Leo Varadkar (Dublin West, Fine Gael) | Oireachtas source

We have not yet decided. My plan is for it to be chaired by a Department official but I am open to views on that. There should be independent input, particularly a patient representation.

I touched on the outpatient appointment issue. There are 412,000 people now waiting for their first appointment with a consultant, although there could be a fair bit of double counting. We will let the committee know about that. It is always important with waiting list figures to drill down and 170,000 of those people are waiting less than 12 weeks. In some cases they are waiting a few days. That refers to anybody, in effect, who has been referred by their GP to a consultant. It is not the case that they are all waiting inordinate lengths of time. The figures may be confusing. With the surgical area, the number of people waiting less than three months for a procedure is going up, for example, but the number of people waiting a long time is going up. People are being seen quickly by efficient services that are turning people over quickly, leading to improvement, but particular sub-specialties have lists that are getting longer. When I speak with people on waiting lists, they are not all that interested in whether they are number 100,000 or 106 on the list but rather how long they will have to wait. That is why the focus is not so much on getting the numbers down, as every time a new service is established, there is a new waiting list for it. There are waiting lists now in areas that did not exist two years ago.

My focus is on reducing waiting times so that people do not have to wait too long to see somebody. That is why we have set these maximum tolerable limits - which should not be tolerable, but unfortunately, they are - of 18 months by June and 15 month by December. I agree that we will need some help from the private sector and potentially even overseas in order to address some of those targets. That will be expensive but it needs to be done. It can be done through the National Treatment Purchase Fund, NTPF, which was used to eliminate the long waits for urgent colonoscopy procedures at the end of last year. I have no problem doing that again if the budget is available to do so. However, it does not necessarily have to be done by the NTPF in the old way as it can also be done directly by hospitals and groups which are already using the private sector to pick up some of their work.

For example, I refer to the very long waiting list for scoliosis operations for children which I find personally to be extremely worrying. That is why we have allocated an extra €1 million this year for this procedure. We have had to use the Blackrock Clinic as well as Cappagh to deal with some of those cases. However, there are limitations in that there are only so many theatres and so many surgeons. We are putting a whole new theatre into Crumlin hospital even though it will be out of use in three years. A constraining factor is the theatre space and the number of consultants who are trained to do the operations and this has caused us serious trouble. We may need to send some cases overseas for these operations.

There is a bigger picture with regard to waiting times for appointments. We need to reduce the number of referrals because, quite frankly, too many people are being referred to specialists. The best way we can reduce referrals is to support GPs, have more referrals to generalists, build up primary care in particular and also have GPs taking a special interest in areas such as dermatology and ENT. They can be trained up to deal with these areas of medicine. This would allow for inter-practice referrals as is the case in other countries. The e-referral system will mean better referrals. It is really disheartening to hear of patients who wait a year to see a consultant and the consultant tells them he did not need to see them. Better quality referrals using e-referrals, photograph referrals and video conferencing can all help.

We need proper adherence to chronological order and that is not always being done. It is supposed to be urgent cases first and then all routine cases in order but that does not happen. We need better IT systems in particular to ensure this does not happen. We need to change the ratio of reviews to new patients. At the moment in any clinic there is approximately one new patient for every three seen, or one to about 2.6 patients. If that ratio is changed slightly, there would not be a need for more clinics. More new patients would be seen and instead of a review every six months, it would be done every seven months or patients could be discharged back to their GP. A slight change in the ratio with existing resources could actually transform the waiting list. However, making that happen in every hospital and clinic in the country is very difficult, in particular when one is working from headquarters. We need more consultants in many areas, in particular in some of the specialties such as dermatology, ENT, orthopaedics and others. If it was a case of just having more consultants, the problem would have been solved a long time ago. We have more consultants than ever in the health service. However, it is a bigger piece that needs to be addressed; it has never been addressed properly and we are doing our best in that regard.

Deputy Ó Caoláin asked about the closure of maternity units and he said it was premature to be discussing that issue. It is probably premature to be talking about it and I accept that criticism. However, I wish to make it clear that it is not ruled out in that it is part of what needs to be considered. It is important to underline that this is not just a question of staffing; adequate patient numbers are required. For example, if a unit has 2,000 births a year, that is three or four births a day. When that one in a thousand case arrives, that unit probably has not seen such a case before and it is not sure what to do. The nature of specialisation is that smaller centres can give more personal care but bigger centres are more used to dealing with those rare cases, those one in a thousand cases or those one in ten thousand cases. Sometimes these cases can be picked up in advance and referred to the specialist centre but sometimes they are not picked up and that is the inherent nature of a smaller unit when it comes to a specialist service. The same applies to emergency departments, to cancer treatment in the past and to many other conditions.

If I were to explain it very simply, 20 years ago medicine was very safe, very simple and it was not very effective. Now it is very effective, very complex and potentially dangerous. A person having a heart attack 20 years ago would have gone to the local hospital where they would probably not have been able to do very much for the person and any doctor could do it. Now it is totally different. For example, a particular type of heart attack, a STEMI, means a patient is taken by ambulance to a specialist centre where a specialist does primary PCI or else the patient is taken by helicopter in some cases. If it is not that type of heart attack, the patient goes to a different centre which specialises in thrombolycis, a treatment that cannot be done in every hospital and never was or could be done in every hospital. That is why there has to be a lot of changes. Our job as politicians is to explain to people why the best care is not necessarily the nearest care and that it might be better to travel an hour or two to the right place rather than to have local care that is not up to standard.

Another aspect to remember is that staff can become de-skilled, and this issue was raised in the HIQA report on surgery in Portlaoise. If the surgeons are not doing complex surgery every day, they will not be as good at it. It is the case that one will be better at something one does every day rather than what one does only once a week. That is often the problem with smaller centres; it is often not lack of staff but rather lack of patients with those particular conditions and needs.

It must be borne in mind that even where there are staffing issues, the recruitment of skilled professionals is very difficult. There is an international shortage of doctors, consultants, midwives and specialist nurses. As a result they generally want to work in big centres attached to universities and centres of research. There is a struggle to recruit to peripheral centres and this applies not only in Ireland. It is not just a question of money; there are many reasons. It will come to the point where we must ask if it is desirable that we are only keeping services open by staffing them with locums and agency workers who work for a week or two. These are the questions we need to tackle as a country. This was the situation with regard to cancer and it will be the case in other areas.

On the question of maternity models, the strategy group will examine this in the round. In my view there is a lot more space for midwife-led care and midwife-led units and a lot more space for the domino system which means mothers go home early from hospital. There is more room for home births, within reason, if these can be done safely. Therefore, there would be fewer hospital-based births and as the birth rate falls, we would need fewer hospital units. It will not be possible to have the two systems. More midwife-led care, birthing centres, community care and home births, along with fewer births overall, will mean we will hardly need the same number of maternity units. That is just common sense and we need to be upfront about that.

On the question about vaccines, no country in Europe as yet vaccinates its entire population or child population for meningitis B. The UK will be the first country to do so later this year. It is under consideration as part of the service plan for 2016 but it is not under consideration on its own in that other vaccines are available to be considered. I refer to HPV for boys and men. The rotovirus vaccine is not given in Ireland but it is given in other countries. We must also consider the BCG vaccine because it has now been recommended by the experts that we no longer vaccinate everyone for TB and that only high-risk groups are vaccinated. We will look at all the vaccines rather than one at a time in order to develop a package for the service plan for 2016.

Senator van Turnhout spoke about the satellite centres and I agree with her. The planning permission for the children's hospital satellite centres in Blanchardstown and Tallaght will be submitted at the same time, which is this summer. If planning permission is granted, they will be open in 2017, so the satellite centres in Blanchardstown and Tallaght will be open before the main hospital opens. There will be a national network so every paediatric ward in the country will be linked into the children's hospital using the same IT system. The satellite centres will be ambulatory. For example, the Blanchardstown centre is a big three-storey building with a walk-in emergency department, outpatient department and other facilities. The Tallaght centre will be similar. In general, people will bring their children to these centres if a child has a bad chest or an injury and they will not go to the main campus because that will be the specialist centre, by and large.

There are four stand-alone maternity hospitals, Holles Street, the Coombe, the Rotunda and St. Munchin's in Limerick. The plan is to co-locate these hospitals with adult hospitals. This can only be done one hospital at a time and Holles Street will be the first. The planning application to move to the campus of St. Vincent's hospital will be submitted this summer. The hospital will be on the campus but it will be separate from St. Vincent's hospital. A decision remains to be made on where the Coombe, the Rotunda and St. Munchin's will go but that decision will be made in a matter of weeks. The locations are obvious but we have to ensure that the decisions stand up, are supported by data and are not based on any political considerations. We cannot have any allegations that decisions were taken on that basis.