Oireachtas Joint and Select Committees
Thursday, 5 February 2015
Committee on Health and Children: Select Sub-Committee on Health
Estimates for Public Services 2015
Vote 38 - Health (Revised)
I welcome the Minister for Health, Deputy Leo Varadkar, and his officials from the Department of Health: Mr. Jim Breslin, Secretary General, Ms Fiona Prendergast, finance unit, Mr. John Keegan, principal officer, and Mr. Barry Murphy, principal officer. The purpose of today's meeting is to consider the revised Estimates for 2015. Our meeting today will involve a slightly revised format, designed to encourage more focused scrutiny of the financial Estimates by linking them to Department's goals and targets. This is a significant opportunity for the Department and the committee to work together to enhance the scrutiny process and to encourage useful debate. I take this opportunity to thank the Minister's officials and acknowledge their efforts in preparing the briefing material for today's session, and for supplying additional information on specific areas and on performance, which I hope will benefit the meeting.
Session A covers the Department's performance in three areas of activity: the primary care community drugs schemes, acute hospitals and delayed discharges. For the benefit of members and those watching and listening at home, the format is that I will invite the Minister to make his opening remarks and to comment on the issues of performance, after which members, who have been supplied with briefing materials, may ask questions. In the first session, members should confine their questions to the three areas under scrutiny - namely, the cost of prescription drugs, acute hospitals and the issue of delayed discharges. The session will then be followed by an examination of each budget subhead in order. A draft timetable has been circulated. Is that agreed? Agreed.
Members have been given the departmental briefing note on each of the Votes. I will first call the Minister and then invite the Opposition spokespersons, Deputy Billy Kelleher and Deputy Caoimhghín Ó Caoláin, to respond to the Minister before inviting committee members to address questions to the Minister on the areas concerned. I ask members, including the Minister, to be conscious of time. I am aware that the Minister has another engagement. I invite the Minister to make his opening remarks.
I am pleased to have the opportunity to address the select sub-committee today on the revised Estimates for 2015 for my Department - Vote 38.
I very much welcome the new emphasis on performance in these discussions. The briefing provided to the Deputies this year concentrates on the three particular service areas in which the committee has expressed a particular interest - primary care services, acute hospital services and long-term residential care.
On my appointment as Minister for Health, I said on more than one occasion that my first priority was to achieve a realistic budget for the health service. We have achieved that in the revised health Estimate for 2015. Before looking at the Estimates in detail, I wish to make a few general observations on the overall budgetary situation, as there are a number of complicating factors this year.
The disestablishment of the HSE Vote is, we all appreciate, a complicating factor when comparing year on year.
Since the beginning of this year, the HSE is funded by grants provided under Vote 38. The revised Vote structure has resulted in income of €1 billion, previously accounted for as appropriations-in-aid under the Vote of the HSE, being accounted for as income in the annual financial statements of the HSE rather than the Vote for the Department of Health. This income comprises hospital maintenance receipts, superannuation, the pension levy and other miscellaneous income such as car parks, restaurants and the primary care reimbursement service. Restating the Health Vote for 2014 on a like-for-like basis consistent with the new Vote structure, the gross Revised Estimates provision for the Health Vote for 2014 is €12.113 billion, while the post-Supplementary position is €12.793 billion. In other words, the gross Vote for 2015 is €564 million more than the original provision in 2014.
In addition to the increased Exchequer funding, additional non-Vote income collected by the HSE of €131 million and at least €130 million through cost reductions and other savings have also been identified and will be retained within the HSE to support services providing, in effect, €825 millionin additional resources, as compared with the original position in 2014 or, more accurately, €145 million compared with the post-Supplementary position. This funding increase is part of a two-year process to stabilise and improve health funding. The spending ceiling for health in 2016 has been increased by a further €174 million. Given the demographic pressures facing the sector, there is no question that the budgetary situation remains challenging. I am confident, however, that we are in a much more stable financial position than we have been for some time.
The budget parameters for 2015 have allowed the HSE service plan to include a number of targeted enhancements to health and social care services, while providing generally for the delivery of existing levels of services. The service plan also progresses key elements of thehealth service reform programme. In addition, the Minister of State, Deputy Kathleen Lynch, and I recently published our 25 health priorities for the year ahead. These measures include legislation to reduce alcohol consumption, proposals to extend the remit of the Health Information and Quality Authority and the range of services available in primary care, moves to increase the number of people with health insurance and the first national survey in eight years of Ireland’s health. These priorities provide a clear direction for the development of health services and policy in 2015 and align with and support many of the developments provided for in the service plan.
There is, undoubtedly, a strong case for increased funding in health in the years ahead. However, it is also important to acknowledge that, with growing demand, increasing health funding without reform will not resolve the difficulties in our health services. Our experience during the boom Celtic tiger years, when considerably increased year-on-year funding was spent on health without a satisfactory return, is a stark testimony to this. Providing more resources without reform simply will not work, which is why the continuation of the programme of health service reform is of critical importance.
With this in mind, the HSE’s 2015 service plan gives priority to progressing the Government’s reform agenda. This plan provides for the establishment ofcommunity health care organisations,which will improve the way in which primary care in the community is delivered. Likewise, the reorganisation of public hospitals into hospital groups is designed to deliver improved outcomes for patients. Each group of hospitals will work together to provide acute care for patients in their area, integrating with community and primary care. The objective is to maximise the amount of care delivered locally while ensuring that specialist and complex care is safely provided in larger specialist centres. One of my priorities for 2015 is to get the community health care organisations and the hospital groups up and running. As part of the reform agenda, I also expect to see the issuing of the first individual health identifiers, which is the equivalent of an identification or PPS number for health, increased investment in ICT and e-health and the embedding of the activity-based funding model in the health service in 2015. This year’s Estimate provides for an almost 40% increase in ICT funding, from €40 million to €55 million. This needs to be sustained in the years ahead.
The HSE has put in place a considerably enhanced governance and accountability framework for 2015. This is set out in detail in the service plan. The framework provides the means by which the HSE, hospital groups and community health organisations and other units will be held to account throughout the year for their efficiency and control across the balanced scorecard of access to services, patient safety, finance and human resources.
A suite of performance indicators for 2015 is set out in the HSE’s 2015 service plan. Having clear and achievable targets is important both in terms of driving performance and activity forward and in measuring past performance. Performance indicators are particularly useful when it comes to measuring volume and throughput. However, they are not always sufficient in themselves when it comes to evaluating the more qualitative aspects of service delivery. For example, an existing performance indicator for ambulance response times measures the extent to which a target time of 19 minutes is achieved. This is an important measure but what it cannot do is consider or take into account the actual outcome for the patient. For example, an ambulance getting to the patient in 18 minutes but the patient dying is counted as a success whereas the ambulance getting to the patient in 21 minutes, defibrillating him or her on the scene and the patient surviving is considered a failure. That is often how targets work. HIQA now acknowledges that we need to have a different set of targets, with new ones based on clinical audit and actual patient outcomes.
As I mentioned earlier, the 2015 service plan provides for the delivery of an existing level of services, with targeted enhancements in some areas. Enhancements include the commencement of the extension to the BreastCheck programme to women aged 65 to 69 years of age, implementation of the first two phases of a universal GP service, making a GP service without fees available to all children under six and everyone over 70 years, and the provision of €30 million in funding for new hepatitis C drugs which cure the virus. An additional €35 million in ring-fenced funding is being provided for mental health services in 2015. A number of measures will be taken this year to develop primary care services further, thereby allowing more people to receive a wide range of quality services in their own community. An additional €14 million is being provided for primary care developments, including the extension of the pilot ultrasound GP access projects in the south and west and the provision of additional minor surgery services in agreed GP practices and primary care centres. There will also be an extension of the GP out-of-hours services, within existing resources, to areas currently not covered, and more spending on community orthodontic and ophthalmic services. An additional €2 million is being provided to improve maternity services.
The Minister of State, Deputy Lynch, and I are also keen to deliver real improvements in patient access and experience in our hospitals in 2015. For this reason, we have included clear targets for 2015 in relation to delayed discharges, trolley waits and waiting lists times in our recently published health priorities for this year. We want to reduce by one third to fewer than 500 the number of patients with delayed discharges, and we are seeking to reduce by one third to fewer than 70 on average the number of patients on trolleys in emergency departments waiting more than nine hours for admission. We are also committed to developing and implementing a plan to address waiting lists, with a focus on very long waiters, so that by mid-year, nobody will wait longer than 18 months for inpatient and day case treatment or an outpatient appointment, with a further reduction thereafter to no greater than 15 months by year end. These targets involve progressive and measurable improvement for patients and I expect all hospitals to meet them at a minimum and, where possible, surpass them.
As Deputies and Senators will appreciate, there are enormous demands and cost pressures on our health service. Health care demand continues to rise due to our growing and ageing population, the increasing incidence of chronic conditions, and advances in medical technologies and treatments which can be very expensive. Health services all around the world are struggling with this issue of rising costs, deficits and difficulties and getting staff. An interesting article in The Guardianin England pointed out that the NHS has spent €2.6 billion on agency staff because of the difficulties it is having in recruiting staff and that most NHS trusts are now in the red. I am aware of the limitations as to what can be achieved with the additional modest increase in funding available this year. We clearly do not have sufficient funds to address immediately all areas of concern across the health sector. However, what we have been able to do in this year’s HSE service plan is make a welcome start towards stabilising and improving the funding of our health services.
I thank the committee for its attention and I commend the Revised Estimates for the Health Vote to it. I am happy to supply any further information or clarification that Members may request.
I thank the Minister for his opening statement, the conclusion of which, as should always be the case, sums up where we are in the context of the health services. As acknowledged by the Minister and Mr. O'Brien of the HSE, health funding is inadequate in terms of provision of care for people going through the health system. This is very evident in the context of our emergency departments. The Minister said that there is funding in place to stabilise the situation and that we are off to a good start. The bottom line is that we are not off to a good start. Rather we are off to a bad start. In the first month of 2015 there was a huge escalation in the number of people attending our emergency departments.
There is chaos in emergency departments throughout the country. There were 46 patients on trolleys in Limerick yesterday, 40 in Drogheda and 38 in Beaumont. On Monday I spoke to people who attended the emergency department in Cork University Hospital and were stunned by what they witnessed. People did not even have chairs to sit on while they were waiting. We are off to a very bad start.
The difficulty I have is that the plan lacks a certain amount of ambition. In fact, there is no ambition whatsoever in this HSE service plan and the Estimates to underpin and fund it. In the context of waiting lists, the Minister has, in effect, changed the targets because he failed to meet the previous targets. Johnny Sexton never comes off a rugby pitch and says the reason he missed the conversions was because the goals were in the wrong place. It is simply incredible that we now have a situation where we have run the white flag up the pole and accepted that the previous targets were unattainable, and are returning to ones which should be more attainable. The previous targets were wrong.
People should not have to wait eight months. In the mind of the Minister, 18 months is okay. I find it incredible that we are now accepting poorer standards of care. We have always emphasised the fact that, clinically and psychologically, it is bad for people to have to wait, and it is also bad for the health service in the long term because it will cost more when such people are eventually seen.
The Minister should be trying to address what is causing delays rather than changing the targets to make it look like there are no delays. That is what he has done in the context of inpatient and day case treatments. I do not know why anybody would come to the meeting and assume that things are getting better. We have had an appallingly bad start to 2015. We can assume that if things continue like this, within a matter of months we will encounter major difficulties.
I am most concerned about day cases and inpatient day cases because there has to be an acknowledgement at some stage that additional funding needs to be provided for the National Treatment Purchase Fund. There is no point in the Minister, Mr. Breslin or whoever the Accounting Officer for the health services is - I am still unsure about that - sitting here and pretending that we can get through this with what we have. If we try to get through with what we have, the Minister will have very long waiting lists and will have to increase targets again.
We have to accept that to deal with the escalation in waiting lists, the number of patients who have to see a consultant and those who will need to have treatment or procedures carried out this year, we will need to fund the National Treatment Purchase Fund. That is something that we will have to revisit very quickly for the sake of those who are on waiting lists.
I wish that the situation was other than what it is. That is probably the Minister's view of things as they stand. There are many things which are working well within our health services, and that is to be acknowledged. It is important that we start by acknowledging what I have described time after time as the heroic efforts of front-line service providers, not only, but very particularly, across our network of acute hospital sites.
I have noted during the past 12 months a significant increase in patient dissatisfaction presenting to me in specific individual cases and from collective reflection on experiences shared by a number of people, not only within my constituency but throughout the State. That has been added to over the past 12 months by more people who are service providers within the system coming forward in tandem and reflecting on their experiences as workers within the system.
I have no doubt that the Minister is at least as equally aware of this as I and other voices in the committee are. We need to face up to the problems that exist. We can only do that with a collective response in a properly worked out, structured and resourced way. That is not what is happening.
This year is the first time in seven years that there has not been a reduction in the budget; instead there is an increase. Despite all of the marketing language of the budget for the health services, at the end of the day, against the backdrop of the Supplementary Estimates in 2014 and 2015 and the reality that there will be a process of carrying forward what are described as overspends year on year following the passage of legislation during the past year, there are very serious problems not only for this year but mounting year on year for the years to follow.
The Minister has been in office for several months, and I had hoped that by now he would have laid out a very carefully thought out plan of address. Rather than responding to one point or deficiency, I had hoped such a plan would encompass the critical elements that we need to address. These are presented time after time. The need for additional resources is the bottom line. We need more consultants and consultant posts. We need to see more nurses engaged in the hospital network. We need to resource community-led responses. The focus should be on primary care and the prevention of ill health.
No substantive and cohesive plan has been presented that gives me confidence that we will see a significant difference in the course of 2015 as against the year gone by and preceding years. That is a major problem. Problems are mounting on each other, as I have said, and the situation will get worse. I am not reflecting words I have authored, but I am reflecting what service providers have said to me. They have said we no longer have a patient-focused service. That is a very worrying reflection on the situation as seen by those who are front-line providers and have, as I have said, performed heroically despite all of the challenges they face.
I have had considerable experience of our health services over the past 12 months, not only in my personal life but also my family life. I can say without any question that a wonderful level of service is being provided by people who are going far beyond what is or could possibly be expected of them. That cannot be missed. What is happening to them in turn is that they are being worn out and will be burnt out before their time. I said earlier that they have lost the zest for their career path.
All of that must be faced up to. If those we trust to look after our health care needs suffer burn-out and loss of verve patient safety will certainly be at risk.
There has been considerable investment in the development of the mental health services under the programme for Government, amounting to €130 million extra over four years. There was, however, also a lot of frustration at the HSE’s delay in implementing the programmes. The recruitment is often not commenced until March or April of the year allocated. By the end of the year very little of the planned recruitment takes place. How many mental health professionals should have been recruited under the programme up to 31 January last and how many were recruited? Most of those were to go into the community-based mental health services which were a key part of the Government’s plan, which are urgently required and are very welcome.
The investment took place out of the contribution to the child and adolescent mental health service, CAMAS. How much funding was given to CAMAS? What was the planned programme for the development and how has it progressed?
In the third year, only €25 million of the €35 million budget was allocated and a promise was given that it would be made up later. What plans are there to allocate that as promised, when the reduction did not take place in 2013?
If the Minister cannot answer those questions we can come back to them under the development sub-head.
This session is focusing on the key areas of activity under the headings of primary care reimbursement service, drugs refund scheme, acute hospitals and long-term residential care and other support services for older people. Members should keep their questions to those topics.
This morning we received a petition from the Gilmartin family in Mayo whose child, Ryan, has Down's syndrome. We have had regular debates on medical cards and how we fund primary care and support those who need assistance. We are talking about the roll-out of free general practitioner, GP, care for everybody, which should have happened by this year but will not. Free GP care is for those under the age of six and over the age of 70.
Many people who need the State’s support fall through the cracks. They need access not only to their GP but to secondary services and we must address that in a meaningful way. We can talk about political parties and health policies and differing views on how society should be structured but a child with Down's syndrome needs and deserves the support of the State. I understand the complexities involved and that the Minister considered this with an expert group but there is an element of discretion which must be used in a meaningful, fair and compassionate way. We can understand that some people may pretend there is something wrong with them or try to cheat the system but there is no cheating with Down's syndrome. This family needs support. The problem has been going on for a long time, not only for this family but for many others where there is long-term illness or disability and who, because of the means test system operated under the Health Act 1970, cannot qualify on income grounds but should qualify on the grounds of compassion and decency. We have to focus on that issue in respect of the primary care system and medical cards.
If nothing else is done today could the Minister act on the petition sent to the Chairman today, and on others who fall through the cracks? Most people would welcome universal free GP care but not if the Government is funding it by taking money from somebody who has Down's syndrome. In effect that is what it is doing because by the Minister’s admission there is inadequate funding in the health service. Providing free GP care to all those under the age of six means taking it from those who need it most. The Minister can try to dress that up and spin it any way he likes but that is why Ryan Gilmartin was outside the gates of Leinster House this morning, a cold February morning, having travelled from Mayo. The Government has prioritised healthy children of wealthy people over a child who needs and deserves the support of the State. I would like the Minister to address the case of Ryan Gilmartin and the many others in a similar situation. This has been aired publicly and the public expressed its view on it last May, when it was a central issue in the local election.
The Estimate this year does not cater for the Ryan Gilmartins but it will cater for giving free GP care to under sixes and over 70s. We are discussing many people in that predicament. The Estimate is inadequate for overall services but if the Minister tries to stretch it to cover universal GP care the most vulnerable will suffer, as evidenced by what happened outside the gates of Leinster House this morning.
I have tried in my opening remarks although the Minister may not see it, to be balanced and fair. I will try it again. The Minister may not appreciate it but it is very difficult when so much of what is presented to us, certainly as Opposition health spokespersons, can reflect negative and, in some instances, disturbing experiences.
I will start again, as I have attributed, rightly, great credit to our front-line care providers in various health care settings, by saying that I welcome very much the indication of significant savings in the overall drugs bill to the HSE. In the period 2012 through 2014, we are looking at a significant reduction in the total of the primary care reimbursement in regard to drugs. That is the result of a focused address of the issue, but much more can be achieved. That was acknowledged by the Minister's predecessor and I have no doubt it is his own view. Having welcomed the savings to date, I would like to know if further engagements are intended with the Irish Pharmaceutical Healthcare Association on proprietary drugs and with the Association of Pharmaceutical Manufacturers in Ireland in regard to generic drugs. What further engagements does the Minister intend to have? Is he seeking to achieve new and increased savings through agreement with both these bodies?
It is important to note that the figures that were shared with us demonstrate that over the period of the first decade since the turn of the millennium, there was a more than doubling in the number of individual prescribed items across the State. While the IPHA and APMI are undoubtedly to be focused on in regard to cost, is it the case that there is ongoing or intended engagement with GP representative organisations to responsibly address this issue to ensure that the most thoughtful and careful consideration goes into prescribing? The Minister is a doctor himself. I would like to know if he has intentions in that regard and if he considers that there is a need to address the significant increase in prescribing. Does he believe there is an element of over-prescribing in all of this that warrants focused attention?
On the cost of drugs and the nine State basket whereby we determine the median position, I have urged the Minister's predecessors to consider the potential of moving from the median position to the lowest with all of the resultant savings that would accrue to the Exchequer and the health spend. Has the Minister considered that and does he intend to engage in that regard? I ask him to give me some information on this.
I take the opportunity again in order to be balanced to welcome yesterday's HSE decision on Soliris and PNH which followed its recent engagement with the manufacturers. It must be a phenomenal relief to that small number of sufferers outside the ten who are being catered for through the St. James's Hospital arrangements. I commend the decision. There are other products which have had pharmaco-economic assessments. Does the decision on Soliris and PNH indicate a relaxation in that regard and suggest that other critically important products to the health and well-being of other sufferers of other challenges in life might expect a similar response?
The time is limited and we are trying to cover three areas in this new format. As such, will the Chairman allow me to move on to the acute hospitals and waiting lists?
I thank Deputies for their contributions and will do my best to cover them. As of 8 a.m. this morning, the position on emergency department overcrowding is that there were 372 patients on trolleys in emergency departments or on wards. Of those, 183 had been on trolleys for more than nine hours. As such, it is a significant improvement on the position earlier in the week. That ranges of course from no patients on trolleys in Wexford and Tralee to as many as 37 in Tallaght, of whom 12 were on trolleys for more than nine hours.
The situation is certainly worse than it was this time last year and nobody is trying to say otherwise. It is due to a combination of factors. There is a higher level of delayed discharges than this time last year with perhaps 100 or more. It has also been difficult to recruit senior decision-making doctors in some hospitals. Junior doctors who are less experienced are more likely to admit patients to be safe than more experienced doctors. That is definitely a feature in some of the more peripheral hospitals where more than half of patients are being admitted, whereas the statistic should be approximately one quarter. In some hospitals, we have an influenza-like illness, Norovirus, which is adding to numbers and causing beds to be closed for infection control rather than monetary reasons. The situation has been worse in previous years than it is now, but it remains very bad. Aside from the discomfort and lack of dignity, having anyone waiting many hours on a trolley creates an infection control risk and there is a risk of treatment being delayed. It is also a patient safety issue.
In terms of actions, 300 additional fair deal places have been allocated as have 400 additional home care packages. Approximately 500 transition and community beds have been reopened or funded and we are working on getting another 200 beds opened in the next two weeks across the State. We are not taking anything for granted or assuming that things will get better as the spring comes in. In addition, Mount Carmel will be opened as a community hospital for Dublin in March. We will keep plugging away at this. As Mr. Liam Doran of the nurses' union said yesterday, this is the most sustained effort we have ever seen to tackle this issue. We are not succeeding quite yet but will keep at it until we do.
The targets on waiting times have not been changed and the 20-week target for children and the eight-month and one-year targets for adults remain in place. They will be reported on every month in the HSE's PAR as they always have been. When one cannot do what one wants, one does what one can. We can deal with those very long waits where people are waiting 15 and 18 months from within existing resources. That can be done in particular by adherence to chronological order. Unfortunately, there is evidence in a number of institutions of failures for whatever reason to stick to the chronological order. GPs will tell one that they send patients in with the exact same condition, some of whom get their operations within three or four months while others are on a waiting list for a year. We do not know why that is, but it is something that will have to be focused on very carefully to ensure that urgent cases are prioritised and then everyone else is seen in chronological order. Queue skipping is not ethical or acceptable and it has to stop.
There were no targets on waiting lists when Fianna Fáil was in power. There were newspaper reports that people were waiting six years in some cases for treatment under the then Minister, Deputy Micheál Martin, at a time when there were endless amounts of money in the health service. As such, Deputy Billy Kelleher could be a little less shrill in his criticisms, particularly if he wants that man to be the Taoiseach. Obviously, I would like there to be more money.
So people say.
Obviously, I would like to have more money to address waiting times. We do not have it but I would love to get it. If I did have it, we would be able to spend it on reducing waiting times. I am not sure I would use the NTPF mechanism, as the Deputy suggests. What that involves is essentially paying private hospitals to do the work of the public sector. There may be a role for that, but it is not my favoured role. I would prefer to see us opening the closed theatres in public hospitals, such as in Cappagh, and the two closed theatres in Nenagh. I do not think the default solution should be to pay the private sector, because that is an expensive option. It also creates a perverse incentive to have waiting lists if people know that their waiting lists will be bought off by the Government and paid for in the private sector and they can then be paid twice for the same patient in some cases. This would create a very perverse incentive and that is what happened under the previous Government with the NTPF. That is not to say there may not be a role for it where we do not have the capacity in the public system, but where there is capacity we should use the public system's capacity first.
Would the Minister include in that commentary a decision not to change consultants' contracts in order to help tackle the waiting lists and free them up to do more private work, or more public work in some cases?
When consultants are doing private work they are not dealing with waiting lists. They are treating private patients who are not on waiting lists - unless the Government pays for public patients to go private, which has been done in the past.
Deputy Ó Caoláin made a number of very fair points. He said we needed more nurses, and I agree with him. We had 500 more nurses last year than the year before, so the numbers are starting to rise again after a very big reduction. There will be further nursing posts this year, some of which have recently been agreed at the Labour Relations Commission. We now have more consultants and midwives than ever before in the history of the State and fewer managers and administrators than at any time since the establishment of the HSE. This information does not come across very often, but it is true. The HSE service plan provides for more consultants and midwives.
We are having problems with recruitment. Just last week, we secured agreement with the IMO on new salary scales for consultants. Those positions will be advertised in batches over the next couple of weeks. It will take months to fill the positions, as the nature of consultant posts is that people need to move from somewhere else. I am confident that they will be filled, and this will help the situation.
Recruitment is far too slow with regard to other health professionals, such as in the field of mental health and nursing, because recruitment is processed through the national recruitment service in Manorhamilton. That system was set up at a different time when the drive was to reduce the headcount. Now we are trying to increase numbers and we need to turn the whole system around. There will be more local recruitment, allowing hospitals, once again, to do their own recruitment in certain circumstances.
A reference was made to a lack of ambition. I have published 25 detailed actions that we intend to undertake in 2015 alone. If we could complete 22 or 23, we would be doing extremely well. One can be very ambitious but not achieve anything. It is better to be realistic and be in a position to achieve something. I think if we can achieve 22 or 23 of those 25 actions it will be a good year's work. However, it will not solve all our problems.
The issue of drugs savings is being addressed in three ways. We are continuing reference pricing for generic drugs, where the Government sets the price and that is what we pay. These are usually the UK prices or a little above, and that will continue throughout the year. We expect tens of millions in savings from that policy. With regard to on-patent drugs, we are now in the mid-term review of the IPHA agreement. The basket cannot be renegotiated until the agreement is renegotiated at the end of this year. We have indicated to the industry that if a discount cannot be agreed we will use our legislative powers to impose a discount on those patent drugs. That can be done in a matter of weeks.
We undertake individual negotiations, by and large, with the individual companies.
The third area in which we seek drug savings is, as Deputy Ó Caoláin mentioned, the issue of preferred drugs and the medicines management programme. GPs can prescribe alternatives to commonly used medicines. For example, in the case of medicines for the treatment of ulcers, there is already an identified preferred drug from among three or four drugs, and this will be the most cost-effective drug. Other countries have imposed formularies and decreed that doctors can only prescribe the most cost-effective drug in the class. We have not done this yet. In my view it would restrict clinical autonomy, and I would not decide to do that quickly, but it is an option. What we prefer to do, under the leadership of Dr. Michael Barry, is to encourage GPs, consultants and junior doctors to prescribe the most cost-effective medicine in the class and to do this by agreement rather than by compulsion. That is an option if we need it.
When it comes to savings on drugs, it is not all about saving money. The main reason we need to make savings in the drugs bill is so that we can fund new treatments and innovative therapies. We need to find the money from somewhere to fund the additional €30 million being spent on hepatitis C drugs to cure the virus, and this is the reason we are looking for savings on drugs.
The Deputy asked about Soliris. The HSE national drugs committee decided to approve the use of Soliris, following discussions with the manufacturer, Alexion. It is still considered not to be cost-effective. The view of the National Centre for Pharmacoeconomics is that a medicine costing nearly half a million euro a year per patient which does not cure the illness is not a cost-effective medicine. The reason it was approved is that it is an orphan drug, in that there is no other treatment for that condition. Where a medicine is an orphan medicine and there is no other treatment other than this medicine, the drug companies have us over a barrel. The HSE took the decision yesterday not to allow patients to suffer, notwithstanding the fact that the corporation has put its profits first and foremost. On that issue, I hope another company will develop a similar medicine for those conditions sometime soon, in which case I guarantee that both prices will decrease considerably.
With regard to medical cards, Deputies will appreciate that I cannot discuss individual cases. I do not have access to people's medical records nor to their financial information. It would be wrong and inappropriate to discuss individual cases. I will make the point that people with Down's syndrome are entitled to the long-term illness cards, which means they do not pay for their medicines. In that sense, it is actually better than a medical card because medical card patients have to pay a prescription fee. In some cases, very sick children or adults will have a doctor visit card, which means they do not have to pay the doctor. They will have a long-term illness card, which means they do not have to pay at all for medicines for their condition. Neither do they pay for aids and appliances. Patients with these three entitlements are actually better off than if they had a medical card, because medical card patients must pay a prescription fee. That often does not come across well in debates. People often do not realise that sometimes one can be better off having a suite of supports such as the doctor visit card, the long-term illness card and the aids and appliances card, in that these can be better than having a medical card. It is sometimes difficult to explain this to people.
Medical cards are means tested. Approximately 40% of the population - the least well-off 40% - have medical cards based on their means. Discretion is used where people are over the limit, but that discretion is based on their medical costs and their medical bills. For example, if a person is several thousand euro a month over the limit, it is very difficult to see how they would qualify for discretion because the most one can pay for medicines is €144 a month. For example, if a person attends a doctor twice or three times a month, that is €150. Therefore, the maximum one could pay is €300 a month. If a person is several thousand euro a month over the limit, then it is very difficult to find grounds for discretion. However, the number of people with discretionary medical cards has increased from 50,000 to 75,000 in the past year or so. With the addition of those with discretionary doctor visit cards, the number rises to 108,000. The HSE is now permitted to supply aids and appliances - such as crutches or wigs - where appropriate and regardless of income.
The next step in the reform process is the clinical advisory group which was appointed a week or two ago. Within three months the group will produce guidelines to widen discretion further. This will encompass more very sick children in particular, but I do not wish to prejudge the outcome of their determinations. It is important to bear in mind that sometimes the suite of supports given to a patient, such as a doctor visit card, a long-term illness card or aids and appliances, can be greater than the medical card he or she may be seeking. This point is often not understood.
It is important to regard free GP care for the under-six age group as just the first step in providing GP care without fees to everyone in the population. It has not been done yet, so it is certainly not being done at the expense of anyone else. I reject that suggestion because it is not true. It is additional, and it is not just for the children of better-off parents.
It is a new service for all children under six years. It will be an enhanced primary care service that will include areas such as the management of asthma in practice and health assessments for children at certain points as they grow up. All children will benefit. Currently, people go to GP surgeries with an illness for which they are treated and that is it. Under the new primary care service, there will be health checks for obesity, etc. This means that conditions not being diagnosed now are more likely to be diagnosed. That will have benefits down the line.
The real beneficiaries will not be very well-off parents but middle to low income parents, the kind of people who work hard and pay child care fees and a lot of tax without getting anything from the State other than education services. I really do not believe we should begrudge hard-working parents who often run out of money on Friday or Saturday of every week access to their GP without fees. Deputy Billy Kelleher mischaracterises what we are trying to do in that respect.
On mental health issues, my officials will revert to Deputy Dan Neville with more details. I have to hand information which states over 1,150 new posts have been approved since 2012. They facilitate the policy of moving away from traditional institution-based care to a patient-centred, flexible and community-based mental health service in which hospital admissions are greatly reduced, while still providing inpatient care, where appropriate. At the end of December, of the 416 approved posts, 95%, or 397, had been filled. I refer to the posts approved for 2012. Of the 477 posts approved for 2013, 78%, or 367, have been filled. The remainder of the vacant posts are at various stages of recruitment. There have been some difficulties in identifying outstanding candidates, primarily for geographic or qualifications reasons. Therefore, approximately 86% of combined posts in the period 2012 to 2013 have been filled.
On CAMHS, 233 whole-time equivalent posts were allocated for the years 2012 and 2013, of which 193, or 83%, had been filled by the end of the year. Of the 150.5 whole-time equivalent posts allocated as part of the 2012 investment, 94%, or 141, had been filled at the end of last year. Of the 82.5 posts allocated for 2013, 62%, or 52, had been filled at the end of the year. The remainder are at various stages of recruitment. Perhaps I might give a note to the Deputy later that will outline the statistics in more detail.
Let me ask a few questions based on the Minister's reply. With regard to the provision of medical card entitlement for all children under six years in the context of the recent conclusion of negotiations with the IMO, how quickly does the Minister expect to see a rolling out of this now long-promised first measure? Will he indicate to the committee how quickly he intends to move towards the next step? It is only a first step in the rolling out of GP access cards offering universal GP access free at the point of delivery. I pointed out to the Minister's predecessor and the Minister of State with responsibility at the time that I supported the introduction of GP-only cards for all children under six years as a first step. If we were to leave this hanging for some considerable time, it would create another two-tier system. We already have such a system and this would be another two-tier element, which would not be acceptable to me. I was willing to record and have recorded support for this measure in the context of it being rolled out further.
Did I correctly interpret the Minister as having said the HSE now had the opportunity or green light to release aids and appliances, as required, where there was no medical card entitlement? I believe he instanced walking supports. In fear of a burst of laughter at my expense, I must ask whether he also mentioned wigs?
Under the changes made at the end of last year, one does not necessarily need to have a medical card to qualify for aids and appliances. That does not mean, however, that everyone is automatically entitled to aids and appliances. In the past a medical card was the gateway to aids and appliances. There used to be very strange cases where those who needed a prosthesis but who did not want a medical card had to be given the medical card in order to be given the prosthesis. That is no longer the case. It is not an automatic right, but it is open to the HSE to decide.
It will come from the HSE. We will have the position clarified. The change is that one does not now need a medical card to qualify for aids and appliances, but there is not an automatic entitlement to them.
A number of negotiations with the IMO are under way. Those that have concluded are on pay scales for new entrant consultants. The negotiations on medical cards for the under-sixes are still under way. If all goes according to plan, I hope and expect to be able to introduce the provision for the under-sixes by the middle of the year, but it is subject to the negotiations being successful. Once the process is completed – it can be by the middle of the year – we will begin negotiations with GPs on the new contract covering the whole population. It will replace the existing Erskine Childers contract which is a little out of date.
We will proceed to session B. I thank the officials for the briefing note we received. We will deal with the administrative subheads one by one. There are approximately 11, the first of which concerns salaries, wages and allowances.
Mr. Jim Breslin:
It was not unique, but it was unusual that the HSE had its own Vote as an agency. The director general was the Accounting Officer. We have now reverted to the more usual circumstances in which the Secretary General of the Department is the Accounting Officer. However, Mr. O'Brien, just like any CEO or head of an agency, is an accountable officer. The HSE could be before the Committee of Public Accounts in respect of its annual financial statements. However, I will appear before the committee in respect of the entirety of the Vote, including the HSE.
Mr. Jim Breslin:
I have overall responsibility. My responsibility is to disburse the funds and ensure controls are in place in the Health Service Executive when I give over the money. Something could happen, even in a tightly controlled system, that would not be obvious to me and could not be seen in advance. In such circumstances, Mr. O'Brien would have to explain what had happened. As Accounting Officer, however, I have overall responsibility.
On administration, I assume from an analysis that this figure refers specifically to the office of the Minister and the Department. We used to have separate Estimates for the Health Service Executive and the Department, but they have since been combined. The first part of the subhead appears to continue the previous approach. I am interested in only one aspect of administration, although Deputies Billy Kelleher and Ciara Conway may have questions on others. To move matters along, I am curious to find out about the significant increase in the allocation for consultancy services. The 2014 figure is to increase by almost 19% to €1,650,000. Will the Minister elaborate on the reason for this, as it is by far the largest increase in administrative costs in the office of the Minister and the Department?
This is a provision, which means that it may not all be spent. I will provide a breakdown of the figure. The first provision is for the report on the responses received in the public consultation on legislation on the sale of tobacco products and non-medicinal nicotine delivery systems, namely, e-cigarettes. The Institute of Public Health is doing this work on behalf of the Department on a consultancy basis. The next provision which is probably the most expensive of the provisions is for the development of the national clinical guidance guidelines. These relate to early warning scores for maternity and paediatric services and so forth. This work is being done on a consultancy basis by the national clinical effectiveness committee. Approximately €50,000 has been provided for the national clinical audit, the purpose of which is to ensure the scores and guidelines are implemented in hospitals.
Funding has also been provided for the nursing policy unit for nursing products. Approximately €170,000 has been provided for tobacco and alcohol related research which is not conducted in the Department but is usually carried out by universities or other experts in the field. Consultancy is generally undertaken on the basis that the expertise required is not available in-house and that it would be more expensive to employ people to undertake it, rather than commission it on a consultancy basis.
The significant decrease in subhead B3, the drugs initiative, jumps off the page. We have raised questioned on other matters in previous incarnations. Little or no change has been made to the allocation under subheads B1 and B2, whereas the decrease in subhead B3 is almost 14%. Will the Minister explain the reason for this reduction which is in the order of €1 million?
The figure is misleading, as the budget has been transferred to the Health Service Executive. Funding for drug abuse and addiction services for the Department and the HSE has increased by more than €2 million this year. There will not be any cut in funding to the local drug task forces, while the provision for needle exchanges, detox beds and mental health services has increased. While funding for drug services has decreased in the Department's Vote, overall funding has increased by €2 million.
Is the reason we are not comparing like with like that this is the first year of a new approach? Will this anomaly continue in subsequent years or will Deputies be able to more accurately compare the position year on year from 2015-16 onwards? The Minister has noted that the provision transferred to the HSE. We are unable to make comparisons with previous years on the basis of the document supplied.
An explanation is provided in the third footnote on page 38. On 1 January 2014 funding of €21.57 million was transferred from subhead B3, drugs initiatives, to subhead B10 in the HSE Vote in respect of 220 treatment and rehabilitation community drug projects. On 1 January 2015 a further €1.022 million was transferred from subhead B to subhead B10 in the HSE Vote. This is the issue to which the Deputy referred. This allocation was transferred in respect of 12 treatment and rehabilitation community drug projects. Essentially, it is a process of rationalising the funding stream to have it administered through the HSE, rather than the Department. Overall, funding has increased by approximately €2 million.
I accept that changes are taking effect. I thanked the secretariat for providing an expanded and more easily read Appendix 2 of the Estimate. I will show the Minister page 38. He has as much chance of reading it from where he is seated as I have holding it in my hand. I ask him to ensure Deputies receive a document that can be read because reading this document is beyond my visual ability.
The funding provision for the National Treatment Purchase Fund remains unchanged, having been reduced significantly in recent years as a result of the transfer of funds from the NTPF to the special delivery unit. The task of the special delivery unit was to address the issue of emergency department overcrowding, seamless movement of patients through hospitals, step-down facilities, home care services and all that went with them in a manner that would ensure hospitals would deal with patients effectively and efficiently. The Minister has indicated that the National Treatment Purchase Fund is not the ideal way to address waiting lists. That statement is incorrect in cases in which a theatre in a public hospital cannot be used because of staff and consultant shortages and patients are transferred to the private sector. Where there is insufficient capacity in key areas in the public system, the private sector will clearly have a role to play in moving people off the public waiting list. We should not have ideological hang-ups about this practice. Patients want to be treated in a timely, efficient and effective manner.
Duplication is a clear waste of public funds and should not be condoned.
Where there are huge deficiencies in the capacity of the public hospital system to deliver - that is, not enough consultants, medical staff or front-line staff, or just not enough theatres, wards or beds - the private sector would have a role. Otherwise, there would be an increase in the number of people waiting for treatment. I note that the amount is the same as last year. While the Minister said he might envisage revisiting the use of the National Treatment Purchase Fund, it is evident from the Estimates that there is no intention to increase the capacity of the fund. That is an observation, not a criticism, of the Minister. We will try to park it.
With regard to other services - specifically, compensation payments to a reparation fund established under section 11 of the Hepatitis C Compensation Tribunal Act 1997 and the Hepatitis C Compensation Tribunal (Amendment) Act 2002 - there is a small cohort of women who obtained false positives and who are campaigning to be included in the compensation recompense but also for access to the medical card awarded to persons under this scheme. Has any progress been made in this area, in view of the fact that we have met these women? They have made a case to the Minister and, I assume, to the Department and the HSE. These people were infected but at the time were showing a false positive. Are there any discussions in progress in the Department, given that the amount of funding for this year is the same as last year?
The situation as I understand it is that these were not false positives. There is a group of around 30 or 40 women - at present, but there could be tens of thousands - who were given an infected batch of anti-D but never tested positive for hepatitis C. They have a group of symptoms which can be linked to hepatitis C but can also be linked to a large number of other illnesses. The situation is that one has to test positive for hepatitis C to get compensation, and they do not. That is the current situation. In the absence of any medical science to back up the view that it was a false negative, it is not open to them to go to the tribunal, but as I have always said, if this is a decision that is based on medical science and if the medical science stacks up, then that can be reconsidered. The position is that they were exposed to infected anti-D, as were tens of thousands of people, but they did not test positive for hepatitis C. They have a set of symptoms that could be linked to hepatitis C but could also be linked to any number of other organic illnesses.
I wish to raise two points with regard to other services. Subhead A2 - the Food Safety Promotion Board - shows a decrease of just over 5%. Will the Minister give an explanation of the relationship, if any, between the Food Safety Promotion Board and safefood? One of the six cross-Border implementation bodies established under the Good Friday Agreement, safefood, has significant and growing public identification. I am anxious to know the relationship between the two bodies, their specific roles and demarcation and whether there is an overlap. In regard to subhead G, under other services, there is an increase of almost 100% in the provision for the dissemination of information, conferences and publications. What exactly is intended in 2015 that warrants or merits such a significant increase in provision?
In regard to subhead E2, the Food Safety Promotion Board is the official name of safefood. safefood is the brand name in the same way that the official name of Fáilte Ireland is the National Tourism Development Authority. It is a North-South body, and the reason the provision is being cut is that it is part of an agreement with the North to reduce funding for all North-South bodies. That largely flows from the austerity that is now taking hold in the North. The Deputy will be aware that the parties in the North agreed an austerity programme to cut the number of public servants by about 20,000, to close minor injury units and to impose many of the kind of cuts in the North that, thankfully, are not happening in Ireland.
On subhead G - the dissemination of information, conferences and publications in respect of health - this refers to the Healthy Ireland initiative. The main bill under that subhead is for the Healthy Ireland survey, the first survey of the nation's health since Slán in 2007, which is under way. That will now be done every year. If we cannot measure the nation's health we cannot improve it. We are going to measure the health of the nation every year and find out how many people are smoking, how much they are drinking, whether they are obese and so on.
I congratulate the Minister on his cameo appearance in "Operation Transformation" last night and pledge the support of the committee, as has been the case in the past, in regard to the publication of calorie counts. Is there a budget provision for that, or what is the position?
The cost will be borne by restaurants and food producers, but it will not be a very high cost because we have the MenuCal app, a simple app which is free and can be used to calculate the number of calories in most meals. I certainly welcome the Chairman's support and that of the committee because I am sure there will be resistance to the measure. The majority of food service providers that have been surveyed say they are in favour of it, but there will be a minority that will be very much against. We know from research in America that it does affect the food choices of about 25% of people, which is a big deal.
The committee had the leaders of "Operation Transformation" appear before the committee as well as the experts and we were involved with the "Operation Transformation" programme itself. If the Minister can work with the committee he will find support in terms of the pursuit of that agenda.
They were done as a group.
It goes without saying that it is unfortunate to note a decrease across the board in of each of the HSE regions. While one may say that less than 0.5% is small, one would have to translate it in real terms in the context of the monetary value, and it is not insignificant. This is the provision for the HSE and the continuing financing of services in each of the regions - Dublin-mid Leinster, Dublin north east, the south and the west. There is no question about it; it will have an impact. That is something to be regretted at a time when the Minister is very anxious to impress a significant increase in terms of the budget this year - a turnaround on a series of reductions over a period of seven years. Nevertheless, there is a continuing reduction in the HSE regions, and even though it is just below 0.5%, that still adds further strain in resourcing our health services across the board.
Can the Minister address any savings or efficiencies in the establishment of hospital groups and the interface with regional spending? How will this play out? It is a significant change that we have seen throughout the regions. Perhaps the Minister can talk about how acute hospital care, which is quite considerable, will interface with the regions as they currently are in the HSE.
I tried to clarify that as best I could in my opening statement when dealing with subheads I1, I2, I3, I4 and I5. Income for the HSE is not counted in the Vote, which is why it is presented in this way. What we can add to €8,411,717 is the additional €131 million from the health insurers. Under J4, mental health, there is an increase from €41.57 million to €50 million, a €9 million increase. If we are comparing like with like, the figure should be €8.541 million rather than €8.411 million, but the disestablishment of the HSE Vote means that non-Exchequer income does not go into the Estimates. The income the HSE gets from sources other than the Exchequer is separate.
With regard to hospital groups, I do not expect many savings this year because they must be got up and running. They are up and running quite well in Limerick and Saolta but not so much in Munster and the east. In time, there will be savings and economies of scale as health services are reorganised. I do not expect significant savings this year.
Subhead J4 includes the ring-fenced service development funding of €35 million for mental health and funding to deal with delayed discharges. Is that €15 million with regard to delayed discharges part of the amount announced in the budget to deal with the problems associated with the number of people on trolleys in our emergency units in January? Is that figure the €15 million announced last year to deal with the issue of step-down facilities and the increase in funding for the Fair Deal scheme?
In part. A total of €25 million was announced for delayed discharges, and the €10 million for the Fair Deal scheme does not appear in subhead J4 but in the Fair Deal Vote, which is separate. It is under subhead K2. The €15 million is for home care packages.
J5 covers payments to the State Claims Agency in respect of costs relating to clinical negligence. There is a substantial increase, 20%, estimated for this year. Is that because of large cases coming to finality, or is it a projection of cases in process? Are there cases that the Department expects will come to settlement this year? Is it a projection based on an overall increase?
The health committee has had the debate about the duty of candour and the candour clause favouring more openness and a less adversarial system where people access compensation and vindication for clinical negligence by employees of the HSE. Is this an issue that is being examined in trying to address savings in the area? I do not think many people in this room or elsewhere want to see savings being brought about at the cost of the patient and the person who has been damaged. The person in a wheelchair for the rest of his or her life with brain damage or who has a profound disability or other medical complications because of negligence is entitled to compensation. However, a view is emanating that the adversarial nature of our legal system is creating additional stress and cost, as is evident in the context of these Estimates. Have the Department of Health and the Minister looked at other jurisdictions where the duty of candour is in vogue? Do they see merit in it?
Deputy Billy Kelleher has a different set of figures for the State Claims Agency, as I note a significant decrease in the provision for 2015. It is a drop of more than 36%. Can the Minister explain? We can never properly predict the extent of claims arising from cases of negligence. This has been the focus of the committee in the recent past and was raised again earlier in terms of further redress. It is important. Perhaps the Minister can explain the considerable decrease in J5.
Deputy Billy Kelleher referred to subhead J4 and the mental health provision of €35 million. The €20 million allowed the previous year led to the under-provision of €15 million that the Minister of State with responsibility for mental health indicated she would seek, although it transpired that she did not. As the new Minister, does Deputy Varadkar appreciate that the under-provision last year has contributed to the delay in realising all the promise of the policy A Vision for Change? I do not believe the sum of €35 million will be adequate, given the under-provision in previous years and the underspends in previous years that were not always carried forward. In the first year, it was diverted in its entirety away from the intended spend. I would like to know if the Minister, in the absence of the additional €15 million and the €35 million in this current year, will look favourably at seeking additional funding in 2016.
With regard to delayed discharges, the Minister will recall the last time he appeared before the committee, in conjunction with the director general of the HSE, Mr. Tony O'Brien, and an exchange we had about my experience of long-term residential care provision in my county. There is a fine facility in one of our urban settings. I do not dispute the results of a HIQA report carried out there, as I want to see the highest standard of state-of-the-art provision in regard to the comfort and needs of people entering long-term residential care. As a consequence of the HIQA report, in terms of the development work undertaken, there was a reduction in the number of beds. This has been replicated in different facilities around the country, and it is contributing to the difficulties in regard to delayed discharge. Mr. O'Brien indicated that we cannot continue to do this and, at the same time, crib and cry that we are not meeting the needs of the 750 people in discharge units across our hospitals network. Has the Minister any plans for the development of long-term residential care for those who are no longer in a position to live at home independently or with home help or home care provision, aids and appliances, etc.? It is the elephant in the room. We do not have enough long-term residential care beds to meet the needs of our citizenry.
The continued reliance on private provision is not good enough. We must develop public care provision. Does the Minister have plans in that regard?
The last time the Minister was here, he spoke about his commitment to tackling the delayed discharges. I welcome that he will focus on it, as he said, long after it falls off the front of the newspapers, which is worth saying. It is very hard to predict what will come in the future in terms of knowing where the demands come from and where the peaks might be. How realistic are the targets he has set for reducing it and will the money be made available?
There are two issues about the turnaround in emergency departments when people are being assessed - whether they will be discharged, or whether a bed or another facility will be made available to them. I previously asked the Minister about older people who may have an ongoing chronic illness who are being looked after in a HSE facility. Something may go wrong - for example, a spike in temperature or a difficulty in the middle of the night. These very old and sick people then have to go through emergency departments like everybody else. We need to have different pathways for such people because it does not do them any good and it does no good for the staff in emergency departments. I ask the Minister to outline his plans in that regard.
On the State Claims Agency, I have come across cases in recent years of people who have suffered catastrophic injuries, and I am afraid to say that the State gave with one hand and took away with another. When an award is made it can be quite a lot of money, but this person will have huge costs over his or her lifetime and may lose a medical card. I know of parents who are not working who lose because of the care needs of the individual. An older sibling going to college may be refused a grant based on the award made to the person who has been so damaged by misadventure while receiving health care. I know of a number of families where this has happened. It is greatly distressing, because the sick or disabled child may have a huge amount of money, but it is his or her money and yet the whole family has been marked not just by the Department of Health but also by other Departments such as the Departments of Social Protection and Education and Skills. I am aware of cases in which a sibling was refused a grant because of the award made to her brother and where a mother lost her entitlement to jobseeker's allowance because of her child's award. That is something we need to look at, because the needs of these children, young people and adults will be greater and the costs will be very significant. It is a huge worry for the family that the money will run out.
The Estimates could almost be accused of being obscurantist because of their sheer size. Deputy Caoimhghín Ó Caoláin is right. I got the wrong figure, but the same principle applies to projections for the State Claims Agency. How is this done? Is it based on court cases? How does the Department profile the spending in the year ahead? I may have quoted the wrong figure, but I have the same question.
The amount for the State Claims Agency is very hard to predict because it is essentially what judgments the courts make or what agreements are made on the steps of the court. As it turned out, the €151 million which was partially provided for in the Supplementary Estimate at the end of last year was not all required. Only €135 million of the €151 million was required. That can often relate to the time of year the judgments are made and paid.
We are estimating a reduction to €96 million because the Department of Justice and Equality is introducing legislation to cover periodic payment orders. So instead of somebody getting one big lump-sum payment of €2 million, €5 million or €7 million, he or she will get an annual payment which can then be reassessed as his or her needs may change. So the €96 million is contingent on that legislation being brought through and implemented by the Department of Justice and Equality.
One of the Deputies made a very good point on open disclosure and the duty of candour. When I was in medical school it was always drummed into us that we had a duty of candour and should disclose where a mistake is made. People think medicine is an exact science. It is not an exact science; nor is midwifery. Essentially, a medical professional talks to the patient, takes his or her history, examines him or her, carries out a few tests, puts it all together and makes a judgment. Sometimes the judgment is wrong, but that does not mean one is a bad doctor. It is the nature of medicine. It is not an exact science; it is a judgment. By no means are all mistakes down to negligence. It is important to understand the real job doctors, nurses and midwives have in that regard. It is not necessarily that they are bad doctors because claims are made against them - they just made the wrong judgment based on the facts they had.
In some ways it is a bit like knocking somebody down on the street. Someone might run out in front of one and one might hit them. It might be one's fault, it might be their fault or it might be nobody's fault. Failing to disclose openly and not adhering to a duty of candour, for me, is the equivalent of a hit and run whereby one has knocked somebody down and one does not necessarily know whose fault it is but one drives off. That happens in our health service, and I am appalled by the number of cases that I have become aware of. Some of them have been in the news. Essentially, there is adverse clinical or medical misadventure, and rather than doing the right thing - sitting down with the patient and the family the following week to explain what went on - medical personnel effectively abandoned the patients. I find that really appalling. It is not the medicine in which I was trained.
If doctors and other health care professionals adhere to the duty of candour and respect the policy of open disclosure, considerably fewer people will sue. Often people sue because of the bad way their case was handled after a mistake was made. Because this is still happening, it is my intention to legislate for it in the health information Bill and to make it a legal requirement that there be open disclosure and a duty of candour, which I think is just right.
On HIQA, it will be costly to upgrade our community nursing units to HIQA's standards. In some cases they will just be replaced, because it makes more sense to build a new one than to renovate or rebuild an old workhouse, for example. In other cases they will be redesigned. At the moment HIQA and the HSE are trying to agree a multiannual plan to do that. In addition, we will need to build more community nursing units. The Minister of State, Deputy Kathleen Lynch, and I are seeking additional money from the Department of Public Expenditure and Reform in the next capital envelope to do exactly that. HIQA is, of course, an independent regulator. If the committee has not done so already, it should invite HIQA representatives to come before it to go through some of the issues that arise.
On the delayed discharges, we have thrown everything at this in recent weeks and delayed discharges have decreased from about 850 to 750. I had thought we would do better than that. We have set a target of 500, which I believe is realistic and achievable. Some people say it is not sufficiently ambitious and ask how we could possibly say it was acceptable to have 500 delayed discharges across our hospitals. However, when it is broken down, there are issues. For example, there are people who are waiting for rehabilitation, there are people who are wards of court, there are people with issues relating to refugee status and so on. There are one or two homeless people, and of course we cannot and should not discharge people into homelessness.
At any given time there are 200 or 300 people who are counted as delayed discharges but have, in fact, only been in the hospital for a few weeks. There will always be a delay in getting their paperwork together. They may have to go out to see the nursing home to see if they are happy with it. Their family members may want to check out the nursing home and the nursing home may want to check them out. So about 200 or 250 of that 500 will always be there. That is just the normal churn of new delayed discharges.
Deputy Conway asked about the elderly in emergency departments. We are trying to do two things in that space, the first is more community intervention teams. These are the nurses who go into nursing homes and change catheters, and can give intravenous fluids and medicine so that an older person can avoid going into hospital in the first place. We need more of that. I think some nursing homes are afraid of having a resident die in the nursing home. They send the person to the emergency department when it may be better not to and instead they could make more effort to get a GP or the community intervention team to come to the nursing home.
The national clinical programmes are developing a pathway for the frail elderly which might end up as a system of streaming frail old people to emergency departments in a different way. If one visits an emergency department, and I know all members present have, the majority of patients coming through for admission are elderly. I know of one private emergency department where the average age of admission is now 90 years. That is a big change in the past ten or 11 years from when I was working in hospital medicine. The inpatient population is now much older and that makes things more difficult on the front line.
An additional €35 million has been secured for mental health services this year. The Minister of State, Deputy Lynch, has done very well to do so and it is a great achievement. I know she will be looking for additionality on top of that in 2016.
Yesterday the Minister replied to my parliamentary question on the requirement to advise a patient where an adverse incident occurred. We engaged recently with the Medical Protection Society, the State Claims Agency and others and very strongly challenged the "deny and defend" culture. When the Minister is preparing the legislation which he intends to do, I recommend that candour needs not only to be a requirement of the professional front-line service provider but those who are indemnifying them must also be brought into the loop, otherwise there will be a tug of war in terms of conflicting advice. It is clear that they are conscious and aware of a variety of incidents but in spite of their denial, I am of the view that their counsel has been to say nothing. That has to stop.
The Minister referred to it, but I thought we were speaking only to subhead J, however, we are speaking to subhead K as well.
The demographics are alarming when one looks at the age profile of the nation over the next 25 to 30 years. Most politicians live and die by the sword in terms of the next election but there is an onus on us to deal with the very serious and stark issue facing us, the pensions time bomb and the ageing profile and how to address these issues in the years ahead.
Without sounding adversarial or critical, we need to look at the development capital infrastructure in the provision of residential facilities for elderly people in the next number of years. Step-down facilities and-or home care packages are included in the current expenditure phase but the long-term capital requirements will be significant. The HIQA inspections will probably condemn facilities, particularly the public nursing homes which will not be fit for purpose in a modern context. I am aware of the budgetary constraints and while critical I have to be realistic, because we cannot put this off for ever. Are there plans to stimulate the development of further private nursing homes or will we try to ensure we have the wherewithal to develop public nursing homes? If we are having difficulties as is in trying to provide 22,000 nursing home beds through the fair deal scheme, we will have major problems in a short time in light of life expectancy and the age profile.
What are the longer-term implications of the reduction in capital in this year's subhead?
I have glanced at the Minister's explanation of the reason he believes it is achievable to reduce provision for the primary care reimbursement services. The Minister is talking about a significant amount of money, almost €20 million. While it is under 1%, it is a considerable sum. The high-tech expenditure for 2015 is to remain at the forecast 2014 outturn. I suppose Soliris would come in under high-tech? The situation is more fluid than the determination of these figures might allow for. I think there will be an impact. There may be others. Is it wise?
With the upturn in the economy, more people will be back in paid and better paid employment and will not qualify for a GP or a medical card. Consequently, some 60,000 people will no longer be eligible. With the advent of the service for the under sixes and the over 70s, which will all happen in this year, hopefully, I would be concerned that further strain is being placed on the primary care reimbursement service, which has been the focus of much negative engagement from members of the committee and other Members in spite of the best intentions and best efforts of Paddy Burke and his team. In fairness to them, I do not think they deserve to be put under any further strain.
I will deal with the primary care reimbursement service, PCRS, first and long-term care after that.
On PCRS, we are estimating the budget will be much the same, going slightly down from €2.5 billion to €2.485 billion. That factors in the saving from the drug companies as well as the fact that fewer people are eligible for medical cards because of the improving economy. The number of medical cards decreased in 2014, even though the number of discretionary cards rose, as more people were at work and the incomes of those in the private sector rose. PCRS is demand-led. The Deputy is correct to point out that Soliris will have to be funded from that. If it is the case that more medical cards are issued or more medicine is needed than we thought, that subhead will overrun. That is a risk every year. Certain elements in the health budget are demand-led. People have a legal entitlement to medical cards under certain circumstances and doctors prescribe medicines and we cannot control that exactly. There is always a risk of an overrun on the demand-led schemes. That would be the obvious risk for this subhead.
In terms of the medical card review process, as Deputy Kelleher said, this morning we had Ryan Gilmartin's parents at the gate with a petition. I suppose if we are honest that situation should be avoided in so far as we can
I will not comment on individual cases because I do not have access to people's private records. Let me reiterate that somebody might not have a medical card but may have a doctor visit card, a long-term illness card and access to aids and appliances, in which case giving the person a medical card would potentially save money, believe it or not, because he or she would be entitled to less. That is just an aside. I expect when the clinical advisory group reports in three months time it will propose to widen discretion further.
If it does, it does. If that means 10,000 or 20,000 more medical cards than we had thought, then they will be allocated. Every year, there is a risk of overruns under that subhead. Certainly, we are not going to be reining in medicines or medical cards to meet that figure. If it overruns, it overruns.
The committee should bear in mind that the figure for long-term residential care is only the Exchequer allocation. In addition to that there is the contributions people make to the fair deal scheme. Therefore, the real amount spent on the fair deal scheme is closer to €1 billion. That figure can be a little misleading.
We have an existing capital programme for the refurbishment and renovation of community nursing units. I will set out for the committee a list of the units that are being upgraded and refurbished in 2015 alone. They include: Virginia; St. Mary's in Castleblayney, St. Oliver Plunkett's in Dundalk, Ashgrove House on the Navan Road in Dublin; the Dalkey Community Unit; Belvilla on the South Circular Road; Meath Community Hospital; Maynooth Community Hospital; Birr Community Hospital; St. Vincent's in Mountmellick; St. Joseph's in Longford; Bantry; Bandon; Kilrush; Ennistymon; Raheen; Castlebar; and Sligo. It is not that we are doing nothing. Many community nursing units are either being refurbished or rebuilt. It is simply not happening quickly enough and certainly we need to accelerate that.
I acknowledge that work and appreciate what I have seen first-hand in my constituency. However, the consequence of meeting the HIQA requirements has translated into a reduction in the actual number of beds available at these settings. We are not building into the redesign plan further additional bed provision. In the case of the unit in Castleblayney, which the Minister has cited, the number is going down from 76 to 70 as a result of meeting the requirement. People may suggest that is only a reduction of six, but if we add up similar changes across the list that the Minister has read, it amounts to a considerable number and it all contributes to the delayed discharge figures. Those undertaking these works have people on-site and know the design costs and so on. If the facility and the footprint allow for additional provision, then that is what should be undertaken. The time to do that is now, when there are people on-site carrying out works. It should be incorporated into the work being undertaken.
The current capital envelope runs to 2016. Negotiations are under way for the next capital envelope, which will run from 2016 to 2020. Needless to say, a major part of our ask in health is a significant increase in the capital budget for long-term care. A total of 14 priority locations have been identified and they are being progressed through planning to shovel-ready status. I will give the committee a flavour of the list. There are 100 additional beds in Dublin north in St. Ita's, 80 replacement beds in Donegal south, 100 additional beds in Grangegorman for north Dublin, 100 replacement beds for Dublin south, Kildare, west Wicklow and Tallaght, 100 additional beds in Cork city south, 100 replacement beds in Limerick, 50 additional plus 50 replacement beds in Dublin north west at Blanchardstown, 100 replacement beds in east Wicklow, 100 replacement beds at St. Vincent's in Athy, 100 additional beds in Cork city south, 50 additional and 50 replacement beds in south Kerry and 100 replacement beds in west Donegal. This is all being progressed through planning to shovel-ready status. We hope to get the capital for it and to get the diggers in next year.
I wish to comment on the subhead relating to ophthalmic and dental services. There continues to be significant concern - it even runs to distress - in many family cases where young people cannot access dental care through the public system within a reasonable timeframe. Young people are moving out of education without having significant dental work addressed. It is not simply a question of pain because pain can be measured in terms of physical and mental pain. Too often, decisions are taken to refuse orthodontic work that is sometimes described as cosmetic. For the young person concerned, male or female, it is far from that; it is about mental well-being, self-image and capacity to cope in life. I have seen the tragic consequences of the failure to face up to our responsibility to provide adequate provision to allow for address of these problems. These are sorry stories. I am anxious that this should be reflected not only in the provision this year, but that the Minister takes it on board if he is making these decisions for 2016. It is vital that we see a significant change in the provision for these services in the interests of young people in the future. What we fail to do now will result in other needs and issues presenting in later life for the same cohort of young people who we are failing through their education years.
Subhead M4 relates to the recoupment of certain dental treatment services scheme costs from the Social Insurance Fund. Like Deputy Ó Caoláin, I believe this area must be examined quickly. I realise there is a campaign on the fluoridation of water and so on. However, the key issue of oral hygiene is one we are beginning to neglect dramatically. I accept that I cannot blame the Minister for this one. I must blame previous Ministers and therefore the current Minister is exonerated. However, he will be adjudicated on his actions in terms of responding to it.
Cleaning and scaling is proven to have positive dental and oral hygiene effects. Now, people are no longer entitled to cleaning and scaling although they are entitled to extractions. This is a little like saying a person is not entitled to treatment for an ingrown toenail, but we will take the leg off if it gets infected. We should not look at it in that context. We must be proactive in the whole area of dental hygiene. All the socioeconomic surveys show that there are problems in certain groupings and areas and these must be addressed. We cannot simply depend on the fluoridation of water to address all the ills of dental and oral hygiene. There should be a concerted effort. The idea that we will allow extractions or take out teeth but not clean them in advance is something the Department must revisit quickly. Otherwise, it is storing up vast expense in the years ahead with decay and poor dental hygiene.
At this stage, in the area of orthodontic treatment, people have thrown in the towel on the service. It is farcical to suggest that we have an orthodontic service that is timely, efficient and effective. This is not a cosmetic issue; it is a health issue. People need to have orthodontic treatment applied in a timely fashion.
It has a huge impact on young children socially in respect of normal growing up, intimidation and bullying. This affects people who need orthodontic treatment, including their education. There is no point in announcing in the years ahead that we are going to have orthodontic treatment. These kids will be 18, 19 and 20 years of age and it will be too late. They need it in their formative years. It should be done once it is sound to do so dentally. Children can face huge pressure and be at risk of social embarrassment as a result of having prominent teeth. We all know it. In previous times, kids would be bullied. It has an impact on them and can have a very damaging social impact on young girls. We cannot just pretend it does not happen and that they will be looked after-----
I know. We cannot pretend it does not happen. It happens and I do not agree with the idea that we will look after them when they are 17 or 18 years of age when the damage is done dentally and orally and sometimes in terms of their social, personal and developmental skills. I am not blaming anyone but I am urging the Minister to see whether there is any way he can resurrect an efficient orthodontic system. If it cannot be done because of lack of public capacity, can we revisit the dreaded National Treatment Purchase Fund in a more meaningful way to give kids a chance to have orthodontic services provided when they need them?
I agree with Deputy Kelleher regarding orthodontic treatment. In respect of Healthy Ireland, the Minister has spoken about being the person who wants to lead that, for which I commend him. The issue of dental and oral hygiene is linked to that where the Minister and the committee can play a key role in preventive care in the formative years, as Deputy Kelleher rightly noted. From my own office, I know that it has become a huge issue. Deputy Kelleher alluded to the past. One of the biggest mistakes made by a previous-----
In terms of the issue we are addressing, namely, young people and dental and oral hygiene, it took away the ability of parents to make that choice. They did not make the choice and elected to not do anything.
The second issue is ophthalmology in the south. I know it is probably a HSE matter rather than the Department's Vote but it is an issue that is becoming very difficult in the south.
I am afraid I cannot comment on ophthalmology specifically in the south but I will ask the HSE to give the Deputy information on that.
We are developing a new oral health policy that will fit into the Healthy Ireland framework and is being led by the chief dental officer. The initial research coming back is that Ireland's oral health is improving. Children have fewer cavities than they had in the past so notwithstanding the fact that services have been curtailed, oral health is improving and there are fewer cases of caries and cavities than there were in the past. I do not know whether this is down to increased hygiene or the fact that the bug that causes the cavities is less prevalent but oral hygiene in Ireland is definitely improving and we have the evidence to support that.
A total of 24,000 people are having orthodontic treatment at the moment. However, 17,000 people are awaiting treatment. We will do exactly what Deputy Kelleher suggests. A total of €1 million has been set aside in the service plan to tender to the private sector for orthodontic services to address those waiting a very long time. That requires a procurement process which will start quite soon. The treatment for those cases will begin towards the end of the year. I accept completely what Deputies say about orthodontics not being just cosmetic and the psychological impact of bullying where people have problems with their teeth but it will still be the case that we must prioritise those who have a problem with their bite. Orthognathic surgery must be prioritised but €1 million is set aside for a specific outsourced initiative for orthodontics this year.
Is the Minister happy to move on? As we have come to the end of these subheads, I thank the Minister and his officials in assisting the committee with its consideration of the Revised Estimates. I thank the Secretary General's officials most sincerely for the amount of work they have done in helping the committee. I know it is a new format and it is taking us all a while to get to grips to it. I ask the Secretary General to thank his officials for the work they have done in the preparation and compilation of what is a massive tome of information for members of the committee.
I am quite sure there is a room next door you will be looking forward to going to on a regular basis. I like the format. It is more proactive in terms of a broader discussion. I know it is a small thing and maybe it is just me in middle age but the print in terms of the figures in the Estimates can be a bit small. I know it is very hard for the officials to address this.
I thank the Minister, Mr. Breslin and the officials. This was a change this year in terms of how we would address the Estimates. I was apprehensive at first but I have to say it was a worthwhile engagement. I appreciate the Minister's frankness in terms of the issues we tried to explore. Most importantly, I hope he would recall some of the points we have made in his deliberations with colleagues in preparation for next year. I hope some of the areas where we have argued for improvements will reflect themselves when we meet next time in this format.
I thank Deputies for their contributions and for highlighting particular areas that require more resources and investment. Anything that the committee can do to recommend more money for my Department would be much appreciated.