Simon Harris (Wicklow, Fine Gael) | Oireachtas source

I thank the Vice Chairman. I apologise for the late delivery of my script and the answers to questions. My officials and I will endeavour to work with the committee secretariat to ensure a more satisfactory situation in future. I welcome the opportunity to once again appear before the committee. I am joined by my colleague, the Minister of State with responsibility for mental health and older people, Deputy Jim Daly, and Mr. Jim Breslin, Secretary General, and Mr. Greg Dempsey, deputy secretary general, of my Department. I also welcome Mr. Tony O’Brien, director general of the HSE, and his officials.

Last year, 2017, was a significant year in terms of the progress made in reforming our health service. To make the changes required to create a health service of which we can be proud requires significant preparatory work. I acknowledge the very valuable work done in driving the reform agenda. Several key pieces have been put in place, not least the Sláintecare vision which several members of the committee were very influential in developing. My Department has overseen the finalisation of the ESRI’s projections of demand for health care in Ireland 2015-2030, the health service capacity review to 2031, the national strategic framework for health and social care workforce planning, the national trauma strategy which I am delighted was yesterday approved by Government and the national cancer strategy 2017-2026 which was published last July. These will feed into the Government’s response to Sláintecare, on which extensive work has been undertaken and which shortly will be finalised. Several key reform building blocks of which all members are aware and have discussed as being necessary were identified and published in 2017. This is needed in order to build the health service we want through identifying the capacity required, looking at specialties such as trauma and seeing how we can put in place plans to save lives rather than talking about it for years, working with organisations such as the ESRI to look not just at the current needs of the health service but what we will do when people in this country continue to age and, thankfully, live longer and in terms of ensuring we have the required workforce and make further strides in regard to cancer, where there have been extraordinarily significant improvements in survival rates in recent years, with figures published last week showing over 60% of Irish people with cancer now live five years or longer after diagnosis, up from only 40% in 1994-98.

I would like to take the opportunity to thank all those in our health services for their tremendous work in providing a high quality of care for patients, often in challenging and highly pressured circumstances. Our staff and patients deal with the system as it is today, both good and not so good, while those in positions such as mine urgently seek to introduce improvement and respond to growing needs.

Government is committed to the implementation of a significant programme of health care reform, as outlined in the Sláintecare report. I am pleased to inform the committee that significant progress has been made in developing the Sláintecare implementation plan, a draft of which has been shared by my Department with the Departments of the Taoiseach and Public Expenditure and Reform. Following discussions between Departments, I intend to shortly bring the plan to Government. As members are aware, the recruitment process for an executive director of the Sláintecare programme office, as raised with me on my last appearance before the committee, is now well under way and I expect the selection process to be completed by April.

I acknowledge that members are particularly interested in discussing the issue of overcrowding in hospitals and I assure them it is also a priority for me and I will address the issue at the outset. I am of the same mind as members in regard to patients on trolleys waiting for long periods in overcrowded emergency departments. Neither I nor anyone else in the Government or the HSE is claiming that the difficulties which arise immediately after the new year are unpredictable, which is why detailed plans and extra resources were in place. However, we still encountered a surge that was extremely challenging for the system. There is a difference between predictable and avoidable and to achieve the latter we will have to break the cycle of overcrowding. All present accept that will not be done by any one year’s winter plan.

I wish to first focus on this year’s winter plan. As part of budget 2018, an extra €30 million was made available to respond to winter pressures in 2017, with a further €40 million being provided in 2018. This investment is aimed at alleviating pressures in our emergency departments during the winter period, includes increased access to home care, transitional care and extended access to diagnostics along with additional bed capacity. While it did not achieve all that everyone in this room would have wished, it is having an impact, which is very important. An extra home care package, an extra transitional care bed or one of the 170 or more extra beds we have opened in the health service is a benefit to the man or woman availing of it. The extra resources produced benefits for patients in the health service.

However, we must consider the context in terms of emergency department attendances, which rose by 2.8% last year. We can get lost in figures but that is over 34,000 additional patients compared to 2016, including a 5.6% increase in emergency department attendances by people over 75. Within this context of increasing demand, HSE data indicates that at the end of December 2017 there had been 2.6% or 2,517 fewer patients waiting on trolleys in 2017 compared to 2016. Although there are varying figures in this regard, such as those produced by the INMO, it is important to note that even the INMO figures for November noted a significant drop in the number of patients on trolleys, so we did see some benefit from the extra resources put into the system. That is based on the measures being implemented at all levels and shows incremental improvement within a challenging operational environment.

However, it is important to acknowledge that in spite of the intensive efforts of staff, management and the HSE over the winter, since the beginning of January this year we saw the annual situation whereby the system tipped over and there was a significant increase in the number of patients on trolleys, along with a continued increase in the age and complexity of those patients. Each winter, the system must also deal with the increased demand for services due to the prevalence of flu, which is currently at its height. Our system is also working hard to grapple with the challenge of infection prevention and control, specifically the emergence of superbugs. We might later have an opportunity to discuss how the health service infrastructure does not help in terms of stopping the spread of superbugs and the need for capital investment in that regard.

Considerable reform and additional capacity are needed to reduce the unacceptable number of patients who are still ending up on trolleys. This winter we are opening over 300 additional beds. As I stated, 170 additional beds have been opened with a further 139 due to come on stream. The capacity review report will inform our plans for increasing capacity further.

Notwithstanding the rising demand and pressures on our hospital system, some hospital sites have made a considerable leap forward in improving their trolley performance in the past year. That is testament to the great and local work being done by health service staff. I acknowledge the hard work of hospitals that continue to focus on improving patients’ emergency department experiences in challenging circumstances. I hope those working in the health service can take heart from the national patient experience survey, whereby we did not listen to commentators, politicians, representative bodies or the Minister but spoke directly to patients. Almost 14,000 patients who spent one night or more in an acute adult hospital were asked about their experience, with 79% rating their admissions experience as good or very good and 85% rating their overall hospital experience and stay as good or very good. Even in the very challenging circumstance of over 1.2 million people attending our emergency departments every year, the vast majority report a good experience in that regard. It is obvious that there are still far too many people for whom that is not the case and we must work on that. The capacity report outlines in an evidence-based, internationally peer-reviewed way the number of further beds needed in hospitals and the community out to 2031. There is now nowhere to hide as the figures are available. Even if we reform the health service, as we must, we will still require 2,600 additional hospital beds by 2031, some of which are urgently required and will have to be front-loaded. I am advancing the capacity report through conversations with Government colleagues in regard to the capital plan.

I wish to reassure people that the budget for the national treatment purchase fund, NTPF, and waiting lists has now dramatically increased and I expect there to be good progress in driving down waiting lists as we come into the spring. In five of the last six months of 2017, there was a reduction in the number of patients waiting for a hospital operation or procedure. Far too many people were waiting but in five of the last six months of 2017 the number waiting for procedures on hips, knees, cataract or other inpatient day case procedures fell. The increased investment we are making does make a difference. Now that we are significantly increasing the size of that investment this year and giving the NTPF a total budget allocation of €55 million, which more than doubles its 2017 allocation of €20 million, I expect further progress in that regard.

Colleagues in the HSE and NTPF are working on additional waiting list measures, including scheduling a much increased volume of procedures over that undertaken in recent years. The HSE is also focusing on scheduling patients in public hospitals in specialties that have patients waiting long times for procedures and when more complex procedures are required.

It is important to note, and something we do not hear very often, at present in this country over 57% of patients wait less than six months for a hospital operation or procedure. I want to drive that down further but that is the reality. More than 84% of people wait less than 12 months. We want to drive that down further as well. However, that is the reality. This is happening despite the additional demands on our acute hospitals, which, since 2000, are carrying out four times more procedures for patients aged 65 and over and twice as many in the under-65 age group. That is an incredible figure. Four times more procedures being carried out in Irish public hospitals for patients aged 65 and over than in 2000.

It is important to acknowledge our outpatient waiting list remains the biggest challenge. It is worth noting last year almost half a million, 479,000, outpatients did not attend their appointments. That is not patient blaming in any manner or means. It is acknowledging that almost half a million people last year who were invited into an Irish public hospital to have an outpatient appointment did not attend. That suggests to me there is a serious issue to ensure the accuracy of our lists. Every one of those missed appointments is somebody else who could have had an appointment.

When people in this room, including myself, commentate on the size of outpatient waiting lists, it is important to inject into that conversation that 479,000 outpatients did not attend their appointment last year. We need to get under the bonnet in working out why that is the reality. The HSE is working with my Department in respect of that. In tackling that issue, we also need to look at the balance between new and return appointments. That will free up considerable capacity to address outpatient waiting lists. A number of steps are being taken to ensure the lists are accurate and these efforts are going to intensify significantly in the coming months.

In line with Sláintecare’s recommendations, we also need to prioritise the improvement of our primary care services. Last year, I extended eligibility for medical cards to children covered by the domiciliary care allowance. We are working now to enable all persons in receipt of carer’s allowance to qualify automatically for a general practitioner, GP, card from later this year. That has been welcomed by all political parties and groupings. Investment in additional staffing and service re-orientation has also been made in the therapy areas, most recently in budget 2018 with funding provided for the recruitment of extra occupational therapists. Additional funding has also been provided for continued investment in, and expansion of, our community intervention teams, a vital nurse-led service which is a successful hospital-avoidance measure, as well as enabling patients to be discharged earlier from hospitals.

To build on these developments a key priority for me and the whole of Government in 2018 is the negotiation of a new GP services contract. I acknowledge the important role GPs play in our health service and my strong commitment to the development of a new GP contract. One of the key objectives is to develop a contract which has a population health focus, providing in particular for health promotion and disease prevention and for the structured ongoing care of chronic conditions. In this country, we have people being managed for chronic diseases in our acute hospital settings that in most other European countries would be managed in the community. Our GPs are up for having that conversation, we need to have that conversation and we need to shift the management of chronic disease from our hospitals into the community.

A process of engagement with the representative bodies of contracted health professionals is planned, aimed at putting in place a new multi-annual approach to fees, commencing in 2019. We are also looking at service improvement and contractual reform in line with Government priorities and the Sláintecare report. Agreement in principle on this process has now being achieved with the Minister for Public Expenditure and Reform. It was reflected in the revisions to the FEMPI legislation he brought through the Houses of the Oireachtas before the Christmas recess. Officials in my Department are undertaking preparatory work with the Department of Public Expenditure and Reform and with the HSE in respect of this important agenda. This is an vital issue in the context of the GP contract negotiations, as representative bodies have sought clarity on this matter. I hear them clearly on wanting a process to address FEMPI and discuss what more general practice and other health contractors can do in the context of the reform agenda.

It is essential that engagement on GP contractual issues is aimed squarely at meeting the substantial challenges, current and future, the health service and general practice face. I want to be clear to our general practitioner colleagues. We their profession to be sustainable and we need them to have confidence that being a GP can be a sustainable career now and into the future. At my request, officials of my Department are working with their counterparts in the Department of Public Expenditure and Reform and in the HSE to ensure that the overall approach is focused fully on the strategic challenges and on the reform agenda. The wider reform agenda set out in the Sláintecare implementation plan will inform the approach to be taken in developing our GP services and improving access. I look forward to intensive progress in the coming months on the GP contract and I hope and expect agreement can be reached on the introduction of a range of service developments starting in 2018.

I want to turn briefly to the recruitment and retention of staff within our health services. I accept we face challenges. We discuss this on a very regular basis at this committee, although it is important to acknowledge that the level of recruitment in the health services is continually increasing. There are more people working in the Irish health service this year than last year and more last year than the year before. A national strategic framework for health and social care workforce planning has been developed by a cross-sectoral group led by the Department of Health. It will support the recruitment and retention of the right mix of workers across the health and social care system to meet planned and projected service needs.

The issue of pay restoration in section 39 organisations has been the subject of considerable debate, most recently in this committee last week. I have asked the HSE to carry out an evidence-gathering exercise to establish the factual position regarding pay reductions and pay restoration in these organisations. This analysis will establish, with supporting evidence, whether, when and to what extent reductions in pay rates were applied during the crisis in each relevant organisation. It will also establish whether, when and to what extent restoration of pay reductions has happened and will identify the financial implications for each organisation, taking account of all sources of funding, associated with addressing the issues identified and will propose an appropriate plan for phased resolution in each case. It is anticipated this process will bring about the necessary clarity and transparency and lead to an agreed way forward. Contact is continuing with the parties involved and it is at a sensitive stage. This issue needs to be resolved and put into a process. It needs to be resolved without the need for any industrial action that would cause any difficulty for any patient, client or citizen in this country.

The 2018 national service plan sets out a budget of more than €14.5 billion for the HSE. That is the highest budget ever allocated. This represents an overall increase of over €600 million on 2017, which is, by any measure, a substantial additional level of funding. The amount allocated each year follows an extensive process, which must consider both the funding requirements as submitted by the HSE and the reality of the fiscal position this country faces. This process concludes with the Government making a decision as to the funding it will be in a position to provide to the HSE.

These types of engagements are a normal part of the budgetary process and happen with all agencies across Government. All public bodies put forward spending proposals but all such bodies, including the HSE, are required to operate within the amounts proposed by Government and determined by the Dáil. While increased resources contribute to health service improvement, there are also ways in which improvements can be achieved within the current resources. I know this is a view shared by HSE colleagues and the HSE has my full support in achieving these improvements as part of our shared reform agenda. It is simply not possible to achieve in one budget all that we want to achieve.

However, it is absolutely possible to achieve a number of those things over a multi-annual basis. As economic stability and growth of this country continues to move forward, we will be able to build on progress every year. However, it is a statement of fact that every year every agency in this State will seek more funding from the Exchequer than the latter can provide. Each agency then has to work to turn that into a plan for the organisation during the year. The HSE, as I said, has my full support in the delivery of what I think is an ambitious and exciting service plan. It will see all services either maintained at last year's level or, in many cases, being increased on last year's level. I touched on a number of those areas where we will see increases.

We all share the same goal. Working together, we need to find sustainable solutions to the issues facing the health services. I believe 2018 will be the year of reform and the beginning of adding extra capacity in order that we can build a better health service for patients and staff. It marks in a very real way a reversal of previous Governments' failed policies of reduction of bed capacity by making it clear we need more hospital beds. This year commences with the publication of a trauma report so that we can build on patient outcomes and save patient's lives. The recruitment process is under way for a Sláintecare lead. I refer also to the publication of a capacity review and very shortly the publication of an ambitious and exciting Government capital plan. There will also be external reviews for all maternal deaths in our health service, improved cancer statistics and a renewed and energised focus on a GP contract and FEMPI.

I look forward to the year ahead and trying to build and show demonstrable progress in a number of areas of our health service.