I will begin with the Chairman's question. He asked about waiting times for outpatient appointments which represent a very central part of the commitments the HSE has made for 2010. As members know, Dr. Barry White has taken over as clinical affairs director for the HSE and among the initiatives he will introduce will be care pathways, which will include appropriate care led by consultants across a number of different disease-specific areas but also access to appropriate outpatients, and particularly new referrals. On a number of occasions when he started the cancer control implementation plan, Professor Keane said that his concern was to ensure that general practitioners followed up in the main regarding cancer patients and that consultants were dealing with new referrals. I believe he has made great progress in that area.
The National Treatment Purchase Fund has done well. It has treated 165,000 people to date. At the presentation of the annual report there are normally some very satisfied patients who have been treated in the previous year. The National Treatment Purchase Fund spends less than 0.5% of the total budget spent in the public health service which is a relatively small amount of money. It is there effectively as a universal insurer to procure treatment for those who are waiting longest essentially in a private capacity in this country. A small number have gone to the UK or Northern Ireland. However, more than 90% are treated here in the South. It has been very successful.
The National Treatment Purchase Fund did some useful pioneering work in the area of outpatients, where an outpatient appointment may have led to the need for a procedure. If memory serves me right a very large percentage of those who had their outpatient appointment did not need a procedure. This is particularly true in orthopaedics where up to 70% of those having seen the consultant do not need a procedure. Very often they need referral to a physiotherapist. Among the initiatives Dr. White is interested in putting in place in the area of orthopaedics in particular is ensuring that an adequate number of physiotherapists are available.
That brings me to the issue of the moratorium, which applies to administrative and management staff. There are a large number of exceptions, including doctors, therapists, social workers, physicists, radiation therapists and so on. Outside those categories a case can be made to the regional group that investigates these issues to make a recommendation to fill an appointment, for example a director of nursing appointment, etc. I shall not read out the long list of exceptions, which includes counsellors, emergency medical technicians, clinical psychologists, all the various therapists, physicists, radiation therapists, clinical engineering technicians and so on. Many of those are needed for the cancer control programme.
It would not be appropriate for me to comment on the succession in the HSE. I have spoken publicly on many occasions about my high regard for Professor Keane. However, I equally made it clear that it is a selection process that is overseen by the board by law and it is a matter for the board to make the appointment. Clearly the issue of Professor Keane's candidacy has got into the public domain and he has made a decision for personal and family reasons. I have not spoken to him since that decision was made. However, it is a matter for the HSE to pick the most appropriate person to lead the Health Service Executive over what will be a very challenging period, particularly as far as financial controls and change is concerned. I hope the board of the HSE will be in a position to make a selection in plenty of time for a smooth succession. I understand Professor Drumm finishes in August. I hope we will be able to have a successor in time for a smooth succession from the current CEO to the new CEO.
The agreement reached last night with the public sector unions will have a major positive impact on the health service, in particular in the area of access to diagnostics. The importance of the 8 a.m. to 8 p.m. working day should not be underestimated. Our hospitals need to respond to the needs of patients and clearly a 9 a.m. to 5 p.m. working day, where outside those hours access to radiography, in particular, was so expensive and on a fee per item, has led to many delays in hospitals being able to fund appropriate diagnostics. I believe that will have a major impact.
The HSE has given a commitment that region by region it will reduce the number of admissions from accident and emergency units by 33,000 because it estimates that a large number of them simply require diagnostics, others require outpatient appointments and some can be provided services through the community intervention teams in the home. The VHI is now engaged in a "hospital in the home" pioneering project. I met the group last week and its target for this year is to treat 1,000 people with different chronic illnesses at home as opposed to in a hospital environment. There is great potential to have appropriate treatment at home and in the case of the HSE it is being led by the community intervention teams.
Deputy Reilly asked about the medical card review. It was completed and obviously no change was made in the budget. The McCarthy report had recommended we change downwards from where we are — in other words reduce the financial criteria substantially as far as medical card holders are concerned. The Government did not agree to that recommendation. However, the numbers on medical cards is growing very rapidly as is the cost of medication this year. Some 12,000 full medical cards were issued in January and if that continues through we estimate there will be an extra 140,000 for the entire year. There will be an additional €250 million on drug costs associated with additional medical cards. Clearly in a time of tight financial constraint it is impossible to relax the income criteria. However, I would say that we factor in travel to work costs, rent or mortgage costs, child care costs and so on. Although the nominal income may appear small, it is disposable income and other costs are also factored in. That is why so many additional people over and above the numbers that may be on those kinds of incomes qualify for medical cards or doctor-only cards.
We are preparing eligibility legislation as the Deputies will be aware. It is long overdue. We hope to be taking it to Government this year. It will clarify the items for which people are eligible in the health system. That is particularly important as we move from a hospital model to a community model, particularly regarding therapies. If access is free at a hospital level, but there is a charge associated with it at community level, obviously there are perverse incentives there, so we need clarity on eligibility. It will be a major Bill and will offer a major challenge for this committee to take us through that legislation. We hope to have that this year and it should bring great clarity to the issue of medical cards and other eligibility issues.
Deputy Reilly asked why the Department's Vote had increased by 3% on the policy side. If the Deputy takes a two-year view on the matter he will see that it is less than it was two years ago. Last year there were a number of once-off savings that cannot be factored into 2010. For example in 2009 there was an increase of €5 million, referred to on page 7 of the output statement, which relates to non-pay spending. This was a once-off saving in areas such as legal fees for the Mental Health Commission and the Department, and for the establishment of HIQA. So some once-off matters which reduced in 2009 compared with 2008 could not be counted again in 2010 because they will not recur. However, when 2010 is compared with 2008, there is still a substantial reduction.
One of Dr. Barry White's initiatives is to examine ring-fencing beds for surgical procedures. When there is pressure, particularly from the emergency departments, elective surgery gets postponed or delayed. The only way to avoid that is to ring-fence beds for surgical procedures and his intention is to make that a reality in as many hospitals as possible as part of his initiatives regarding clinical care pathways. That would allow surgeons to manage those beds rather than have patients brought in in advance over concerns that the bed will not be available. In some cases patients come in on Sunday for a procedure on Monday. If surgeons knew they had the beds then patients would come in on Monday. There are many positive reasons for that to happen. I understand that initiative will be put into effect during this year — hopefully soon. It might be a good idea for the committee to invite Dr. White, who is the new clinical affairs director, to engage with the committee.
A new consultant was to be recruited for Sligo — someone retired and that person had to be replaced. I do not know if that is what is affecting the regular mammographies, I will check that, but that was the understanding I got from Professor Keane when the issue arose a couple of weeks ago. However, the intention is that the follow-up will occur in Sligo General Hospital. The reason for going to the specialist centre is for initial diagnosis and surgery and, thereafter, patients were to be managed in the local hospitals. That is what is happening in Mayo and what should happen in Sligo. I will clarify that for Deputy Reilly.
We gave a commitment that the vaccine would be introduced this year for first year girls. The intention is to start after Easter. The Irish Medicines Board has indicated the second dose must be given exactly two months after the first dose, with the third dose being given sixth months later; that will be a challenge. The Chief Medical Officer and public health doctors in the HSE are engaging on this issue. I will repeat our commitment that all first year girls will get the vaccine during 2010.
Deputy Jan O'Sullivan asked about the successor to Professor Drumm. She is right, when Professor Keane came to Ireland, the eight centres had been identified following a recommendation by a group that was composed of 19 clinicians and three others. Professor Keane, however, did not disagree with the identity of those centres. He did not get involved in the issue because it was a project he came to implement but it was project he was happy to implement.
The issue comes down to what is safe and how we can get the volume of patients to guarantee highly skilled clinicians performing surgery — 150 new procedures a year for breast cancer. Other than for breast surgery, and there was one breast surgeon in Sligo, and there could not be a service if that person was not there, all other major cancer surgery went either to Dublin or Galway.
There is a satellite centre in Letterkenny and I have been in discussions with my counterpart in Northern Ireland on the radiation centre for west of the Foyle which the Northern Ireland authorities intend to put in place by 2015 as a satellite for Belfast City Hospital. We have already procured treatments in Belfast City Hospital for some patients from Donegal but a good outcome for the north-west would be to have a radiation centre in the north-west supported by patients from both sides of the Border. Our talks have been successful and the Government has committed to investing in the provision of that facility by way of a capital allocation and ongoing service level agreements related to the number of patients. Minister McGimpsey is positive about this matter.
We have sent some of the H1N1 vaccine back. We had 12 million vaccines either that we did not pay for or do not have to pay for. We are also talking to another manufacturer about some other vaccines.
A large part of the reduction for voluntary and public hospitals is pay. Galway university hospital, for instance, has more than 3,000 staff. Given the cutbacks in public sector pay, a large part of the €16 million reduction would relate to pay. The same applies to voluntary hospitals where the pay scales are in line with public sector pay norms. Not all savings, however, are in the pay area, hospitals must move to more day case activity, which has increased by 4% per year, although there is still some way to go to get to best international practice.
There are demographic issues with regard to dialysis, additional cancer treatments and more people requiring disability services so the €70 million I mentioned earlier is in that space. It has been called the demographic pressure in health but it relates to unavoidable provision of patient services.
I heard about Quinn Insurance this morning. Health insurance is affected but the regulator made it clear that the administrator will ensure the company continues to trade and can take new business. All claims will be honoured. There is an insurance compensation fund that will be applied to meet the gap between the assets of the company and the liabilities, which I understand are considerable. There is no immediate concern about the health insurance element. Quinn has 23% of the private health insurance market and all those policy holders are fully covered. That will continue to be the case.
The resource allocation group had a target of finishing in April. I have not heard of any delay being sought so I expect the report during April. The group was asked to look at how a resource is raised for health, be it through insurance, taxation or a combination of both and how it should be allocated to get the best results for the patients. The group engaged widely. It is made up of key stakeholders and those who have looked at funding models and I look forward to receiving and debating the report.
We had to make reductions in dental services. The cost of the dental service had increased by 50% in one year. I have engaged with the Irish Dental Association recently and it put forward some suggestions. I asked the HSE to come forward with plans for allocating the money on a month by month basis. I do not want the money to run out in June and there to be no service available. We are involved in that engagement process with the HSE. There are different dental schemes, the public scheme, the medical card scheme and the social insurance scheme; in an ideal world we would bring all of that together.
We do not have comparative data but Ireland is at the higher end of the scale for admissions from accident and emergency departments into acute hospitals. Generally, attendance at accident and emergency is higher where there is an accident and emergency unit and where there is not a good out of hours service. We spent €108 million last year on out of hours services for medical card patients — they spent £18 million in Northern Ireland for the same number of people, so we are spending a considerable amount on out of hours services. There are some deficiencies but there have also been wonderful things happening, with areas that did not have out of hours cover now having it.
I do not have data on the number of people visiting their doctors. Given that we make capitation payments, it is not easy to understand that, regardless of the number of visits, the capitation payment remains the same for in-hours consultations. We may be able to get some data from prescribing practices and, if we can, I will make them available to Deputy O'Hanlon.
The HSE is making a better effort at a fairer distribution of home care packages. It does not mean they are allocated on an equitable basis county by county. Obviously it relates to demand. Last year more than 12,000 families benefited from that and at any one time, 9,500 are receiving those packages at home. We get positive feedback from families on the home care packages. An extra €10 million is going into them this year and we must continue to develop the home care package model.
We do not have on-line bookings or the IT system to do that. The HSE is working with GPs and hospitals on messaging between the two. In many cases, hospitals will send patients a text message to remind them of appointments. The physiotherapy department in St. James's has had great results in dramatically reducing the numbers of no-shows as a result of introducing a text message service close to the appointment time. There is scope for the further use of technology. We will bring forward the health information Bill this year, it is almost ready, and that will provide the legal enabling powers to allow us to use technology in a range of areas to develop better health care. It also requires considerable investment in IT systems.
Deputy Neville asked about social workers. They are exempt from the moratorium. Since the HSE was established, we have recruited an additional 3,100 health and social care professionals, a considerable additional increase, across several areas. There are never enough and I do not suggest we will have enough. There will always be a need for more. However, we are making good progress and both Ministers of State, Deputies Andrews and Moloney, who have responsibility for children and disability, respectively, will ensure that commitments made in the budget regarding recruitment of social workers, speech and language therapists and physiotherapists will be honoured.
Deputy Neville referred to suicide. Recently my office engaged with one of the larger voluntary bodies in this area and I tried to encourage, if possible, the coming together of some of the voluntary organisations. There are a large number of these, each with its own chief executive officer and administration, which compete for funds. I do not say this in any negative sense, rather in a positive sense, but I speculate on whether we might make the money go further if there were to be a coming together of some of the organisations.
This does not apply only to suicide-related groups. Laurence Crowley is heading up a committee at the request of the Minister of State, Deputy Moloney, to look at the voluntary sector in general and see how we might have further rationalisation so that the money we can make available can go into actual services rather than have too much of it consumed in administration. There may be scope in the area of suicide. I hear what the Deputy says and I know his commitment. He will find that the Minister of State, Deputy Moloney, is very focused, especially this year, on the implementation of A Vision for Change. Later today, he and I will meet with key officials in the HSE concerning some of the initiatives we need to put in place this year, including in the area of suicide prevention.
