Oireachtas Joint and Select Committees

Thursday, 10 July 2014

Joint Oireachtas Committee on Health and Children

Quarterly Update on Health Issues: Minister for Health

9:30 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I remind members, witnesses and those in the Gallery to ensure mobile phones are switched off or in flight mode as they interfere with the broadcasting of proceedings and the work of staff. This is our quarterly meeting with representatives of the Department of Health and the HSE, as well as the Minister for Health, Deputy James Reilly, and the Minister of State, Deputy Alex White. I thank everyone for attending. We have received apologies from the Minister of State, Deputy Kathleen Lynch, and Mr. Tony O'Brien, the chief executive of the HSE, as well as Deputy Peter Fitzpatrick.

Members have submitted written questions in advance and the responses to those have been circulated. If there was any delay in members getting them, it was beyond the control of the committee secretariat. For the benefit of officials, I remind those attending about privilege. Witnesses are protected by privilege in respect of the evidence they give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I welcome the Minister, Deputy Reilly; the Minister of State, Deputy White; Dr. Siobhán O'Halloran, chief nursing officer; Mr. Matthew Collins, principal officer responsible for eligibility in the Department of Health; Ms Fiona Prendergast of the finance unit in the Department of Health; and Mr. Paul Howard and Mr. Seamus Hempenstall, also of the Department of Health. From the Health Service Executive we have Ms Laverne McGuinness, deputy director general and chief operations officer; Mr. Stephen Mulvany, chief financial officer; Mr. Pat Healy, national director of social care; Mr. John Hennessy, national director of primary care; Dr. Anne O'Connor, national director of mental health; Dr. Áine Carroll, national director of clinical strategy and programmes; Dr. Tony O'Connell, national director of acute services; and Mr. Dara Purcell from the office of the director general.

Maybe it is for the last time - although it may not be - at the health committee-----

Photo of Alex WhiteAlex White (Dublin South, Labour)
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Does the Chairman know something we do not?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I said "maybe". The Minister is very welcome.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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All I can say in response is that anticipation is half the pleasure. I thank the members of the committee. I am accompanied today by the Minister of State, Deputy Alex White, and the Chairman has already gone through our team. They are Dr. Siobhán O'Halloran, chief nursing officer; Mr. Matthew Collins from the eligibility unit; and Ms Fiona Prendergast of the finance unit. As the Chairman noted, unfortunately, the Minister of State, Deputy Kathleen Lynch cannot be with us and sends her apologies. We all wish her well. We are also accompanied by seven members of the HSE, including Dr. Tony O'Connell, the new director of hospitals; Mr. Stephen Mulvany, chief financial officer; Mr. John Hennessy; Dr. Anne O'Connor; and Dr. Áine O'Carroll.

The committee has asked that I address issues raised by the Irish Nurses and Midwives Organisation, INMO, and the availability of epipens, arising from hearings by the committee. The INMO raised issues regarding staffing in the health services. The committee will be acutely aware that public sector staffing and public sector pay is subject to national pay agreements, specifically the Haddington Road agreement, and the moratorium on public sector appointments. The health service is required to achieve savings of some €290 million in 2014 under the Haddington Road process, and this is set out in the 2014 service plan. The HSE’s national directors developed an implementation plan to achieve the savings involving the review of rosters, skill mix and staffing of hospitals to ensure the extra hours provided for under the agreement are maximised so we can reduce spending on agency work and overtime. This must be balanced against the overriding need to ensure patient safety is maintained. The committee is aware that patient safety is the biggest priority in the national service plan for 2014.

The same imperatives apply to the number of staff employed in the health service. There is a target to be reached as part of compliance with employment control frameworks but this must be balanced against the need to ensure patient safety. That is why the HSE may recruit where it is necessary to do so in order to ensure patient safety and quality care and to support service delivery. In other words, the moratorium is not a blanket approach but it is being used in a way that where staff are no longer necessary in an area, we can replace them with staff in other areas. We are allowing for a change in the model of care and getting the skill mix right. As we move to a more community-based model, particularly with mental health, we can in this way get more community nursing and other therapists in the community. Similarly, when the Minister of State, Deputy White, addresses the committee, I have no doubt he will point out that the move from a hospital-centred model to a community-centred model means we need many more staff in the areas of speech and language, occupational therapy and physiotherapy, and this is accommodated for with additional money made available for primary care. The Minister of State can deal with that in more detail.

There are almost 34,600 nurses and midwives in the health service, as well as almost 3,200 health care assistants, including interns. Whereas the Haddington Road process concerns staff numbers, it also deals with issues like the graduate nurse and midwife initiative and the support staff intern scheme. The graduate nurse and midwife initiative supports the retention of graduate nurses and midwives within the health system and enables them to gain valuable work experience and development opportunities after graduation. Two-year contracts are being made available under this initiative and nearly half of these have been filled. I take the opportunity to note that the HSE has a specific sponsored student public health nurse programme, graduates of which fill public health nurse vacancies. The support staff intern scheme facilitates interns in achieving the FETAC level 5 qualification, which is an invaluable asset in their professional development. These interns will provide vital support to health care professionals, including nurses, in the health care setting.

Whereas overall nursing numbers may have fallen by 12%, or nearly 5,000, since 2007, they still represent one third of the health services work force. Alongside this, the number of midwives has increased by 46% or 400, weekly working hours have increased, 450 nurses and midwives have started the graduate scheme and 330 health care assistants have started the intern scheme. In this way the Haddington Road agreement has provided additional resources and should be seen in the context of the overall reform programme and the range of initiatives we are pursuing to improve our health services and enhance patient safety.

Collectively, these additional resources will enable the HSE to reduce expenditure on agency staff and my Department, with the Department of Public Expenditure and Reform, is also looking at other ways to achieve savings on agency expenses in light of developments with regard to the nurse bank initiative. Given the challenges we face, we cannot conceive of our health services as just a numbers game. That is why we are reforming how we deliver health services. Hospital groups are especially relevant because the changes inherent in their establishment will enable us to make optimum use of our high quality resources, including nurses.

There is a wide range of challenges associated with determining appropriate nurse staffing and skill mix levels in hospitals in Ireland. Deciding on an optimal number of nurses is not an easy task, and there is a delicate balance to be struck to meet patient safety and economic requirements.

Achieving this requires relevant expertise to be applied to the decision-making process.

It is for this reason that we are establishing a task force to develop a framework that will determine the staffing and skill mix requirements for the nursing workforce in a range of major specialties. The focus will be on the development of staffing and skill mix ranges which take account of a number of influencing factors. In this regard, I wish to highlight that nursing is now a graduate profession and Ireland was one of the first countries to embrace this. We have had the undergraduate pre-registration programme since 2002. The benefits of this highly trained workforce are just one of the factors that must be considered in looking at staffing levels.

Phase 1 of the task force project will focus on developing a staffing and skill mix framework related to general and specialist adult hospital medical and surgical care settings. The task force will be chaired by Dr. Siobhán O'Halloran, the chief nursing officer, and will comprise a range of experts. The use of staffing ranges, as opposed to staffing ratios, will retain flexibility in the system while ensuring the safety of patients. The Irish Nurses and Midwives Organisation is represented on the task force, the first meeting of which will take place on 23 July.

With regard to epipens, let me first take this opportunity to extend my deepest sympathy to Ms Sloan and her family on the loss of their daughter, Emma, who suffered an anaphylactic reaction last December. I know that this tragedy prompted the committee to hear evidence from a number of contributors regarding the provision of adrenaline auto-injectors in Ireland, and Ms Sloan was one of those who appeared. The Pharmaceutical Society of Ireland, whose primary function is to regulate the pharmacy profession in Ireland, is undertaking a statutory investigative process related to events on the night Emma died. In these circumstances, therefore, it would not be appropriate for me to comment further on the specific case.

My Department is examining the feasibility, taking account of policy and patient safety considerations, of amending prescription regulations to facilitate wider availability of adrenaline pens in emergency situations. The Department plans to conduct a consultation process which will serve to inform a policy decision on the matter.

If I may discuss the issue more broadly, the incidence of allergy, including nut allergy, in developed countries has risen steadily in recent years. While the reasons for this increase are not fully understood, the effects of a nut allergy can be severe. Avoidance is key, along with a combination of proper diagnosis, attention to food labelling and the availability of emergency medication. Adrenaline auto-injectors, as injectable medicines, are supplied as prescription-only medicines. Under Irish law, designated health professionals, that is, registered medical practitioners, dentists and nurse prescribers, may prescribe adrenaline auto-injectors. Strict controls are placed on who may supply medicines to patients, for example, registered pharmacists. Regulations control the health professionals who may administer prescription medicines to patients in certain circumstances, for example, registered pre-hospital emergency care personnel, registered opticians and others. The regulations also provide that a pharmacist can supply a prescription medicine in emergency circumstances without a prescription. That is a key point.

Proposals to widen access to adrenaline auto-injectors range from making them available without a prescription to making them available in every school and restaurant in the country. However, there are complex considerations to be considered to ensure patient safety is fully protected. These include, for example, the identification of the category of persons designated to administer the auto-injector. This would involve a register to identify clearly the individuals who have an entitlement to supply or administer the adrenaline auto-injector. To qualify for inclusion on the register, an individual would have to complete a certified training programme which would cover such things as identification of an anaphylactic reaction, the administration of the medicine and the follow-up care after the injection has been administered. It would also involve setting up a clinical practice guideline or protocol which would cover such aspects as the supply of the auto-injector, the certification of the establishment where the auto-injectors are located, their storage, persons responsible for storage and record keeping.

There are also serious patient safety considerations. These include the possibility of a misdiagnosis of anaphylaxis and the potential adverse implications of incorrect or inappropriate administration of adrenaline. There is potential for harm if administered to a patient with certain underlying conditions who is not suffering from an anaphylactic reaction. These include administration to patients with a history of or who have underlying cardiac arrhythmias and cardiovascular disease, including angina and hypertension, where incorrect administration could result in an exacerbation of these conditions or a significantly worse health care outcome.

Availability of auto-injectors is another issue. The Health Products Regulatory Agency, HPRA, formerly the Irish Medicines Board, continues to work to ensure there is availability from multiple sources. In view of the potential for supply problems, however, it is essential that adrenaline auto-injectors are utilised in the best possible manner. The shelf life of these products is relatively short, ranging from 18 to 24 months. It is important that the products are not used after the shelf life has expired as after this time the efficacy for the product can be reduced. I support making medicines more accessible to patients where it is safe and appropriate to do so, and my Department is examining this particular issue as a priority.

I realise members have many questions. I am joined today by a range of people from both the Health Service Executive and the Department who will be more than happy to help the committee in any way they can.

9:40 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I invite Ms Laverne McGuinness, deputy director general and chief operating officer of the HSE, to make her introductory remarks. Mr. Tony O'Brien has sent his apologies to the members. He is away at present.

Ms Laverne McGuinness:

I thank the committee for the invitation to attend the meeting today. The Chairman has already introduced my colleagues.

The committee requested information and replies on a number of specific issues prior to this meeting and the members will have received a written response to these matters. I will therefore confine my opening statement to updating the committee on the following matters.

Quality and patient safety underpins the delivery of our health service and is one of the core values of the HSE. We are therefore striving to improve quality and safety throughout our services. Every month, performance against our service plan targets and deliverables is monitored and measured. The published performance assurance report shows that in April 2014 the health service saw an increase in new emergency department attendances of 3%, or 11,353 people, and the numbers admitted as inpatients from emergency departments has increased by 783 or 1% when compared with the same period last year. Admissions through medical assessment units have risen by 1,101, which is 10% higher than in 2013. Trolley numbers are down 8.8% when compared with the same period last year. The month of April 2014 compared with April 2013 shows a 19.8% reduction in patients waiting for a ward bed. That is an improved quality outcome for patients.

Elective admissions in April 2014 were 5% lower, at 1,771 people, than April 2013 and day care attendances were 2% lower, at 5,644 people. The percentage of patients waiting less than eight months for an inpatient or day case procedure is commensurate with April 2013 values. At the end of April, 90% of all adults were waiting less than eight months for a planned procedure and 10%, or 4,462, were waiting over eight months. Outpatient attendances are 26% ahead of target, with 1,071,808 attendances for the first four months of the year.

During the first three months of the year the ambulance service responded to more than 72,226 emergency calls, AS1 and AS2 categories, which is an increase of 4.5% compared with last year. On average, the national ambulance service, NAS, has received an increase of, and responded to, 1,000 calls per month. The introduction of intermediate care vehicles and operatives in 2013 to manage patient transfers between hospitals continues to have a positive effect on the availability of emergency ambulances. In April, 75% of all transfer calls were handled by an intermediate care vehicle.

With regard to our finances, the net expenditure for the year to date in April 2014 is €3.97 billion. The available budget reported for this period at €3.862 billion has reduced by more than the expenditure, leading to a reported deficit of €107.5 million. The acute hospital sector is reporting a deficit of €80.4 million at the end of April, which represents 74% of the overall deficit. Acute hospital agency costs overall have increased by €25.8 million, up 56%, compared with the same period last year. However, 80.3% of that increase is in the areas of medical and support services staff and this primarily reflects the diminishing capacity to recruit doctors and price increases for agency staff.

The national director of acute hospitals, Dr. Tony O'Connell, has written to all hospital groups setting out clear key messages around the need to reduce costs safely and to submit additional cost containment plans. This was followed up by a series of high level performance assurance meetings.

The board chairs, CEOs and clinical directors of the ten hospital groups with the greatest financial challenges have been met to ensure their financial deficits are discussed at the highest level and highlight the necessity to maintain patient safety and quality at the highest levels. Site visits to most hospitals as part of the assurance process set out within our plan for maximising delivery under the Haddington Road agreement have taken place.

With regard to primary care, there was an overall deficit of €18.8 million in April. The deficit is largely attributable to local demand-led schemes of €14.5 million. Based on the figures for the first four months, the HSE is not flagging new financial risks beyond those set out in the service plan in January. However, it should be noted that the financial risks include a number of items that are not within or are not fully within the control of the HSE. One of these is a €114 million revision by the State Claims Agency.

Members are aware of the Government’s decision on Thursday, 29 May to develop an enhanced policy framework for medical card eligibility to take account of medical conditions, in addition to the undue hardship test. The HSE has established a 23 member expert panel to examine the range of conditions that should be brought into consideration and acknowledges that this process may include the development of a new legislative framework for the operation of the medical card scheme. While the task set for the expert panel is an extremely complex one, it has been requested to furnish a report to the director general by September. The panel includes a range of clinical experts from primary care, specialist services and therapies. It also includes patient representation.

A public consultation process has commenced to seek the views of the public, including patients, patient representative groups and professional bodies. Approximately 3,143 public submissions have been received by the HSE which is also putting in place a consultative forum of representative patient groups to support and enable them to feed into the process in a structured fashion. In the meantime, the HSE has suspended reviews of existing medical cards granted on a discretionary basis and no further reviews for this category of medical card will commence pending the outcome of the new policy framework. Arrangements are also under way to restore medical cards withdrawn during the period of July 2011, subject to three conditions specified in the memo to the Government. It is anticipated that up to 15,000 medical and GP visit cards will be issued to people with serious medical conditions as part of this process. The HSE is analysing its databases to identify the people concerned and intends to have the bulk of the medical cards issued by mid-July. We hope to have 10,000 concluded by the end of this week. It is important to note that reviews of general medical cards and medical cards held by those over 70 years of age continue.

In terms of current activity, at the end of April 1.8 million people, or 39.2% of the population, held medical cards. Included in these are 50,375 medical cards granted on a discretionary basis. Some 125,166 people held GP visit cards, including 29,841 granted on discretionary grounds.

The National Ambulance Service, NAS, serves a population of 4.6 million and employs over 1,600 staff across 98 ambulance stations. It is serviced by a fleet of 523 vehicles. Its budget is €138 million and the budget available increased by 4.3% between 2012 and 2013, with a further increase of 2.35% in the 2014 allocation. The NAS is one of the few services in the health sector that has seen increased investment in recent years. This investment has been made as part of a strategic programme to develop a modern, high quality national ambulance service that is safe, responsive and fit for purpose.

Between 2013 and 2014, €26.2 million has been invested in the development of the national control centre, of which €14.2 million relates to capital, including €7.6 million invested in ICT for a digital voice recognition and computer-aided dispatch system. Since 2012, the National Ambulance Service has been on a journey of significant reform. A major reconfiguration of the way in which it manages and delivers pre-hospital emergency care services is under way. The reform programme reflects many of the strategic changes under way in ambulance services internationally as they strive for efficiency and increasing specialisation. The NAS control centre reconfiguration project is a significant and complex multi-year national change project aimed at reducing the number of command and control centres from 11 originally to six at present, with one national centre on two sites. This key project will deliver a single state-of-the-art national emergency control operation centre for Ireland on two sites, at Tallaght and Ballyshannon, which are almost complete.

In the last quarter of 2013 a decision to procure a formal capacity review was taken. The purpose of the review is to independently assess the required resources and the optimal deployment of these resources to meet the needs of a modern ambulance service. The company selected to undertake the review has extensive international experience of modelling ambulance operations. It will complete a detailed technical analysis of computer aided dispatch data, coupled with data for ambulance deployment and rostering arrangements. It will then use advanced modelling techniques designed to determine the ability of current resources to meet existing and anticipated demand and identify any gaps in provision. A component of the work will include Dublin fire brigade activity. It is expected that the capacity review will be completed in the third quarter of 2014.

The committee specifically asked for my opening statement to address the issue of adrenaline pens. On behalf of the HSE, I extend my deepest sympathy to Ms Sloan and her family on the loss of their daughter, Emma, who suffered an anaphylactic reaction last December. The Minister has covered some of this topic. Persons with a confirmed diagnosis of anaphylaxis are prescribed adrenaline pens and shown how and when to use them. The current recommendation is that two pens should be carried with the individual at all times. Those identified as being at risk may also be prescribed adrenaline pens. Patients who experience an allergic reaction are advised to keep the injections to hand and sufficient quantities are reimbursed under the community drugs schemes to enable them to be kept at multiple locations such as at school, at home and in child-minding facilities, etc. The HSE has published guidelines on its website. Extending the availability of adrenaline pens is a complex matter and under consideration with the Department of Health, as outlined by the Minister. The medication is available only on prescription and an alternative would require amending legislation.

The committee also asked that I address the INMO and the Haddington Road agreement as part of the update. The HSE notes the engagement on 17 June between the INMO and the Joint Committee on Health and Children. The planned meeting between the INMO and HSE management referenced in the transcript of the meeting on 17 June has been rescheduled owing to diary issues. Our HR director is on leave. The Haddington Road agreement has been designed to provide significant enablers and provisions to extract costs and reduce the overall cost base in health service delivery, while radically reviewing and changing work practices, rosters and work patterns in the context of the reform and reorganisation of the health service. All areas of employment within the public health sector are being examined to see how they can best contribute to this cost extraction challenge as required by the Government, while minimising the impact on front-line services, patients and clients.

That concludes my opening statement. Together with my colleagues, I will endeavour to answer questions committee members may have.

9:50 am

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome the Minister, the Minister of State, the deputy director of the HSE and her colleague. I will refer to specific questions I posed in advance. There are so many issues one would like to raise in the course of the meeting, but it may not be possible to do so.

I will begin with the 24th question concerning the conflict of interest in the appointment of the chairman of the non-executive board of the West and North West Hospitals Group and the appointment of a consultancy firm, in which he was a 50% stakeholder, to carry out a review of maternity services in the Galway and Roscommon Hospitals Group which subsequently included Mayo, Sligo and Letterkenny general hospitals. The reply I have received states the HSE internal audit team was assured by the CEO that he had made the decision to source D & F Health Partnership Limited based on its suitability for the project.

The report that was prepared by the internal audit committee and presented on 21 May 2014 states that the CEO advised audit that in his view D & F Health Partnership Limited had the necessary skills and resources available at the time and of course, internal audit established definitively that no procurement exercise was carried out at the time.

How is it that the CEO of the West-North West Hospitals Group could make such determination in respect of D & F Health Partnership Limited, a company of which the chairman of the board had a 50% stake, when there had been no previous engagement with that company and no other contracts had been entered into with it, and as the internal audit report states there are no firm plans to engage D & F Health Partnership Limited on any future consultancy projects? On what was the CEO basing his assessment of D & F Health Partnership Limited having the necessary skills and resources available at the time when the level of expenditure concerned required that three tenders be secured before a final determination be made as to who should be appointed to carry out the review and report on maternity services in the said hospitals? We must remember that the national financial regulations state very clearly that all purchases between €5,000 and €25,000 excluding VAT require a minimum of three written quotations. Why would the CEO have acted as he did, and on what basis was his assessment of D & F Health Partnership Limited undertaken? We require an answer that will give us clarity on the process.

I note also that in the reply I have received it states that the investigation found that while Mr. Daly had disclosed to the board that he was a former employee and former director of D & F Health Partnership Limited, he failed to disclose that he continued to hold a 50% shareholding in the company. However in the internal audit report presented on 21 May 2014 by Mr. Paul Hannon, it actually states that audit was advised that on the day prior to the board meeting - not on the day of the board meeting as the reply that I have received states - a pre-meeting was held with some members. Is that normal practice? Who would be included in such a pre-meeting and who was not included at this pre-meeting at which the Chairman offered to absent himself from the chair for the board meeting on the following day? This offer was declined because it was felt there was no conflict of interest. It is a fairly serious matter that those present did not realise there most certainly was a conflict of interest.

It states in the recommendations in the internal audit report that a register of members' interests should be established at the hospital group and should be reviewed when sourcing potential suppliers for the group, and that the register should be comprehensive and subject to review and updated on a regular basis as this will help to avoid situations in which a potential conflict of interest may arise with a supplier to the group. That recommendation is particular to the West-North West Hospitals Group. I would like to know if that recommendation has now been applied across all hospital groups so that the situation that arose in the West-North West Hospitals Group cannot and must not arise in any other situation where a potential, and I emphasise potential, conflict of interest may arise in the expenditure of public moneys on specific contracts for performance. In this instance I would like to know if that particular recommendation has now become a directive across the HSE. On what date was the final report of D & F Health Partnership Limited actually produced? I understand a draft report was in situ at the time of the carrying out of the internal audit. At what time was a final report from D & F Health Partnership Limited presented on maternity services across the five hospitals concerned? If time has not run out-----

10:00 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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The Deputy has two minutes remaining.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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In respect of Question No. 23 on the medical card issue, it states in the reply I have received that the Department of Health will develop a policy paper by the end of September 2014 on further phases of providing for a universal GP service. The Minister of State, Deputy White, would know that I would welcome that because I have been pressing for such a programme and a time-frame for the roll-out of access to a free universal GP service. The system may or may not, but it appears that it is leaking like a sieve for a variety of reasons. Some in the media are already speculating today that perhaps the next phase might be the restoration of medical cards to all those over 70 years. Will the Minister comment on whether he expects the policy paper will actually lay out a time frame for the specific roll-out and follow on to the provision of free GP care for all children up to the age of six years?

In respect of the expert panel to examine the range of conditions on the new policy framework for eligibility for health services, I understand from the reply that the process will include legislative requirements as necessary and being in place as early as possible in 2015. Is it the Minister's expectation that legislation will be required and if the expert panel is to be in place as early as 2015, when does he expect it to report to him?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Thank you Deputy Ó Caoláin. Before I call Senator van Turnhout may I ask the Minister or Ms McGuinness to outline the process for the restoration of the medical card programme as outlined, as there was a reference to it being underway. Are they in a position today to outline the timetable? Following the Taoiseach's announcement in the Dáil on the medial card for those aged over 70 years, will Ms McGuinness address the issue and confirm if there will be a moratorium on reviews pending the roll-out of that policy?

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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I welcome the Minister for Health, Deputy Reilly, the Minister of State, Deputy White and Ms Laverne McGuinness and officials.

I too will limit myself to two questions. The Seanad has passed a Bill to ban smoking in cars that are carrying children, we had been told that the Bill would be taken in the Dáil on 23 June and then on 8 and 9 July. We are still waiting.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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That would be a matter for the Whips rather than for the committee.

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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I ask the Minister to encourage those concerned to ensure that the legislation would be taken in the Dáil. In respect of GP care for those under six years, I want to be clear that I support the Bill but the amendment yesterday was about a gagging clause and I do not want any perception that there could in any way be a gagging clause. I do not see the reason that the amendment that was agreed in the Seanad yesterday could or should delay the passage of the Bill. I believe there has been a misinterpretation of how votes have gone. I fully support that Bill.

I tabled a question on palliative care, Question No. 13, and when I looked at the reply my initial response to it was that it was excellent.

Unfortunately, however, when one drills down into the figures in tables 1 and 2 of the reply, one finds that while the services have exceeded all targets set for community and inpatient units, the figures provided are consolidated and do not show regional disparities. For instance, the Dublin and mid-Leinster region includes south Dublin, which is very well served by large inpatient units and hospices, whereas the midlands region does not have any inpatient beds. The same types of disparity arise between Dublin and the north east region. While the Dublin area is well served by hospices, there are no inpatient units in the north east counties. Given that it is proposed to introduce a new framework for development and configuration, is it not time the HSE presented figures in a more focused manner, one which shows the distribution and performance of teams in different areas? Some areas have inpatient beds while others do not. Are target figures available for each county? May we have detailed figures on staffing levels for all palliative care teams in each county and region? I also seek greater detail on who will be involved in drawing up the high-level framework. Who will be the members of the group and who will oversee it?

I am particularly concerned about children's palliative care outreach nurses. One of the first questions I asked when I was made a Senator three years ago was on the funding for posts that are currently funded by the Irish Hospice Foundation. Is the HSE preparing to take over incrementally the funding arrangements for children's palliative care, as agreed? Will it guarantee that there will be no loss of services as the funding changeover takes place? I am very concerned that we are unable to obtain clarity on this issue.

Question No. 14 relates to assessment of needs under the Disability Act 2005 and speech and language therapists. Unfortunately, the figures provided are also misleading. I asked specifically for figures on the number of speech and language therapists working with children. The figure of 838 cited in the reply refers to the number of speech and language therapists in the Health Service Executive - in other words, in primary care, acute hospitals and services for older people - and is not confined to speech and language therapists working with children. Informed sources have indicated to me that the approximate number of speech and language therapists working with children is between 260 and 270. This is, however, an estimate. I ask for an accurate figure for the number of speech and language therapists for children.

As with the figures provided in the previous answer, the figures on speech and language therapists do not show the geographical disparities. Furthermore, as we know with figures in the health system, the figures do not show that generally, approximately 10% of staff are on leave of absence, maternity leave or other type of leave. I have been informed that 80 posts under the progressive disability service for children have not even been advertised. This raises questions if it is true and I ask the witnesses to clarify the matter.

On the waiting list for therapy services and assessment of needs, the reply notes that services can begin before an assessment of needs has been done. The figures I have seen suggest otherwise. Some 3,000 people have been waiting for more than 12 months for speech and language therapy services and 2,000 have been waiting 12 months or more for occupational services.

On the reply to my question about the national disability strategy, none of the three legislative pillars has been fully commenced. The issue here is that while one hears that the legislative pillars are in place, it transpires that they have not been commenced.

Perhaps I will pursue Question No. 15 with the Minister of State, Deputy Kathleen Lynch, as it relates to nursing homes. The issue is one of planning ahead. The Central Statistics Office forecasts that the number of persons aged 85 years and over will increase by 46% by 2021, which is only seven years from now. This is the age cohort that is most dependent on continuous care services in the community and in nursing home and community nursing home settings. We must plan ahead if we are not to face a situation ten years from now in which members of this committee are asking why the issue was not addressed, given what was known about the ageing of the population and the need to provide care to meet demand.

10:10 am

Photo of John CrownJohn Crown (Independent)
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I welcome the Minister, the Minister of State and the various officials. I hope this is not the joint committee's last meeting with the Minister in his current job, because he has been a reforming Minister with a radical agenda. He was, however, dealt a lousy hand on assuming office given the economic context at that time and the ferocious pressure the Government was under from extra-jurisdictional sources to implement a single agenda in health care - namely, cost reduction. I am not happy with the reports I am hearing as I fear the Department of Health will move from being a vehicle for radical change to becoming a branch office of the Fine Gael directorate of elections as it seeks to have someone appointed Minister who will maximise the chances of Deputies in marginal constituencies being re-elected. That is not the way to run a country. I fear we will have a major dose of the same old technically inexpert Ministers being led around by the nose by members of the Beyoncé-and-Jay Z-style entourage of bureau-rappers and spin doctors who come in here on a regular basis.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I remind Senator Crown that this is a quarterly meeting.

Photo of John CrownJohn Crown (Independent)
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It is very difficult not to be cynical about the process of politics. I add my support to Senator van Turnhout's comments on the amendment we tabled to the general practitioners Bill yesterday. This has been a case of misinformation, rather than a misunderstanding. It is being suggested to the press that our attempt to insert a rational and limited amendment in the Bill, which would have protected general practitioners who wish to whistleblow or point out deficiencies in the health service from being victimised, is being used by others as an opportunity to delay the Bill and painted as a reason why parents will be forced to pay for GP care for their children for a further six months. The Minister and Minister of State know that if they were to accept the amendment, the legislation could be passed by the Dáil and signed by Uachtarán na hÉireann before the summer.

To return to the specific questions, while I am very troubled by the position with respect to many aspects of the health service, the position in trauma continues to be extremely unsatisfactory. We do not have one centre in Dublin that can provide comprehensive trauma care to somebody who has a complex set of injuries. The services are still fragmented, with neurosurgery in one centre and burns care in another. A limited number of centres can deal with a penetrating cardiac injury, which is, thankfully, an uncommon type of injury.

On a more basic level, it is still the common experience of people who work on the front line of the health service, including in fine university hospitals that may lack some aspect of the specialist care that an individual patient needs, that the barrier to getting a trauma patient moved from one hospital to another can sometimes result in an unconscionable and life-threatening delay. Without getting personal about it, I have encountered cases involving individuals who I have no doubt would have lived if an ambulance had brought them to a hospital that could have provided the specialist care they needed. It is critically important to tackle the hospital politics involved and to understand that it may be logical to have only one or two centres to which trauma cases are brought in the capital city. We also need to build up trauma services in Cork, Galway and local centres to an appropriate level.

I also tabled a question on the possibility of allowing private insurance premiums to be weighted, specifically to allow people who do not smoke to apply for a discount in their private health insurance. This is not an attempt to thwart community rating, redistribute resources or punish people. It is a specific measure to provide an additional incentive to people to give up a habit that is very bad for them. While the saving to the system would be relatively small, it would give individual patients one more reason to give up smoking. In addition, the measure would not be contrary to the spirit of community rating. A 65 year old cannot choose not to be 65 years old and a person born with an illness or malformation cannot choose not to have a pre-existing illness or congenital malformation. However, one can, subject to the powerful influence of addiction, choose to be either a smoker or non-smoker. There is no reason to believe this proposal would somehow create a fundamental chink in the armour of community rating, which is an approach I hold dear. If we eventually move to a model of social, not-for-profit insurance for the entire population, with everyone playing on a single, level playing field, as I hope we will, I will fight for community rating with my last breath. Rather than thwart community rating, the proposed measure would encourage people to make positive and healthy lifestyle choices.

I wish the Minister well in the coming days and hope things do not work out in the manner that is being played out in the newspapers.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I share the final sentiment expressed by the Senator.

I propose that I write to the Whip's Office on behalf of the committee to ask that the Bill sponsored by Senators Crown and van Turnhout be included in the schedule. Is that agreed? Agreed. The committee has no role in the formatting or scheduling.

10:20 am

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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In response to Deputy Ó Caoláin’s questions about the west and north west group, the CEO’s actions and the appointment of the chairman, as is well known the chairman has stood down. He did not want any damage to his reputation or that of the hospital group. I share that concern. It is already on the record that the CEO has been admonished for failing to follow normal procurement rules. I refer the deeper questions to Ms McGuinness as the acting CEO.
Mr. Hennessy, who is the director of primary care, can answer the questions about primary care and medical cards. The Minister of State, Deputy White, will want to address some of those issues and I will defer to him on those.
I support the committee’s anxiety to see the Children's Health (Tobacco Smoke in Mechanically Propelled Vehicles) Bill introduced. There is a lot of legislation concerning tobacco and we are having trouble getting it introduced because of the pressure relating to legislative requirements. I am absolutely committed to both those Bills. I have given that undertaking.
I will let the Minister of State deal with the question about the GP care for children under the age of six. It was never going to be the case that any clause in the GP contract would prevent doctors speaking out if they saw inadequacies or wrongdoing or any other dangers for patients. That could never be the case. As a doctor and a Minister I would not stand over that, not in a democracy. It is not unusual for people to be asked not to bring their organisation into disrepute. One does not bring it into disrepute by pointing out its deficiencies and getting them addressed. The Minister of State can deal with that more comprehensively. I will ask Ms McGuinness to answer the question about palliative care on a county basis and the funding arrangements, and the figures for speech and language therapy for children.
The Minister of State with responsibility for care of older people, Deputy Kathleen Lynch, cannot be here today so I will comment on continuous care and the increasing number of people over the age of 85. People are living longer and they are healthier. That is the goal of Healthy Ireland – A Framework for Improved Health and Wellbeing, not just to increase the number of years one has on this earth but to ensure that one actually enjoys them and that we do not, as one colleague put it to me, die old, cold and incontinent. It does not have to be that way. The department of health economics in Trinity has shown that the last ten days of one’s life are the most expensive for the State and to die in one’s 70s, 80s or 90s costs one third what it costs to die in one’s 40s or 50s, so everybody can win. Long-term care in a nursing home is not the only solution. We are examining a range of alternatives with more home care packages, more home help, other sorts of tiered support within the community. I have visited some places where people stay. They are quite well, they get three meals a day and have a bed at night. Some stay there all the time and go out to do their shopping in their community but this becomes their new home, others stay during the day for company and go home at night, others sleep there because they do not like to stay at home alone at night. We have to address these different models that help people retain their independence for as long as is humanly possible.
I have addressed the gagging issue raised by Senator Crown. There is great validity in what he says about the trauma care centre. I was in Manchester last summer, where there are 4 million people and three trauma centres. They say that is ridiculous and they should have only one. We need to examine what our excellent hospitals do and realign the services in a way that gives the best outcomes for patients but also secures the future of the hospitals. For instance, does it make sense having two or three hospitals doing transplants when we should have one national transplant unit? Does it make sense, as Senator Crown says, to have between four and six emergency departments open in Dublin none of which is truly a trauma centre when one would probably serve the city or two certainly would? When I hear what is said in Manchester I believe one would do. There needs to be reorganisation but as Senator Crown points out, inter-hospital politics would be very problematic, because of the attitude of "what will we get if we give that up?" I believe a solution can be brokered if people step up to the line and stop thinking about their service per seand think about best outcomes for the patient, which we are supposed to be here to achieve.
I would be well-disposed to the weighting for non-smokers but we would have to consider it very carefully for unforeseen consequences. As a GP of over 30 years’ experience, I know that patients might be inclined to be economical with the truth in filling out life insurance forms if there was loading for being a smoker. If down the line one can prove that person was a smoker the whole policy is null and void. That sort of initiative can make such issues messy. It would need to be examined very carefully. I have no problem with the principle as a way to promote a healthy lifestyle.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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In response to Deputy Ó Caoláin’s questions about the further roll-out of free GP care, it is correct to say that at a recent meeting the Government decided to bring forward a policy paper in September of this year to address this issue. It may be that the Government is bringing forward some of that work. The Deputy might be pleased to hear that the opportunity has been taken to have discussion of the timelines and the roll-out earlier than September. It would be desirable for the matter to be laid out as specifically as possible. There are constraints on resources and so on but the Deputy is right, the more specific we can be about the future phases and timelines the better. I share his view but cannot give him an absolute undertaking on what that policy document would look like.

On Second Stage of the Bill in the Seanad last week we had some discussion about this and I said there is still considerable potential for moving forward on this matter on the basis of age cohorts, for example, children over the age of six and adults over the age of 70. The Taoiseach advised the Dáil yesterday that the Government is actively considering, which is the phrase I used last week in the Seanad, several categories for the phasing in of the universal GP service such as those over the age of five and the over-70s who are a key cohort to be covered. There is a meeting of minds in Government on that. The over-70s are a key public health priority group. There is no question about that. I understand the Government will return to this matter at its meeting on 22 July. The commitment to bring the discussion forward is important and underscores the Government’s priority of implementing a universal GP service for the entire population within its term of office. I expect the legislation to implement it would be included as a priority in the legislative programme for the autumn.

There is a commitment that the expert panel would report by September of this year.

We will only know whether legislation is required and, if so, to what extent after the expert panel reports as it simply is not possible to pre-empt the report and we will see what it says in September. It is an important area and it is not without complications but this does not mean it cannot be done. If legislation is required, it will be produced, but the process cannot be pre-empted before the report.

Many medical cards that were issued on the basis of discretion were returned and Ms McGuinness might address this as I have not seen the report in a few days. Work is proceeding at a considerable pace.

The Chairman raised the issue of people over 70 years of age. We are discussing a card for general practitioner, GP, services, not the full medical card. The universal primary care project aims to extend free access to GP care at the point of use to the entire population and this entails, as we saw when the scheme was applied to children under six years of age, the extension of a statutory entitlement. The statutory entitlement will be extended to other groups through legislation.

10:30 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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What happens to ancillary services and supports if a person over 70 does not automatically get a medical card?

Photo of Alex WhiteAlex White (Dublin South, Labour)
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Each individual is different and some people over 70 will retain the full medical card.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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What of those who do not retain the full medical card? Is it assessed on the basis of need?

Photo of Alex WhiteAlex White (Dublin South, Labour)
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What we are talking about regarding universal primary care is access to GP services. We are always trying to improve access to services for the entire population. The key point is to get people the services they need but access to GP services is an important but narrow issue. People over 70 years of age are a public health priority group and should have access to a GP to manage health, chronic illness and so on.

The Chairman used the word "moratorium" and it is hard to see how that flows from this. First, we should get a formal Government decision and then prepare legislation.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I will rephrase my question. There is still confusion among people over 70 relating to discretionary medical cards and many feel they will get their medical cards back.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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No, the extension of free GP care to the people over 70 will not be retrospective but prospective. There will be a change in legislation that will apply prospectively, not retrospectively.

Senator van Turnhout mentioned the gagging clause and I completely accept her point on her support for this legislation because she made it clear in the Seanad. I did not say to anyone that I regard yesterday's amendment as an effort to stall the Bill as I do not believe it is. Nobody said this on my behalf. In the broader firmament, there are those who believe this will never happen and some will seize on any event to support such a view. It will happen.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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On the question of the particular amendment, it is an issue that can be resolved through negotiations between the Health Service Executive, HSE, and the Department on one side and the Irish Medical Organisation, IMO, on the other. My overarching point yesterday, which was not fully accepted by Senator Crown and others, was that negotiation on the contract is a matter for the parties to the contract rather than a matter of statute. I do not regard it as appropriate for the Oireachtas to step into negotiations on the contract but I agree with the Minister for Health, Deputy Reilly, and I am a very strong advocate for free speech. I believe in advocacy for professionals, administrators, those working in all kinds of services and people generally in society. I have always believed we should have the maximum amount of free speech possible, allowing for certain constitutional restrictions. Free speech should be the default position, rather than something to restrict, and I fully associate myself with the comments of the Minister, Deputy Reilly, as there is no intention to have a gagging clause in this contract. The Department and the HSE will continue discussions with the IMO and I believe this matter will be resolved in a satisfactory manner for Senators van Turnhout and Crown. I will not accept an amendment to the statute in circumstances where it is a matter for negotiation between the parties. I have given my own view on this.

Photo of John CrownJohn Crown (Independent)
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This matter has been voted on and dealt with. The amendment went through the next stage of the democratic process. Am I to understand the Minister of State, Deputy White, is to launch a legislative campaign to remove the amendment to protect whistleblowers? This country has been destroyed by its failure to protect whistleblowers in the areas of child care, the economy and so on. Is this the message the Minister of State wishes to send?

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I have no idea how Senator Crown could interpret my words in this way.

Ms Laverne McGuinness:

Deputy Ó Caoláin is correct about the procurement issue for the west-north-west hospital group. The financial regulations set out that three quotes must be obtained for procurement up to €25,000 and that did not happen in this case. The HSE does not consider that this was acceptable practice and the director general took strong action by asking the internal auditor to carry out a review. He wrote a stern letter to the group chief executive officer, CEO, and the chairman. The audit review was carried out and the group CEO gave the rationale that an urgent procurement issue arose due to recent maternity deaths but nothing was set out at the time to support this. He was not aware at the time of the 50% shareholding held by the chairman as it had not been disclosed, though the chairman had resigned as a director. The group CEO has confirmed he will comply with all future procurement requirements, as set out in our financial regulations. I am not aware of a pre-meeting but the chairman was given the opportunity to absent himself from the meeting and it was decided there was no conflict of interest. Clearly the 50% shareholding meant there was a conflict of interest and the chairman subsequently resigned.

The recommendations have been accepted in full by the group CEO and the new chairman and a register will be maintained of any conflicts of interest, which is common practice in the HSE directorate and board structure. The financial regulations are currently under review and the recommendations will be taken on board by the chief financial officer, CFO.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Ms McGuinness says she is not aware of a pre-meeting so I direct her to the internal audit report that refers directly to this. A pre-meeting was held on the day prior to the board meeting and some members attended. I believe the reference to "some members" is irregular - either the board should have attended or not. This requires further explanation and if Ms McGuinness is not familiar with the pre-meeting and is unable to speak on the issue today, she should revert to me having taken the time to look at Mr. Hannon's report of 21 May.

10:40 am

Ms Laverne McGuinness:

I am aware of the report. What I am saying is that I am not familiar with what took place with regard to that particular pre-meeting other than there was an opportunity given to absent of which the chairman, at the meeting itself, did not avail. I will revert to the Deputy with any information I can discover regarding what actually happened at that pre-meeting and why it took place, which is really what he is seeking to establish.

Senator van Turnhout is correct in what she said in respect of palliative care. We are delivering to the target we set out in our national service plan, albeit at a regional level. There is some disparity at county level. We would have information available at local health office level and I will try to procure it for the Senator.

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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I would appreciate it.

Ms Laverne McGuinness:

On children's services, I will deal directly with the Senator in order to obtain the confirmation she requires. If it is acceptable, I will take her details after the meeting. In the context of speech and language therapy services, I will ask Mr. Pat Healy, national director social care, to comment.

Mr. Pat Healy:

The report acknowledges some of the issues the Senator raised and the implementation of the 0 to 18 programme is our response. The 80 posts will be advertised this month but we are also going to utilise the resource associated with that to facilitate the part of the 0 to 18 programme which emphasises the need for training, education and working with local teams, etc., in rolling out change programmes. We will also be targeting a number of specific waiting lists while the permanent posts are being put in place. The Senator can take it that this will be happening.

Senator van Turnhout also asked us to capture certain information for her. Unfortunately, it is not available in the exact form she was seeking. I was trying to demonstrate the point that there is a prioritisation of therapy posts. The Senator can take it that we prioritise therapy posts in the children's service and I state in the report that issues arise when people take maternity leave, etc. In such circumstances and given that the service is not fully resourced, vacancies and things of that nature can arise. This poses a challenge from time to time but we do prioritise the filling of posts within the children's service. I also set out in the report a number of creative initiatives people are implementing locally in order to try to overcome of the challenges presented by the existence of vacant posts. I will make further efforts to see if it might be possible to present the information requested by the Senator on a more localised basis.

Ms Laverne McGuinness:

To clarify what I said earlier in reply to Deputy Ó Caoláin, it was the chairman who offered to absent himself and it was the CEO who believed that there was no conflict of interests.

It is envisaged that up to 10,000 discretionary medical cards will have been returned by the end of the week. It is further envisaged that the balance, which may or may not be as many as 15,000, will be returned next week. If individual members have any issues regarding returns, Mr. Hennessy has indicated that he can be contacted.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Hennessy and the staff of the PCRS who have assisted members. I also thank them for the briefing provided to us in the audio-visual room. However, there are issues with regard to members of the public obtaining information. Perhaps there is a need for a consistency of approach on the HSE's end. I thank our guests for the courtesy they have shown the committee.

Photo of Colm BurkeColm Burke (Fine Gael)
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I wish to follow up on the question posed by Deputy Ó Caoláin but I will not go into too much detail. In the context of report on the West-North West Hospitals Group and the breaches that occurred, were full fees paid to the company in respect of the work carried out?

Question No. 22 in my name relates to the filling of posts in the HSE without their being advertised internally or externally. The answer appears to indicate that of the order of 1,000 posts at administration level were filled on a temporary basis initially and then the people who took them up were eventually made permanent. Am I correct in my interpretation in this regard? The reply to my question refers to 943 employees from grade IV to grade VII who were initially employed on a temporary basis and were eventually made permanent. A further 141 staff were also made permanent at higher grades. In addition, some 42 staff are on temporary contracts at present. Will our guests clarify for the committee that 1,000 of the 14,000 posts within the HSE were filled without being advertised and in the absence of any of those who currently hold them being interviewed?

In the context of the current overrun on the HSE's budget, I note that for the first four months of the year the amount in respect of hospital groups was €80.4 million. What proportion of this amount relates to the payment of agency staff? This ties in with an issue which has been a hobbyhorse of mine for the past three years, namely, the way we treat junior hospital doctors. Three years ago I flagged up the fact that we were going to experience problems and this has proven to be the case. I accept that three reports have been compiled by the MacCraith group in respect of this matter. Unfortunately, I was obliged go outside the Department of Health in order to obtain a copy of one of those reports yesterday. I am absolutely astonished that a report which was compiled in respect of this issue was not circulated to members of the Joint Committee on Health and Children. I am disappointed that the Department of Health is treating the committee as if it is not involved in the process, particularly in view of the fact that I have continually raised this issue during the past three years.

I tabled a question in respect of the total number of non-Irish graduates working as doctors in the hospital system here and I did not really receive a clear answer in respect of it. We have invested over €200 million to upgrade medical education here in order that we might produce more people with medical qualifications. The Fottrell report was produced in 2006 but we have done nothing to try to retain Irish graduates in our hospital system. In the context of the targets we are going to set with regard to ensuring that the review recommended in the MacCraith reports will be implemented, when will proper training contracts be put in place and when will proper career paths be planned out for those who want to remain in the Irish hospital system? I have been raising this matter for three years and very little progress has been made in respect of it. As a result, we are now paying for agency staff.

Photo of Eamonn MaloneyEamonn Maloney (Dublin South West, Labour)
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I welcome the Minister, the Minister of State and the various officials. I thank them for the replies provided in respect of the questions I posed. I will avoid discussing any of the matters to which they relate and which have already been covered here. I will, however, welcome the progress that has been achieved in respect of the urgent care centre at Tallaght Hospital.

Both of the matters I wish to pursue relate to the reply I received in respect of question No. 1 and to the dreadful condition that is multiple sclerosis. MS. I daresay there is not a person in the room who does not know someone who suffers from MS. I accept that progress has been made in the context of making the lives of those with MS easier by means of improvements to treatment. However, the reply I received failed to refer to two matters. In the first instance, it does not indicate when the statutory order might be signed. I would be grateful if a specific reply could be provided in that regard. When the order is eventually signed, when will a licence be granted in respect of the Sativex medical product?

I would be grateful for clarification on that.

10:50 am

Photo of Catherine ByrneCatherine Byrne (Dublin South Central, Fine Gael)
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Both the Minister, Deputy Reilly, and the Minister of State, Deputy White, brought a breath of fresh air to the entire health system, particularly to the Department of Health and the Health Service Executive. I hope both of them remain under the remit of that Department and that we can continue the work already started.
On the death of Emma Sloan, and I am not a medical expert, I did not know Emma personally but I know she was involved in a local project where I live in the Bosco youth centre. I believe, because of the way Emma died, that if common sense had been used, she might be alive today. I say that with the greatest respect to the medical profession. Emma was a beautiful young person, and her mother, her family and her friends are devastated by what happened to her.
I refer to the two questions I asked. On the question on nicotine replacement therapy in pregnancy, 35% of the age cohort who have a medical card can avail of free NRT if prescribed by their general practitioner. Is that nicotine patches? We need to define what that means. If so, how many people have sought to avail of that process and thereby not smoke while pregnant? Why are the other 65% who do not have a medical card and who have to go to their GP not being treated equally? They should be. Information from the NHS in England states: "Overall, although the data currently available are limited, the use of NRT in pregnancy does not give undue concern and any harm caused by nicotine replacement must be compared with that caused by continued smoking - which is extremely harmful to both the woman and her child".
I came across this book in a GP waiting room this week. It is called Give Your Baby a Breather. It states: "Being pregnant is a great reason for giving up smoking - one decision that benefits two lives." That is right. I do not know who wrote this book but it is being given to women. It also states: "Be prepared. Think of the things you can do to keep your hands and mouth busy." This is advice to women. It goes on to state: "Doodle with a pen ... (or just chew on the end) [of it]; do some cleaning; file or paint your nails" and to bring it all together it states: "Keep busy. Boredom can make smoking seem more important ... than [you think] it really is." I do not know who wrote this book. It is from the HSE, but it needs to be binned permanently. It must have been written by a man.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Did Garth Brooks-----

Photo of Catherine ByrneCatherine Byrne (Dublin South Central, Fine Gael)
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Not at all. I am not finished.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Thank you, Deputy.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I must say it is-----

Photo of Catherine ByrneCatherine Byrne (Dublin South Central, Fine Gael)
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It is from the HSE, it states that on the back. I will give it to the Minister and he can read it.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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It is probably from the Health Promotion Unit.

Photo of Catherine ByrneCatherine Byrne (Dublin South Central, Fine Gael)
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Professor Clancy, who is a leading expert on bronchial conditions, came before this committee and I asked him if it was better for a pregnant woman to have a nicotine patch than smoke, and he replied that he was 100% in favour of giving a pregnant woman a patch rather than have her smoke.

My second question is on IVF treatment. There is a great deal going on here this morning so I will be brief. Since 2005, the report on assisted human reproduction has been spoken about. The Minister expects to bring the proposal on these issues to Government late this year. I hope it is the Minister who will do that. It is important that there is equal access for people who are undergoing IVF treatment. It is very expensive for young couples, many of whom are faced with paying huge mortgages. Some of them cannot manage to do that and it is heartbreaking to ask people to spend up to €10,500 to €12,000 for just one session of IVF treatment. It is important that we allow these people who want a child, and the 3,000 people affected by infertility in Ireland, to have a chance at their dream of having a family. I await patiently the report due later this year, and when it is published, I hope it will answer some of the questions I have asked about IVF treatment on many occasions.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I will call the Minister and then Ms McGuinness. We will then hear from the four other speakers offering.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Senator Colm Burke raised the issue of the percentage of agency staff and their cost as a proportion of what we spend on hospitals. I will ask Ms McGuinness and perhaps Mr. Mulvany to address those. The Senator contends that nothing has been done about retaining the non-consultant hospital doctors and addressing their terms and conditions. I am on record as having made it very clear that I was astonished that interns are still doing what I did as an intern more than 30 years ago. That was the purpose of the three MacCraith reports. The Senator made the point that they were not furnished to this committee. They were on the website but I believe he had some difficulty accessing that. We can make the hard copies available to any member of the committee who wishes to have them. There is no problem with that. This is an area that is critical to the future of our health services. I commend Professor McCraith and the people who worked on the group with him who gave of their time freely and had hundreds of hours of interviews with many stakeholders, including junior hospital doctors, which was critical. It was critical they were all interviewed, that is, not all NCHDs but people at every level. They were all interviewed because the needs of somebody finishing their specialist training is very different from that of somebody who is still trying to get on a specialist training scheme.

The issue of it taking 12 years to train a specialist in this country when it takes six years elsewhere is clearly a matter of serious concern. The lack of respect and dignity that many junior hospital doctors feel is what drives them out of this country. Those issues are all addressed in those documents. As a consequence of the middle report, negotiations are taking place at the Labour Relations Commission on the starting pay for consultants and how that might operate into the future. As I have said previously, it was never my intention that this reduced salary would apply to someone who had been, for example, an associate professor in Toronto or somewhere else and is returning here having been away for ten years. We have already addressed the issue of the unintended consequences of the movement of consultants within the country being such that they are forced to go back to a starting level. That was not something that was intended, that has been ironed out and the remainder of this will be ironed out. Having a proper structured salary increase for years of experience once one becomes a consultant is appropriate. That is what is done in so many other walks of life. The guy who has been the manager for one year is not on the same rate as the fellow who has been a manager for ten years. It should be no different in the medical field. We need to address this issue. Without being political about it, it is an issue that was ignored for more than 30 years. It is like so much else in our health service. It just evolved in a chaotic fashion over a period of time. In terms of our reforms around hospital groups, primary care and health insurance, this is part of it as well around training.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Where are we at with the EU working time directive in terms of the hours?

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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On the European working time directive, I will defer to Tony O'Connell from the HSE on this, but from memory, with respect to the 24-hour maximum shift, we are more than 90% compliant. When it comes to the maximum working week of 68 hours, we are 99% plus compliant. There are still areas where people are being asked to work hours that are far too long. It is particularly difficult in the smaller more rural hospitals where there are a smaller number of doctors and it is very difficult to create rosters that can address the issue, but the hospital groups will be hugely important in this respect.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Accepting that progress has been made and the issue has been tackled, it is bizarre, as Senator Colm Burke rightly said, that some of our brightest and best are travelling to the four corners of the world and will not stay here and that, anecdotally, some hospitals are finding it difficult to recruit people in some specialties.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Yes. Can I address that?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Sure.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I would be a great supporter of and would continue to encourage our young doctors to travel abroad to broaden their horizons and get training outside of this country and bring that expertise back with them, but they should do that form a basis of wanting to and being curious and innovative and not because they are utterly frustrated with the system they have to endure here. Specifically, on the European working time directive requirement, in regard to the maximum 24-hour shift, in quarter one of 2013 we were only 43% compliant, in quarter two we were 44% compliant, in quarter three it rose to 53% compliance, in quarter four we reached 77% compliance and in March of this year we were 93% compliant.

As for compliance in respect of an average 48-hour week, the quarterly figures for 2013 were 34%, 34%, 37% and 40%. As it was only 48% in March, we have a way to go but we are getting there. The 11-hour daily rest compensatory rate was 53% in quarter one of 2013. I will not go through all the figures but in March 2014, it was 93%. The weekly-fortnightly rest or compensatory rest was 75% in quarter one of 2013 and is at 97% this year in March. A huge amount of improvement has been made and the Government is committed to this. I do not believe it is safe for patients to be diagnosed by doctors who have been on their feet for 36 hours. We do not allow lorry drivers work for more than eight hours in a day. Why would we allow young doctors to make life-and-death decisions in those circumstances to the detriment of the patients, to the detriment of their mental health and well-being and to the absolute destruction and detriment of their careers if they make a mistake? This is about creating the system that protects patients, citizens, families and communities from the human errors that always will occur, because to err is to be human. It is to put in place a system, and certainly a system that demands a 36-hour stint from a young trainee doctor is not a system that goes anywhere near doing this.

11:00 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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May I ask that this information be circulated to the clerk in order that it can be given to members?

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Absolutely, that will be done.
On other issues raised and as to when the statute will be signed, the Minister of State, Deputy White, will address that, as this is his area of competence. However, he has my 100% support with regard to legalising this product for the relief of spasticity in those who suffer with multiple sclerosis, MS.
Deputy Catherine Byrne raised the issue of the nicotine replacement patches for people in pregnancy. Obviously, there are issues in this regard in respect of competing demands for funding. It certainly is one towards which I would be well disposed and have been considering, but it needs to be discussed further in the Department. I acknowledge the Deputy has raised this matter a number of times. As for the last issue regarding assisted human reproduction, a lot of work has been done within the Department on this subject. A child and family relations Bill will be coming soon and this will form part of it. However, it is a complex area because it is not simply about in vitrofertilisation, IVF, but also concerns the issue of surrogacy, which is a landmine area at present. It is a very complex area that also has all sorts of international complications associated with it. Certainly, something will be submitted to the Government in respect of the assisted human reproduction and IVF elements later this year.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister and call on the Minister of State, Deputy White.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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On Deputy Maloney's question regarding Sativex and similar products, I agree with him and agree with his remarks on the value of making this available. It is critical that this be done. His direct questions relate first to the regulations that are necessary because it is not lawful at present to manufacture, produce, prepare or in any way deal with cannabis or cannabis-based medicinal products. It simply cannot be done under the law and consequently requires regulations to be signed. Draft regulations are in being. I have been dealing with this matter and was and remain hopeful that I could sign these regulations by the end of this week. That is how imminent this is. If it does not happen by the end of this week, and I will endeavour to do everything in my power to ensure it could be, there are one or two issues of a legal nature that need to be ironed out. I am hopeful it can be done this week but, if not, I expect it will be early next week. Once the regulations are signed, it then will require the Irish Medicines Board to deal formally with the matter. It already has approved the product itself but of course it cannot proceed until the regulations themselves are signed by me. I have indicated this will be done imminently.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister of State and call Ms McGuinness.

Ms Laverne McGuinness:

I will deal with Senator Colm Burke's question on management and administration staff and the regularisation of some posts. First, many of those management and administration posts are front-line posts. The holders are people who are seeing and making appointments for outpatient clinics and inpatient clinics, etc. These posts are included in our management and administration numbers, which are not simply about back-office staff. Overall, we have reduced by more than 2,000 staff in that category when one takes into account other agencies the HSE has subsumed. In 2009, a Government decision was made placing a moratorium on recruitment and on promotion. While we have lost more than 2,000 such staff during that time, there are key roles that obviously must be performed, some of which were at a more senior grade. For example, someone in a more junior grade, such as a clerical officer at grade 3, might have been assigned to a post that was vacant in a busy outpatient clinic at grade 4 - there is a lot of responsibility there - to carry out that function and task. However, that person would not have been given any additional money to do it. In other words, such people would have been so assigned, on their existing pay and arrangements, for a period of up to two to three years. Under the greater broader framework of the Haddington Road agreement, part of the negotiating process concluded that were somebody in a position like that, that is, covering unpaid for a significant period of over two years unpaid, he or she would be established in that post. In other words, that post would be regularised because there was no opportunity to externally advertise in respect of any promotional posts.

Photo of Colm BurkeColm Burke (Fine Gael)
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The question I asked pertained to internal advertising. My understanding is not even internal advertising is happening in respect of posts that are being temporarily filled at present. I have been so informed by hospital staff working on the front line - I am talking about junior doctors who go through an interview process every six or 12 months but who find they are dealing with administrative staff who are not obliged to go through any interview process. They go in on a temporary basis and then within a short period are being made permanent without any process being gone through.

Ms Laverne McGuinness:

In that regard, under the Haddington Road agreement our first port of call is to reassign somebody into a post. Consequently, if a post becomes vacant, a person can be reassigned to a post up to a radius of 45 km away but not at an increased pay level. If there is an increased pay level, it will be done through an expressions of interest process but there actually are not any. It normally involves replacement on a post-for-post basis without any increase in pay.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Okay. I call on Mr. Mulvany.

Mr. Stephen Mulvany:

On the question of the agency costs or the agency element of the deficit, as the Senator stated, the deficit in acute hospitals at the end of April was €80.4 million. The increase in agency costs in hospitals year-on-year is €26 million. Certainly, that €26 million is a major part of the €80.4 million. I do not have to hand the specific figures for the overall expenditure on agencies in the first four months but it is in excess of €60 million. While one cannot say that comprises all of the deficit, in total we are spending in excess of €60 million on agency costs within this year's total expenditure and, obviously, that is driving the deficit. It is important to state that in the majority of cases, this growth of agency costs arises in medicine, that is, in doctors. Moreover, the bulk of that is in price, not volume. It is not that there is a huge number of additional doctors on the ground but that the cost, because of recruitment difficulties, is getting more challenging for us. There is obviously also an element of additional costs associated with the working time directive. The bulk of the agency costs are in that area and while the Haddington Road agreement obviously has given us significant savings opportunities in respect of many grades for agency and overtime, because the junior doctors were already on 39 hours, it did not provide additional hours for junior doctors. Nor did it provide additional hours for the other area associated with the biggest increase in agency costs, namely, support staff, who again were already on 39 hours. Consequently, there are huge savings coming from that, as well as huge budget cuts to go with those savings, but it does not assist in those areas. This is one of the big drivers of the overall acute hospital deficit.

As we stated, we are working to reduce that deficit as safely and by as much as we can. However, one must look at the overall reduction in expenditure in hospitals over the past four or five years and the reduction in budget, which are without comparison internationally in a system that has not fully hit the wall. Looking at one or two years obviously is relevant and year-on-year comparisons are relevant but we stress that from 2009 to 2013, hospital expenditure reduced in net terms by approximately 11.5%. It has grown between 2011 and 2013, marginally, by approximately 1.3% and will grow again slightly this year. However, even allowing for that, over that period of six years it will still have reduced in net terms by approximately 10%. As I stated, that is fairly unparalleled in the general Western world in terms of hospitals, as these were real cash reductions. Most international economies, when they talk about hospital costs and indeed community costs in health, talk about how they have a reduction of 2% or 3%. What they mean is that costs are growing by X, their governments are only able to fund them by Y and the difference, while they are getting an increase, is what they call a cut.

In this economy, generally speaking, what we are talking about over that long period is an absolute net reduction in the cost and the cash, which is different than most other western developed economies.

11:10 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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In that case of the €60 million, would one be better off in recruiting staff on a permanent basis rather than having this ongoing agency bill?

Mr. Stephen Mulvany:

In general terms, where one can, yes. Certainly, our director of HR and colleagues on the service side are looking at specific areas where we can recruit additional staff and reduce agency and overtime. Obviously, one must ensure that one does not end up having additional staff and the agency and overtime remains.

I emphasis, "where one can recruit". There must be a market with applicants who are willing to take the jobs. In that regard, there are issues on the medical side. Where we can get additional staff to reduce agency and overtime and we can be reasonably assured that such agency and overtime will not creep up again, that is part of what we are seeking to do this year in terms of reducing our overall deficit towards break even.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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The IMO, which was before the committee a couple of weeks ago, made the point regarding agency and staffing and the moratorium.

Mr. Stephen Mulvany:

In terms of reducing agency and overtime, it is definitely one of the opportunities.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Mulvany.

Photo of Colm BurkeColm Burke (Fine Gael)
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I seek clarification. On the €80 million in the first four months, is Mr. Mulvany saying that €26 million of that is for agency staff or is he saying it is €60 million?

Mr. Stephen Mulvany:

I am saying that agency costs in hospitals have increased by €26 million and there definitely is not any budget for an increase in agency.

Photo of Colm BurkeColm Burke (Fine Gael)
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For the entire year, what is the total agency budget? I accept Mr. Mulvany cannot give me the exact figure, but I seek an estimate.

Mr. Stephen Mulvany:

To clarify, that growth is certainly directly driving the deficit.

The Senator asked how much in total are we spending on agency. There is some budget for agency. It is unfair to say that the full €60 million that we are spending is causing the deficit, but a significant chunk of it is and, certainly, all of the growth is.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Is it fair to say then that we have not tackled sufficiently the agency cost?

Photo of Colm BurkeColm Burke (Fine Gael)
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We cannot.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Then that we cannot, perhaps because of the moratorium?

Photo of Colm BurkeColm Burke (Fine Gael)
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We cannot because of the shortage of junior doctors.

Mr. Stephen Mulvany:

We have shown areas where we have reduced agency and we have shown significant reductions in overtime, but the levers to reduce the agency and overtime, particularly in medical and also in support, are just not largely there.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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For additional information, many of the NCHDs are choosing to abandon jobs or training and to go to the locum agencies for employment. They get much greater remuneration doing that with a view to getting out of this country and pursuing their career somewhere else, and that is a real problem.

Part of it is borne by something that I want to put on the record here that I find appalling. There have been reports of NCHDs working overtime and not being paid for that overtime, and having to challenge the relevant hospital management to get the overtime involving their union. The sort of message that sends to non-consultant hospital doctors underscores what I said earlier about the lack of respect. It is something that is being addressed and needs to be fully addressed. There is little point in talking about reducing overtime if one is forcing staff to work the hours and then not paying them. That is pure injustice. There is no excuse for it. It is utterly unacceptable. As Minister for Health, I make that clear here today.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Deputies McLellan, Dowds, Conway and Healy are next. I thank them for their patience.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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Likewise, I welcome them all here this morning and thank them for their presentations.

I am glad that the Department is examining the EpiPens issue as a priority. We had Ms Emma Sloan's Mam and a number of stakeholders in here a few weeks ago. This issue around the EpiPens is so preventable. I strongly believe that there should be such pens in every school, crèche and restaurant. I understand the HSE cites some complexities around it. It is good to have a register and to have staff certified and trained. I wonder is there a register currently because family members are administering this currently and I do not know whether they have been trained or educated on it properly. I also wonder when the HSE's considerations with regard to this will be concluded.

Mention was made of the potential adverse implications of the incorrect or inappropriate administration of adrenaline. They can correct me if I am wrong, but I thought the stakeholders told the committee that they did not believe there were any known cases of adverse implications.

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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They stated there could not be any.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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They stated there could not be, there were not any.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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Perhaps they could clarify that or update us on it.

I tabled questions on medical cards and I want to go back to that issue. I have two points to make on it. The first is a general point. I would ask that when considering the over 70s it be based on their net pay, not their gross pay, because over 70s also have outgoings.

I will use my time here to raise an issue where I am experiencing problems with a particular case with the primary care reimbursement service, PCRS. I will not mention who or what, but the scenario surrounding it. On 30 May I made representations on behalf of a family that had a very sick child and I asked that it be viewed as an urgent case. I submitted the documentation by email. I received a reply where they were looking for another document - I think it was a bank statement - which we sent back straightaway. A couple of days later, on 11 June, we got an acknowledgement that the document had been received. Since then, however, I have been toing and froing with PCRS trying to get a decision on an urgent medical card. There have been phone calls as well as emails.

On 24 June, I wrote stating that the application was submitted with all documentation completed on 11 June - the initial submission was made on 30 May - and that it was not acceptable that nothing had been done up to that point. I was getting the general replies, for example, that it was the subject of assessment.

I also want to make the point I was informed, on 2 July, that in the event of further urgent cases, I should not hesitate to contact the office which would ensure any urgent information would be passed to the relevant department.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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That was fine.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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That was grand. All that was wrong about it was I was not getting any decision. It had been a month.

Then yesterday, because I followed up on it again because I still was not happy, I got the following reply, and this is where I am baffled. The reply stated that in cases where a medical card is required in emergency circumstances, an emergency medical card may be issued, and it included five examples of the type of emergency. I would presume that the one I am looking at would come under that of a person with a serious medical condition in need of urgent or ongoing medical care.

The reply further stated that emergency applications can be initiated through the local health office the manager of which has access to dedicated contacts in PCRS, that as this person's application was not sent from his local health office his medical card application would not fall under the emergency medical card assessment, that the official could confirm that the application is subject to discretionary assessment and the PCRS is currently reviewing approximately 15,000 discretionary medical cards, and that, as one can appreciate, this can take some time and should be completed in approximately mid-July.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Deputy McLellan.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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When did the policy change? Is the HSE now not taking representations from TDs with regard to emergency medical cards? I would make the point that the person who told me not to hesitate to bring urgent medical card applications to his attention last week gave me this today, six weeks after I made the initial application for an urgent card.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Deputy McLellan.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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At the centre of all this is an extremely sick child. It is not about me. It is not about PCRS. It is about that family. It is not acceptable for one to receive that six weeks later and I want an answer on it. I want to know how the process of urgent cards works and how the HSE deals with such representations made by TDs.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Afterwards, Mr. Hennessy might meet Deputy McLellan separately on that issue as well.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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I wanted to put it on the record because there are other cases like this where we get such nonsensical correspondence.

Everybody has better things to be doing. Ultimately, all we want is to have applications processed. If an applicant is ineligible, that is fine, but we should at least be responded to. What is happening is absolutely ridiculous. I am not alone in experiencing it; others are also. I have referred to just one case.

11:20 am

Photo of Robert DowdsRobert Dowds (Dublin Mid West, Labour)
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I remind Mr. Healy that I am awaiting a response on the CRC issue.

On the questions I put on the agenda, is the Minister or Minister of State able to say anything further on the question of the motorised transport grant and the mobility allowance? Obviously, there is some kind of review taking place of the new travel subsidy scheme. When will there be clarity in this area?

My second question related to the medical card situation, particularly discretionary medical cards. I understand there is no entitlement to a medical card based on having a particular disease or illness. If one has a particular disease or illness, there may be very considerable costs involved. Therefore, to what extent does the cost of looking after a person with such a disease or illness come into play in the determination of income? What is the position on somebody whose income is just over the threshold for entitlement to a card? In practice, if one has considerable medical expenses, it has a significant impact on one's ability to look after oneself.

My third question concerns the problem of people committing suicide very soon after their release from hospital. I appreciate that this is a very difficult area. Even trained psychiatrists can get it wrong when determining whether they believe somebody is vulnerable. Can the Department put figures on that? With regard to the appalling problem of suicide in general, is an attempt being made to learn from the experience of other countries' approaches to it?

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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I want to focus in particular on Question No. 38, on the cardiology department of University Hospital Waterford. The Minister knows we have spoken about this at length. Unfortunately, there are now headlines in the local newspapers referring to a cardiac crisis. Services have been suspended for one or two afternoons per week in the hospital. This directly contradicts what I was told on 13 May 2013, which was that, with the formation of the group, replacement consultant posts in areas such as emergency medicine and dermatology would be forthcoming. The dermatology services have ceased to exist in Waterford. Therefore, we have been going backwards rather than forwards since the establishment of University Hospital Waterford. People who become unwell on Wednesday or Friday afternoon will have to go to Cork. We have been told the necessary staff are being recruited and that we are to work together within the group to ensure the necessary staff will be in place, such that we will have what we were told we would have, that is, a 24-hour CAT laboratory at the disposal of the people of Waterford and the rest of the south east. What is happening in regard to this? Circumstances are going from bad to worse. Services are being closed down.

I am sure the Minister is aware that, despite the removal of the dermatology service in University Hospital Waterford, Waterford has one of the highest rates of skin cancer in the country. I want to know what will happen. In response to a Topical Issue matter I raised in the Dáil, the Department stated staff from the hospital in Waterford would go to the hospital in Cork to be trained. I want to know why the consultant dermatologists are not coming down from Cork to treat the people in University Hospital Waterford.

What will happen to cardiology services? We were given a specific undertaking, in light of the Higgins report, that the cardiology services will be available to the people of Waterford and the south east on a 24/7 basis.

I would like to ask Mr. Healy about early intervention teams and vacant posts. He said they are being addressed locally. He will appreciate that with regard to early intervention, waiting lists are counterintuitive for the children we are trying to help. Children are usually screened when they are three years of age. However, in Waterford the psychologist posts have been vacant for nine and 12 months. Therefore, the children in Waterford are again to be disadvantaged by the fact that no solution has been found locally to ensure they will be screened and receive the services they require. When Mr. Healy says services and vacant posts are being addressed locally, what does he mean? Why is it not happening in Waterford?

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I apologise for my having to leave the meeting earlier. Most of the relevant questions have been raised but I want to return to the question of medical cards. I agree fully with Deputy McLellan. The public, my office staff and I are totally frustrated dealing with medical cards. We have no difficulty with the HSE staff who are involved because they are as courteous and helpful as can be but the system in place is completely frustrating. For example, there is a delay of at least a fortnight in the registration of information on the system. The processing and assessment of applications by medical practitioners in the PCRS is a nightmare. Usually, an application goes into a queue to be seen by the medical practitioner and it certainly does not emerge from it for at least a month. I have encountered cases where the period was from six weeks to two months. A recent case, which I raised with Mr. Hennessy and which, I am thankful, he sorted, involved an application going into a queue for a medical practitioner on 19 February 2014 and not emerging until ten days ago. That is the position in which we find ourselves. I refer not only to public representatives but also to members of the public.

A very significant difficulty for us is that there is nobody we can consult or deal with, either face-to-face, over the telephone or by e-mail. There is nobody who has any real input into the decision-making process. That is a huge problem and needs to be addressed. The Chairman will know that I was one of the first, if not the first, to raise the issue of entitlement to discretionary medical cards on medical grounds. I raised it for two years before anyone came to realise what was happening. I hope it can be considered and solved quickly.

By any chance, has the Department or HSE even considered the question of reversing the centralisation of the processing of applications for medical cards and returning responsibility to local areas? There is a fundamental problem with the centralised PCRS.

11:30 am

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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As regards Deputy Sandra McLellan's comments on the EpiPen, I do not want to get into a clinical row with anybody. Certainly, if a person has cardiac arrhythmia of a particular nature and is administered adrenalin, it could kill him or her. It can also contribute to hypertension, with rather unpleasant, unfortunate and even catastrophic consequences. There are issues that require further elaboration, about which there is no question. The last thing we want to see is somebody who is untrained delivering it in the wrong circumstances.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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Yes.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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A question was asked about a CCP presentation made to the committee.

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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I asked that question.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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That is fine, but I have a different view. I am sure we will get the best experts in the country to confirm it. My comments are informed by the Department through the Chief Medical Officer. We do not want to make a bad situation worse.

There is an interesting point concerning the lifespan of these products that needs further exploration and I will talk to the Department and the HSE about it. We should have a system whereby, within three months of expiry, they are returned centrally to be used in hospitals where they are used very quickly. The level of use of adrenalin in hospitals is much greater than anywhere else. That is certainly what I used to do as a GP; I used to return it to the pharmacist who would get it back to the hospital to be used there. I referred to the EpiPen. It is open to a pharmacist to make-----

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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Yes, I know that.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Without going into specifics, I think the Senator knows where I am going.

I was asked about medical cards for the over-70s and whether net or gross pay would apply. It will be superseded by the roll-out of GP care. I will allow the Minister of State, Deputy Alex White, to address these issues.

Let me make some general comments on the medical card issue. The legislation concerning under six year olds is going through, which is to be welcomed. As regards legislation, if required - it probably will be - for the over-70s, we already have consensus at the Cabinet that this should be done. We also have the expert panel and the issue of those with medical needs. That is a real change in approach because up to now, as the Minister of State and I have made clear, it has been means-tested based on income. Medical conditions are taken into consideration only in so far as they create financial hardship but not in terms of the much greater hardship many chronic diseases and life-long conditions create for families. That development is to be welcomed.

I was listening to somebody on radio this morning who said the ethical thing was to look after the most vulnerable and those who were sick first. That will precisely be the net result of what the Government is planning to do. The highest numbers of users of the service are the over-70s and the under-threes and both groups are included. In addition, it will include the many people with life-long conditions, including chronic illnesses, who because of their medical condition face real hardship in life unrelated to their income. I welcome this development and I am sure the Minister of State will want to address the matter more comprehensively.

Deputy Robert Dowds mentioned the mobility allowance which I addressed in a Topical Issue debate yesterday. The Government is doing a lot of work on it in conjunction with the groups involved to develop a new scheme. The old one was left sitting there and the Ombudsman had serious concerns about its legality in terms of issues related to equality of access. Unlike previous Governments that ignored it, we are dealing with it. In the meantime, recipients have the money ring-fenced for them. The longer the issue drags on, the more people will be able to apply to avail of it. However, as there is no system in place for them to take advantage of it, the matter is being progressed. I expect to receive a report to deal with it in the coming months.

As regards Deputy Ciara Conway's question, I am disappointed to hear cardiac catheterisation treatment has been cancelled. I will ask the deputy director general of the HSE, Ms Laverne McGuinness, and Dr. Tony O'Connell, the director of hospitals, to address the issues around dermatology and cardiac catheterisation. I know appointments have been agreed to. I agree with the Deputy's sentiment that the hospital group should be functioning in a manner that allows it to help the dermatology service by bringing a dermatologist to Waterford from Cork. It would have my full support in that regard.

Mr. Pat Healy will deal with the issue of early intervention.

Deputy Seamus Healy raised questions about medical cards with which the Minister of State will deal.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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Deputy Sandra McLellan referred to the forthcoming extension of free GP care to the over-70s. She asked us to look at net, rather than gross, income, but that will not apply because there will be no charge. Once it is universal for all those over70 years the income limits will be irrelevant. One simple way to deal with the over-70s issue in legislation, although I am not saying it is the way we will deal with it, would be to remove the current income limits for GP cards. Therefore, there would be no income limits and, if we had a universal system, the only test would be the age of the person concerned.

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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We are not talking about GP services but about access to drugs.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I am answering the question I was asked. What I wrote down was "when considering the over-70s". That is what the Deputy said.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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I actually made a connection between-----

Photo of Alex WhiteAlex White (Dublin South, Labour)
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Can I deal with the Deputy's question? If Deputy Seamus Healy has questions, I can answer them also.

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The Minister of State is deliberately distorting the questions being asked.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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We are not going to have a discussion on that matter.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I reject that suggestion. As the Chairman knows, I do not tend to react to such remarks, but I reject Deputy Seamus Healy's suggestion I am trying to avoid any question or change a question in any way. I am trying to be helpful. Most Deputies and Senators will know that I have tried, at all times, to be helpful in answering questions. The Deputy, therefore, really should not have made that remark.

On gross versus net income tests, it suits most of those over 70 years to apply the gross income test. It is true, however, that in some cases the net income test would be better. A person who is over 70 years can opt to use the net income test, if he or she so wishes. In fact, persons over 65 years of age are in a slightly more advantageous position than others in respect of the net income test. However, one cannot combine gross and net incomes. In other words, one cannot opt for the gross income thresholds because they are more attractive, while importing some of the rules that apply to the net income test. One must opt for one or the other, which makes sense.

On the emergency medical card, I listened very carefully-----

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I am sorry to interrupt, but I must inform Senators that there is a vote in the Seanad.

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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I thank the Minister of State for his comprehensive reply.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I will ask either Ms McGuinness or Mr. Hennessy to deal with the specific matter of issuing an emergency medical card and the delay referred to by Deputy Sandra McLellan. Based on what she described, the delay does not sound acceptable at all.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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No.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I will ask the HSE representatives to deal with the matter. The role of public representatives, including the Minister, arises in that regard. It is important for public representatives to have the opportunity to raise these issues. The Minister and I have communicated privately and are now doing so publicly that public representatives should be facilitated in a timely and efficient manner.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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It also concerns the citizen.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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Absolutely. The issue of public representatives was raised, but, of course, citizens should also be facilitated. However, I need to remind colleagues about the HSE governance legislation.

It is not open to a Minister to give a direction to the HSE in respect of an individual's eligibility for services. In fact, a Minister is prohibited from doing that under the HSE legislation. He or she cannot say if a particular person should be eligible or not.

11:40 am

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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That is not the issue.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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That is not to say public representatives should not have every opportunity to advocate on behalf of their constituents. I support that as a public representative myself. Deputy Robert Dowds asked about the costs associated with an illness or condition, which is exactly what the discretionary regime is there to deal with where a person is over the limits. Costs associated with the illness or condition the person has are dealt with under the guidelines the HSE has published on its website. Mr. Hennessy or Ms McGuinness can elaborate how this works for the Deputy if necessary and set out how the HSE takes into account expenditure a person has in respect of an illness or condition.

Deputy Seamus Healy expressed frustration at dealing with these issues. I take him at his word even if he does not take me at mine. He is a very assiduous public representative as others are in the room and I am sure they find it frustrating at times. Deputy Healy referred to a number of issues including delays in the registering of information. I must ask Mr. Hennessy to deal with those operational issues of PCRS and the system itself. There is no proposal or intention to reverse the decision to centralise the system. The point has been made before that we had a starkly differential level of coverage in regard to medical cards nationally. There were considerable variations which seemed to arise from the way the scheme was administered in the past. There are equity issues involved and there ought to be a system which works in a consistent way across the country. That said, we need better linkages with local input and local knowledge. It is something Mr. Hennessy might comment on. We need more local input and the system must improve and be improved to take into account local input and local knowledge. It is extremely important and I urge the HSE to ensure we improve the systems to take the issue into account.

Ms Laverne McGuinness:

I will ask Dr. Tony O'Connell to address some of the issues raised by Deputy Ciara Conway on Waterford Hospital.

Dr. Tony O'Connell:

The issue with Waterford is the challenge of having an adequate number of consultants to provide the service. The acute coronary syndrome programme suggests that to have a 24/7 service certain criteria must be met. These include a critical mass of patient population and a critical mass in terms of consultant manpower with a minimum of five wholetime equivalent consultants and two cath labs. It is for that reason the programme designated six 24/7 services in Ireland, three in Dublin and one each in Cork, Galway and Limerick. The challenge in Waterford is that there are three consultant interventional cardiologist posts at the hospital and they are supported by two visiting consultant cardiologists from Wexford and South Tipperary, each attending one day a week. Due to a recent transfer, only one of the three posts is filled permanently while two are filled on a temporary basis pending two permanent appointments by 1 September next year. There is a challenge to consistently maintain the critical mass of consultants to deliver the service in a high quality and safe manner. The hospital is examining proposals to extend its service. Currently, the service is a five-day service from 8.30 a.m. to 5.30 p.m. Clearly, challenges with having enough consultants on the roster mean it may not be possible to maintain that roster consistently.

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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With all due respect, Dr. O'Connell is reading out what he has given me in writing. I want to know what is happening to ensure we address the issue. I want him to address the fact that the limited service we currently have will be closed for two afternoons per week for the rest of the summer and all day on 13 August for maintenance during service time. If it only operates on a 9-to-5 basis, why cannot the maintenance be carried out after 5 p.m.? Why does a critical service for a substantial population in the south east have to close during working hours for routine maintenance? I would like Dr. O'Connell to answer that.

Dr. Tony O'Connell:

The hospital is examining proposals to extend the service but that will depend on funding being made available in the 2015 national service planning process. The maintenance is not provided by the staff of the hospital. Servicing of this very complicated imaging equipment is carried out by external companies and it is not inappropriate to have such maintenance and servicing carried out during 9-to-5 hours. If the service is not available on a 24-----

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Can it be done out of hours?

Dr. Tony O'Connell:

We will need to examine whether the providers of the maintenance service are able to do that.

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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When is it likely that will be known? The maintenance is due to take place on 13 August.

Dr. Tony O'Connell:

I am sure we can have those conversations with the maintenance provider in the next couple of days. The other half of the question was on dermatology. We are having a similar problem with the recruitment of dermatologists. Clearly, we would like with the development of hospital groups to have a shared service across all of the hospitals within the group. However, that is limited by the absolute number of hours the consultants can provide. Nationally, especially in the middle and west of the country, there are challenges in getting consultants across a range of specialities. The plan is not to shrink the service but to provide the service that is possible within the context of the number of consultants available and employed.

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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The service has ceased. It is a very serious issue. There is no dermatology service in Waterford, with the highest level of skin care demand in the country. I was told by the Minister and Professor Higgins that during the establishment of the hospital groups patients would not be required to travel as the consultants would go to where the need was. Why are consultants not coming from Cork to treat and screen patients at Waterford University Hospital?

Dr. Tony O'Connell:

There are not enough dermatologists to do that rotation at the moment. Certainly, patients can receive a consultation in other centres but currently there are not enough consultants to cover every hospital in the country for each of the potential sessions that are available. We are finding that we have to pay agency rates for a number of consultants nationally. For example, we are currently employing at least 50 consultants at a cost of €300,000 per annumto provide services in places like Limerick and Galway. There are huge challenges in attracting consultants to deliver these services and there is only so much work that individual consultants can do.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Does that go back to the point I made to Mr. Mulvany that we should be recruiting people permanently rather than using agency staff? Do we have a plan to solve the impasse regarding the people in Waterford who may have to travel to Cork as opposed to someone coming to them?

Dr. Tony O'Connell:

Certainly, the intention is to make the most of the consultant staff available across the whole group and to spread them as evenly as possible to service the patients. With certain services, there will not be enough consultants to go to every single hospital for each of the potential out-patient clinics available.

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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That directly contravenes what the Higgins report was set up for.

Dr. Tony O'Connell:

The Higgins report is tending to give us an ideal system and provides us with the foundations on which we can build one. However, we are still constrained by the realities of how many consultants we have in the system.

Ms Laverne McGuinness:

We might examine the details in relation to Waterford in the next number of days and revert to Deputy Conway with as full a response as possible.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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There is a need to put a plan in place to safeguard and provide a service.

Ms Laverne McGuinness:

Deputy Conway asked another question relating to early intervention, to which I ask Mr. Healy to respond.

Mr. Pat Healy:

In my written response to Senator Jillian van Turnhout, I made the point that we had prioritised therapy services. That is in a context in which from 2007 to date there has been a reduction of 11.5% in the staffing numbers overall in the health service. While that has been happening, there has been a 13.99% increase in the therapy grades.

In the past year there has been a 1.5% reduction in staff numbers in the health service but a 2.36% increase in therapy grades. That shows we are prioritising them and we still have the resource.

A key intervention piece is the roll-out of the 0 to 18 years programme which we have prioritised. The top priority in the south east has been Wexford because there is a significant difficulty in the region due to the population and the number of therapists. Wexford was prioritised in our operational plan this year so the service will get posts this year.

Waterford is one of the locations that will make preparations this year. That means it will put in place a range of consultations, policies, and there will be engagements with local communities and schools as this is a joint initiative between the HSE and the Department of Education and Skills. Waterford will be prioritised in terms of resources next year so there will be additional resources going in that direction. We have figures but we are not able to break them down into grades, children's services and local health office. I shall establish the position and get back to the Deputy on the position in Waterford. The priority in the south east for this year is Wexford and Waterford is prioritised for next year once the consultation and preparatory work is done by the team this year.

11:50 am

Ms Laverne McGuinness:

Two pieces are left and the first one relates to the Chairman's question on agency and consultancy. We have the ability to recruit consultants but we just cannot get them. They are not available to fill the posts. That is not the same issue as having a moratorium on consultants. We are able to recruit them but cannot attract them.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Is the reason the HSE cannot attract them down to anything in particular?

Ms Laverne McGuinness:

There are various reasons. Some say it is pay arrangements if they come back - a matter which has been addressed as part of the McGraith report, the implementation of which has been worked through with the Department and the HSE.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Will a solution be found?

Ms Laverne McGuinness:

We hope so. A number of Deputies raised the issue of medical cards, particularly access to emergency medical cards and procedures which do not appear to be satisfactory. I ask my colleague, Mr. Hennessy, to address the question.

Mr. John Hennessy:

A specific procedure is in place to deal with emergency medical cards in cases of urgent medical need. The procedure and protocol overrides the normal application process and there is a turnaround period of 24 hours, generally, for the cards. The scheme is confined to very critical and urgent medical need which is where different interpretations may arise. I am happy to take the details of the case that Deputy McLellan mentioned and will go through it with her in detail.

A couple of other points were raised. The medical expenses and how they are handled was dealt with but I will explain it very briefly. The costs of medical treatment are calculated, usually, by the medical officer involved and are included, and added on, as an allowable expense in dealing with medical card eligibility. That is done with the knowledge that there are caps and maximum limits on people's outgoings. For instance, the maximum a household must pay for prescribed drugs and medicines is €144 per month. Plus there are maximum charge limits in our hospitals that apply to all citizens. The calculation of the costs allowable, for medical cards purposes, takes into account the caps and maximum limits that apply to all.

We are conscious of and trying to deal with the delay issues that were mentioned. At present there are a number of competing issues with the restoration of discretionary cards that may have an impact. The scheme is very big and covers almost 2 million people. It works quite well, believe it or not, for the vast majority of people especially when all information is supplied with the initial application. A completed application is turned around within 14 days. In instances where all the information has not been provided, or is unavailable, with the initial applications the HSE must seek in writing the required information or details and therein lies delay. The committee has visited Finglas before and the chairman of the PCRS office. We would be very happy to have a further meeting in Finglas, if that is appropriate, and will spend all the time needed to go through the cases.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Part of the difficulty for a citizen is getting to talk to the decision-maker, which we have discussed here before, and to talk to the same person twice. Making contact with a different person each time is part of the problem.

Mr. John Hennessy:

Volume is another part of the problem because we deal with nearly 2 million people.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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The staff in the PCRS are very courteous, helpful and considerate. I do not want to leave the delegation with the impression that we are being critical of them. I repeat, the staff that I and Members have dealt with have been very courteous and helpful.

Does Deputy Ó Caoláin wish to make a quick comment or will he let Mr. Hennessy finish?

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I will let Mr. Hennessy finish and will make a brief comment at the end.

Mr. John Hennessy:

I will conclude. The scheme covers a lot and deals with almost 2 million people, approximately 100,000 new applications per annum, 8 million pieces of correspondence per annum and nearly 20,000 calls to the centre per week. A lot of people are very satisfied with the service that is now available and the online application process. Obviously there are a small number of people who are not and we intend to manage, deal with and close out those queries and thus end complaints.

We have a complaints procedure which is available to all. There is a procedure and process for handling and dealing with those cases. The appeals system deals with approximately 6,000 appeals per annum and in an efficient manner. We also have an access route for Oireachtas Members which enables them to contact us. If there are problems with it please let us know and we will deal with them.

Photo of Robert DowdsRobert Dowds (Dublin Mid West, Labour)
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Can Mr. Hennessy deal with the issue raised by the Chairman and Deputy Healy? They asked whether a citizen can deal with the person who makes the decision. I appreciate the scheme must deal with a huge number of people.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Deputy Dowds and call Deputies Ó Caoláin and Healy, in that order.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Mr. Hennessy made reference to the last visit we made to Finglas. He will recall that I made the opening contribution. I knew I spoke on behalf of all of us when I made the point that we need a dedicated office team of whatever size. We, as Oireachtas Members, act as a buffer zone for people because community welfare officers no longer deal with the people. The HSE headed off into its lair in Finglas and even the sign on its door said "This is not a public office". As a result, Oireachtas Members became that cohort and it is not a comfortable place to be. I appreciate that somebody engaged with me on certain cases on the day but I do not have a continuum and further problems have arisen. That is a fact of life. I support my colleagues and made the point very strongly on the day that I believed that such a decision taken would be in the interest, not only of our roles, but of the entirety of the medical card processing system and would help Mr. Hennessy's team enormously. We are not at loggerheads and, therefore, should work together.

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I have no problem with the staff. As the Chairman has said, they are courteous and helpful in so far as they can be. Any time I have been in contact with Mr. Hennessy, either in his briefings here, over the telephone or whatever, he has been helpful. However, we have heard from him now exactly what we heard about the discretionary medical card issue for two years - a refusal to accept that there is a problem.

My colleagues and every other Member of the Oireachtas know there is a serious problem with medical cards. I have many questions but I will just ask one. Mr. Hennessy referred to emergency cards. While emergency cards can be issued within 24 hours, the applicant must have a medical certificate stating that he or she is terminally ill. There are difficulties in obtaining such a certificate but if the family is prepared to request one and the GP is prepared to issue it, there is not a problem in obtaining a card within 24 hours. If an individual has a serious medical issue, however, his or her application goes into a black hole and, once it gets into a queue for assessment by a medical practitioner, it will not emerge from that hole for at least a month. I am aware of one case in which the applicant waited from 19 February to the end of June. I ask that the situation be investigated.

12:00 pm

Photo of Alex WhiteAlex White (Dublin South, Labour)
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In the circumstances to which Deputy Seamus Healy refers, people need the assurance of getting a card promptly. However, in the event of a delay of, perhaps, one month what would typically happen to the expenses which would otherwise be covered by the medical card? In other words, would the applicant be at a loss for that month?

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Yes, of course.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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All of the expenses, such as hospitals and drugs -----

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The issue also arises of access to other services through the medical card. Even though Mr. Hennessy previously told us that the medical card does not qualify holders to other services, in practice it is a gateway to those services.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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In such circumstances, could Mr. Hennessy deal with the issue? I know it is not possible to backdate eligibility but perhaps the date of application rather than the date of grant could become the operative date. This sounds to me like a problem that could be addressed.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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The Minister of State indicated that applications for medical cards are processed speedily in many cases but we encounter the problematic ones. It is impossible to get onto somebody in order to deal with an issue. We need to have access to somebody to discuss the problem over the telephone but the back and forth e-mails are driving everyone berserk because they are no use. We need to be able to speak to a person who can give us an answer. It need not be the right answer; it could be any answer but we need be able to discuss it with somebody. We should get not a different person giving the standard answer every time we pick up the telephone. We are going around in circles at the moment.

Mr. John Hennessy:

We accept there are problems with the medical card scheme. There is no refusal to accept the reality of that. We have heard examples from members and others and, indeed, we have responded to them over the past several weeks. We are also investigating the possibility of local contact points to be of assistance to applicants who, for whatever reason, are not comfortable with online application systems and call centres. I recognise that significant numbers of people are not comfortable with such methods and that we have to make proper arrangements for them. We are also in discussions with certain local authorities which are interested in providing support and assistance of this nature.

In regard to medical officer delays, if I can get the details from Deputy Seamus Healy I would be happy to investigate the matter. If we can get the details of problems we can deal with them on a case by case basis and, hopefully, resolve them. In regard to Deputy McLellan's comment, it is not the case that any answer will do. Obviously it has to be the right answer.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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I was not saying that the card has to be approved. If it is not approved, we want that answer too once it is accompanied by the reasons for refusal. However, we need an answer.

Ms Laverne McGuinness:

It is clear that members are asking for a single point of contact with PCRS who can answer their questions -----

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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Continuity.

Ms Laverne McGuinness:

----- and offer continuity so they do not have to repeat themselves. We will discuss that within the HSE and revert to the committee.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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In regard to the point I raised on question No. 24, I understand that Ms McGuinness is going to revert to me in regard to the pre-meeting of some members. I refer her to the internal audit report and ask her to address the other point I raised at the outset, namely, it is all very well for the CEO to say the chairman did not play a role in making the decision but there is no basis or understanding, as if the right questions were not asked, as to how the CEO made the decision to appoint a company with which the group had no previous involvement, good, bad or indifferent. The group would have dealt with a number of consultancy firms over the years for various purposes. What prompted him to ask this particular individual, who he stated had the necessary skills and resources? I could provide a list of ancillary questions but I think they are self-evident.

Ms Laverne McGuinness:

I will revert to the Deputy on that question. According to the CEO there was an urgent requirement to carry out an independent review of the maternity services and certain issues that had arisen. As the Deputy does not regard that answer as acceptable, I will investigate further and revert to him on the two points raised.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I thank members for their questions. Sessions like today are critical because the medical card issue continues to be problematic. Mr. Hennessy made a fair comment. The vast bulk of the 2 million people involved find that the process is reasonable but there is no doubt that a small percentage of people still find it too arduous and that it creates huge uncertainties for them. Most people find it difficult to deal with uncertainty and in this regard Deputy McLellan makes a reasonable request that she be provided with answers so at least she will know what is happening.

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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Yes, that is what I meant.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I commend the committee for going to the PCRS and I encourage it to do so again to further streamline the process in respect of these more difficult cases so that eventually we will reduce those who find it difficult to the smallest possible number. I think we can do that. In regard to the comment that Deputies need to be able to speak to the decision maker, that seems perfectly reasonable on one level but on another level, if the decision maker is always on the telephone to Deputies he or she will not be making decisions. We have to find a balance to ensure that the citizens who are most vulnerable get the care and support they need.

The health service is improving in many ways but we all know that we have significant difficulties in certain areas. Deputy Conway outlined some of the difficulties that arise in the south east and many other parts of the country. We have pockets of real problems, whether in respect of community and social scheme, the medical card scheme or hospitals, but these problems are being addressed in a much more transparent way. This is valuable because the more people who have input, the greater the satisfaction we will get at the end of the day.

I cannot let this opportunity pass without commending the men and women in our health service who do such a sterling job day in, day out to keep our people safe and help them recover from serious illnesses.

12:10 pm

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I remind members that the report on end-of-life care will be launched at noon on Tuesday, 15 July, in the audiovisual room. The interim report on the review of medical training and career structure, the MacCraith review, has been sent to members.

I thank the representatives of the Health Service Executive for attending and the work they do day in, day out for all of us. I also thank the representatives of the Department of Health; the Minister, Deputy James Reilly; and the Minister of State, Deputy Alex White. I wish them well whenever the reshuffle takes place.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I also wish the Chairman well.

The joint committee adjourned at 12.20 p.m. until 9.30 a.m. on Thursday, 17 July 2014.