Simon Harris (Wicklow, Fine Gael) | Oireachtas source

I will take the questions in reverse order while they are fresh in my mind. On Deputy Durkan's comments, I think those of us in the political system may ask if there are people in the Civil Service who are committed to health reform. However, if we are to be honest, those in the Civil Service might also ask if those politicians are ever committed to health reform. I do not think Ireland Inc., the political establishment or the Civil Service have covered themselves in glory in terms of starting a reform process. There has been stopping, starting and changing. I certainly am aware of the level of confusion there has been in my Department in respect of health policy for a significant period. None of us can be fully absolved of blame in this regard. There is a great level of enthusiasm right through the Department now that there is a roadmap and also a plan that is not going to keep changing. We can actually get on with a body of work now, which is quite encouraging.

I take the Deputy's point about public representation. It should not be seen as a dirty word. People are elected to represent the citizens and have a right to stand up for their communities and constituencies. I think 8,000 parliamentary questions were asked of my Department last year. Certainly, the volume of issues Deputies are highlighting is quite immense.

I feel strongly about reinstating the board of the HSE. I spoke very strongly about that matter before the Sláintecare committee. I do not think it is appropriate that a CEO is effectively reporting to himself. I do not mean that about the individual CEO because I have heard that director general say the same thing publicly as well. We cannot have a situation whereby people meet and tell each other whether they are doing a good job or a bad one. In fairness, it was an interim arrangement because it was meant to be about dismantling the HSE. We now have the Sláintecare report and need to embrace the fact that there is going to be a national entity, albeit with much devolved to the regional structure. It is clearly stated on page 26 of the report that this is a move towards a form of regional health resource allocation with accompanying governance structures. There are some things that will always be done better on a national level. We would not have delivered a national cancer strategy that is saving thousands of lives if we had taken a fragmented approach. We would not have delivered some of the clinical programmes in respect of sepsis. Lots of progress has been made on the basis of operating at national level. Nonetheless, far too much has been centralised and is done at that level. There are often too many layers between the patient and the solution. The HSE, as currently configured, is not the vehicle of the future. The Deputy is entirely correct in that if we were to take the policy elements of Sláintecare and impose them on the current structures, we would not fix the health service. In fairness, the report does not propose that we do so but, rather, that we make significant changes.

The point about the budget is accurate. I can have an old and broken car and even if I spend an awful lot of money on repairs, it will still be old and broken. It is right and proper that we increase investment in the health service but the car we are driving needs to change. It is not sustainable to keep pouring money into the current model. Change and reform are not things that are nice to do for the sake of it, discretionary extras or things that we are all doing because we think we are supposed to. We actually have to do them. The system is falling over and we have to put in place a better health service.

In the context of this winter, the HSE publishes trolley figures every day at 8 a.m. They are there for all to view and show that over 1,300 fewer patients on hospital trolleys this November than last November and, overall, fewer patients on trolleys every day this November than last November. However, there are still far too many patients on trolleys. We cannot pretend to be surprised when we have not linked demographics to health services. I often use the example of education. One would be envious of being Minister for Education. That Department does not always get it right but, broadly speaking, every year it knows that there will be X children turning four, five or six and that Y number of schools, teachers, desks and so on will be required as a result. With, I accept, a few bumps in the road, it generally matches. We have not done that in the health service. That is what the Sláintecare report, the bed capacity report, the capital plan and the GP contracts are all about. It has to be demographically linked from now on and I want to assure members that it will be.

Senator Colm Burke referred to primary care. There are things we can do quickly to show a shift to primary care and make a real difference. There is the big stuff and the ten-year plan but there are things we can and should do next year. I was in Castlebar at the opening of the primary care centre, which Senator Rose Conway-Walsh attended. There were 517 people in April in Mayo waiting for an X-ray. They opened a primary care centre and put in an X-ray facility. There is an ultrasound facility going in now also and there are zero people waiting for an X-ray in Mayo. We are going to do one in Tuam. There are straightforward things. A very good example is the primary care eye review. Dr. Billy Power as clinical lead and others came together. Ophthalmologists in the community and acute hospital settings have spoken. At relatively small cost, they can shift an awful lot of procedures and review appointments out of the hospitals. We can do that. We should be able to start that in a real way next year. There are things we can do quickly.

There are other things that are going to take a little bit longer. This is where there is friction, which is recognised by the committee and the report, between building capacity and increasing the service. We have to be sure we get that right. I take the Senator's point that we do not want to lose what is good about our GP service. Recently, I launched the report by Professor Tom O'Dowd of Trinity, which showed that about 90% of Irish citizens are very happy with the GP service they get. They would like more and all that stuff but they are very happy. That will not come as a surprise or shock to any public representative or citizen. However, we do not want to end up with a waiting list for GPs. That is part of the Senator's point. When I tried to articulate that recently at the launch of the report, it got completely distorted by a GP organisation, which tried to say that I was making an outrageous point. I will restate the point I made now and on every occasion I am asked. It is that there are parents who go to bed worried about finding €55 or €60 to go to the doctor the next day. Regardless of whether GP organisations like me saying that, I am going to keep saying it. It is not acceptable. There is not just an equity of access issue in secondary care. There is an equity of access issue in primary care. Does that mean everything has to be absolutely free? I do not believe so. The Sláintecare report refers to "no cost or low cost" and there will be different things for different services. The point I was trying to make was that we need to have that discussion. It is not about competition authorities or setting fees. It is interesting that they said the Minster is interfering. People usually call on me to interfere in absolutely everything but when I dare to say something about €55 or €60 being too much for a lot of working families that do not qualify for a medical card, I am criticised. That does not mean it has to be entirely free. We should listen to GP organisations about the lessons from the provision for children under six, which are significant.

The Senator asked where we are with the contract in respect of the Financial Emergency Measures in the Public Interest, FEMPI, Act 2015. We have made good progress with the Government decision of two weeks ago. The Chairman has rightly raised this matter with me before on behalf of constituents. The issue has also been highlighted by organisations. We have a process to unwind FEMPI for public servants. People working in the health service today will start to get some of their FEMPI money back over a period. They have agreed to do different things as a result of that and the process is in train and has been accepted by all health unions. The health contractors had FEMPI and have not had a process of restoration. Our GPs have taken huge hits. At the event to which I just referred - although it was not reported - I also said that GPs have been put to the pin of their collar in many cases. They are under huge financial pressure. I acknowledge that. We have a process now whereby we can engage with GPs very early in 2018 in respect of FEMPI. I describe that process as an enabler for some of the changes we need to make to primary care.

The Senator asked where exactly we are with the contract discussions now. He is right that it is a very old document that we are working off and there is a huge amount of work to be done.

We now have a very clear list of all of the issues and all of the things we could do in primary care services. There are some things GPs want to do, while there are others we want them to do. We have that list and are working our way through the issues. I hope we can make some progress on it in 2018 in order that we can provide some additional services. The Budget Statement of the Minister for Finance, Deputy Paschal Donohoe, was instructive in its references to the need for a multi-annual approach. I was pleased when the Minister talked about the need for multi-annual investment in primary care services and the GP contract. The inclusion of that line in the Budget Statement should be seen as significant.

On the point made about administrators and managers, while I do not want to go back over conversations we have had previously or repeat information Ms Mannion has provided for the committee, it is important that we make sure everyone is on board for Sláintecare. We cannot have a situation where there is a different reform programme or process in the HSE from that in the Department or across government. Last week I chaired a meeting of the HSE leadership team and the Department's management team. We had a very good meeting and I felt there was a buy-in by both organisations. My aim was to deliver a clear message that there would be one plan and that was it. Once it is in place at the end of the year, whether someone is in the HSE or the Department, that will be the plan to which he or she will work. All decisions need to stem from it and not from a different reform agenda. There is room for only one ten-year plan. We can address a lot of the issues when we have the plan, but it will be the plan to which the HSE will have to work in the decisions it will make.

At one level the point about management turnover is valid. Deputy Louise O'Reilly often reminds me that it is difficult to make international comparisons at times, but I make the point that in the NHS there is probably a greater turnover of managers. Managers stay for significantly shorter periods in the NHS. That is what I am being told.