about the fact that, as she said, the family would have to pay over €800 a month, I followed up on it and presented the facts in an honest fashion. If we are to have a real debate, we need to be aware of the facts. However, I understand her frustration.

The chief medical officer will deal with the escalation policy. The company which was given the contract was Sanofi and the vaccine will be made in Ireland. In the usual jargon, it is known as "Warts and All". I was not sure I could mention the name of the other company because there was a cooling off period but that has now come to an end.

The primary care policy will be published tomorrow and I hope to attend the publication. I also hope the policy can be implemented within existing resources but we do not have unlimited resources.

Innovation is our middle name.

I welcome the fact that the committee can make a contribution to policy making. It is a very important and useful role of the committee to play.

In the current climate I am reluctant to recommend that the committee travel abroad and members would probably not go. However, I visited the Kaiser health care system and The Vets a couple of years ago and the transformation in cost of care, levels of hospitalisation and outcomes for patients was phenomenal. I would love a mixed group from this committee to have exposure to the change I witnessed.

Where is that system in place?

In Washington; Professor Drumm probably knows more about it. We should look in an innovative way at health care systems that deliver outcomes under a model we are trying to put in place in Ireland.

Dr. Tony Holohan

The Chairman asked about symphysiotomy. We have been in correspondence on the matter and told the committee that it was an historical problem. It was appropriate in obstetric practice at a particular time before being replaced by caesarean sections. People who have been through it suffer a range of symptoms which may or may not be specific to symphysiotomy. The committee has provided us with relevant correspondence and recommended names of some experts who may become involved in a review. I have not finalised my advice to the Minister.

Did Dr. Holohan say the committee would come back or had come back?

Dr. Tony Holohan

It has come back. In a review which has patient safety as its primary purpose the basic requirement is to identify groups of patients who might benefit from a service which is being stopped. That does not arise in this instance. The next requirement is to find out whether people who have been through a service might have benefitted from the experience. The next is to identify services that might benefit such people and a range of services are in place without prejudice to the appropriateness of the procedure. The HSE will be able to give more details on this matter. We have engaged with the Institute of Obstetricians and Gynaecologists which takes the view that the development of guidelines in the here and now for a practice which is extremely rare in western health care systems would not be appropriate. Our energy should be devoted to providing the best quality service for the people who may need one now, rather than divert resources to a review of a practice which was appropriate at one time.

I would be happy to provide members with some of the papers dealing with boarding in. Safety is one issue but when patients are boarded on wards on single trolleys, beds can often miraculously be found quickly. Dr. O'Donnell from Limerick made the case convincingly on "Morning Ireland" but I understand the difficulties he is facing at local level in bringing about change. He wishes to see this introduced.

He has put trolleys on wards but beds have not appeared.

The inference I make from what Dr. Holohan says is that patients are being left in beds needlessly and that the appearance of a trolley on a ward creates a space.

Dr. Tony Holohan

There is published, peer-reviewed evidence on this subject which I will be happy to provide for the Deputy. It finds that when patients are in large groups in a single hospital such as in an accident and emergency department, they are less likely to find their way into beds. Those beds might have been freed up earlier had they been made the responsibility of nursing staff around the hospital.

I thought we were discussing safety.

Dr. Tony Holohan

The purpose is not to avoid safety issues but to improve access to beds.

That implies that professionals deliberately refuse to free up beds.

Dr. Tony Holohan

The challenge to nursing staff becomes much more immediate when the patient comes to the ward and is present and waiting in a corridor for a bed.

There will be no room for a locker or curtain around the bed. Patients are suffering.

In the 1980s I worked in Sligo General Hospital when there were lines of beds in the middle of a ward. It was not safe, private or acceptable. We are going back to that position. It may be slightly safer to have them in wards than in a big congregation in an accident and emergency unit but it is still not safe.

Dr. Tony Holohan

They are under the care of nursing staff who are expert in the management of these conditions.

Professor Brendan Drumm

I will come back to Deputy Reilly about accident and emergency units. He also asked about generic drugs. The Minister set up a group, involving the Department and the HSE, to look at reference pricing. The pricing of generic drugs in Ireland has always been strange. We need to be out of that business and setting the price we are willing to pay for a compound, whether it is branded or generic. We cannot get around the machinations, whereby the industry in Ireland prices drugs without adopting such a stance. It will get us away from having to consider whether something is generic or branded.

The Deputy's suggestion of a national transplant authority would greatly benefit transplantation in this country.

That will be part of a human tissue Bill which is at an advanced stage.

Professor Brendan Drumm

I met the board of the Rotunda Hospital and the plans to move to the Mater Hospital site are in place. The board has engaged very constructively with us to bring the move to fruition, despite the financial challenges which must be tackled by savings in shared services and amalgamations in such services as laboratory services. We will have to look into the cost of hearing aids as it is not something on which we have yet focused.

I agree that access to outpatient departments is the critical bottleneck; it is the most frustrating issue for GPs. Our outpatient data for each unit across the country are now on HealthStat. The big waiting times are in the areas of orthopaedics, ENT, dermatology and rheumatology, although the last data may not be on HealthStat. As we validate the waiting times, many of them drop significantly but there is no doubt that they are huge in these areas. In the Dublin area waiting times are a lot shorter than in outlying areas, while the opposite is the case in accident and emergency departments. We must make significant inroads on waiting times. The suggestion of Deputy Kathleen Lynch that we utilise the expertise of the NTPF is a good one.

The Chairman also brought up the subject of the accident and emergency departments. The situation is very different from a few years ago. It is focused on a relatively small number of places and huge credit is due to accident and emergency consultants and hospital staff for having solved many of the problems. We are trying to address the question of why they have not all been solved. Some processes have still not been standardised. Waterford has the biggest unit in the country outside Tallaght and the latter has a childrens' hospital located beside it. The unit in Waterford is twice the size of the Dublin units but people do not need to wait because it has unique processes which we are trying to implement elsewhere. They include medical assessment and nurse practitioners who have instant access in dealing with minor injuries without there being a need for the patient to see a doctor. There is also an accident and emergency lead which drives the system. We have to change but staff have put in a huge effort in tackling the problem.

We will try to get the information which has been blocked on medical cards. A suggestion was made that we should abandon centralisation but if we do not continue with the process, it will frustrate efforts to get information to Deputies. If we do not have a major industrial relations issue and can move towards the new system by April, it should work much better. I invite the Chairman and members to visit Mr. Paddy Burke's centre at Swords because they will be reassured that the system works. It deals with the management of PCRS, medical cards and drug payments and has a texting system that can go all the way back to the individual patient.

Deputy O'Sullivan asked about extra financial resources for the mid-west. Some extra resources have been provided but the main extra financial resource is internal, with the budgets of the hospitals in Nenagh and Ennis and Limerick Regional Hospital all being consolidated into one. There are far fewer doctors on call in Ennis and Nenagh and fewer junior doctors.

There are separate budgets at the back of the service plan.

Professor Brendan Drumm

A single management structure has access to all three budgets and can apply them across the system. Utilising the budgets as a single entity gives us the capacity to do the things we discussed. For example, junior hospital doctors can now be moved from surgery to anaesthesia to serve the new emergency theatre in Limerick which has had a massive impact on the capacity to provide a service.

I do not know if I have left anything out.

All the matters raised have been covered. I thank the Minister for Health and Children, Deputy Mary Harney; the Minister of State at the Department of Health and Children, Deputy John Moloney, and Professor Drumm and his team for their attention to the questions. I remind members that the primary care report will be launched tomorrow at12.15 p.m. in the AV room. I also remind the select committee that the Adoption Bill 2009 is scheduled to be taken on Wednesday and Thursday, 17 and 18 February. The Bills Office reminds us that the deadline for receipt of amendments is 11 a.m. on 11 February. The next meeting of the joint committee will be held on Tuesday, 23 February at 3 p.m. We will meet representatives of Dáil na nÓg from 3 p.m. until 4 p.m. and the Irish Motor Neurone Disease Association from 4 p.m. until 4.30 p.m.

The joint committee adjourned at 6.40 p.m. until 3 p.m. on Tuesday, 23 February 2010.