Mr. Tony O'Brien:

Prior to the meeting the committee requested information and replies on a number of specific issues and will have received a written response to each of them. We will obviously be happy to deal with further issues that arise.

The service plan for 2015 was published by the HSE on 27 November last, following ministerial approval. The budget to which it relates provides for the delivery of health and social care services within a funding allocation of €12.13 billion, plus an additional €35 million for mental health services. This represents a welcome but modest increase of €115 million in funding. It is the first time in seven years that there has been an increase, not a decrease, in funding. This has allowed the health service to allocate more realistic budgets to hospitals and community health care organisations which puts the health service on a more sustainable footing.

The allocation of more realistic budgets brings with it a requirement for greater accountability to ensure services are delivered within the budget provided. To help to achieve this, we have put in place an enhanced governance and accountability framework which set out clearly the responsibilities of all managers to deliver on the targets set out in the service plan against the balance scorecard. There are a number of core requirements under the accountability framework, the most notable being the introduction of a formal performance agreement with me, as director general, and each of the national directors and cascaded throughout the system.

Emergency department attendances have increased by 5.6%, at 63,123 attendances over the past five years, standing at 1,182,842 in 2014, and with 2014 alone seeing a rise of 2.5% over the previous years. In addition, patients attending emergency departments are now generally more unwell and more likely to require admission than in the past, which is due in part to an increase in the number of frail elderly patients attending. In 2014, there were 6,614, or 1.7%, more admissions from emergency departments compared to the previous year, which equates to 550 more admissions each month. That does not include the cohort of 52,437 patients who presented at acute medical assessment units and medical assessment units during the course of the year.

As previously discussed with the committee, the pressures on emergency departments over the past number of weeks are not new or unexpected. Based on the trends I have outlined, significant action was taken prior to and after the Christmas period to plan for a surge in attendances and admissions. Some €25 million was provided to alleviate the problem of delayed discharges this year and an additional €3 million spend in 2014 was fast-tracked in November and December as part of the winter pressures plan. This enabled the early release of an additional 300 Fair Deal approvals in addition to the routine 700 places each month.

In addition, the following actions have been taken. During December, 165 additional transitional care beds were funded and targeted at hospitals in the greater Dublin area to facilitate egress from acute beds. A further 424 transitional care beds were commissioned nationally up to 27 January in order to move patients whose acute episodes of care had finished. All short- and long-stay public beds are being prioritised to support discharge from acute hospitals. A further 173 short-stay beds are being opened on a phased basis in identified locations during this time of peak demand. Additional home supports were provided, with a specific focus on supporting acute hospital discharge prior to the Christmas period, allowing the discharge of 87 patients from acute hospitals.

The total number of additional home care packages provided to date is 400. Of the €25 million provided, €2 million was allocated to community intervention team services, which are very effective in preventing people from having to attend emergency departments in the first place and allowing for early discharges. The scheme has managed more than 200 patients in the community each day during this time of peak demand.

During December and January, 1,239 people whose acute episodes of care were completed but who remained in acute beds were provided with alternative care more appropriate to their needs. However, a further 1,176 people have been added to the delayed discharge list, which means that the perceived net benefit is small. The number of additional delayed discharges being added to the total weekly list is exceeding the usual intake rate of 100 by a factor of about 1.6, which makes it extremely difficult to sustain improvement. As such, the number of delayed discharges remains high and very challenging, at 745.

The overall position, therefore, remains challenging. The HSE is maintaining a daily focus on this area and is an active partner in the emergency task force set up by the Minister to find long-term solutions to overcrowding. We are also working on developing a detailed plan specifically to address emergency department issues, with a view to a significant reduction in trolley waits over the course of 2015. This is a priority for the HSE and the Government.

On patient safety at Portiuncula Hospital, the review will involve a thorough examination of the delivery of maternity services at the hospital and will include a review of the perinatal care provided to the seven women who were the subject of the preliminary review completed in January 2015. The draft terms of reference for the review have been finalised and are currently being discussed with the families concerned. The investigation team is currently being established, to include two obstetricians - one national and one international - one of whom will act as investigation chairperson, two senior midwives - one national and one international - a patient advocate, a consultant neonatologist and an expert investigator from the national incident management learning team. I can also confirm, in respect of the cases highlighted in the media recently, that the chief clinical director of the Saolta University Health Care Group will meet the families concerned, has met some of them already and will meet others again, with a view to agreeing with them how best a review of those cases should be progressed.

Sometimes, in the midst of the challenges such as those I have described, we can overlook the many things that are improving. During 2014, significant parts of the health system worked very well, with notable improvements over previous years. We continue to meet and exceed our targets for specialist palliative care, with 97% of patients accessing a specialist inpatient bed within seven days of referral and 89% of those receiving palliative care in their own homes. The number of persons in receipt of home care packages is 13,199, 21% above the 2014 target. The numbers waiting more than 12 weeks for a physiotherapy assessment continue to fall and there were 7% fewer people waiting more than 16 weeks for an occupational therapy assessment. With regard to the ambulance service, in 2014, 76% of ECHO calls and 65% of DELTA calls were responded to within the target response times. This compares with 69% and 64%, respectively, in 2013, and comes against a backdrop of an increase in call volume in the order of 4%.

A dedicated GP support line commenced in September to allow closer working between GPs and the HSE, aimed at supporting patients in regard to medical card applications and renewals. The implementation of the expert reports on medical card assessment and processing continues to be a high priority this year. A senior manager has been appointed to lead the process and a number of measures are now under way, as outlined in more detail in the response to question 17 from Senator Jillian van Turnhout. The recent appointment of the clinical advisory group chaired by Dr. Mary Sheehan, who is a GP, represents a significant development in this process and one which adds senior clinical and patient representation to the governance and oversight of assessment of medical card eligibility.

With regard to eculizumab, or Soliris, the HSE has taken a decision to extended access to it to sufferers of paroxysmal nocturnal haemoglobinuria, PNH, and atypical haemolytic uremic syndrome. Due to the exorbitant cost of this drug, which is approximately €430,000 per patient per year, its provision for patients will be on the basis of clinical need. The opportunity cost of the inordinate price demanded for this important drug will inevitably be felt over time in other parts of the health services and will have an impact on our ability to fund other important service developments. We will continue to pursue a more reasonable price for this medicine.

As it is now 18 months since the health service directorate was established as the HSE's governing body to take forward reform, in that time we have made a significant start on re-fashioning the health service to ready it for a post-HSE era. Significant progress has been made towards consolidation of the hospital groups. CEOs were appointed by the directorate in October despite a challenging recruitment backdrop. The community health organisations were designed and progressed, with chief officers appointed to seven of the nine before the end of last year. Health business services have progressed on the journey towards a contemporary shared service platform for the entire health service, providing for the most effective use of resources.

Clarity and transparency on funding and service planning has been brought to each of the five core service domains. Significant progress has been made, as I outlined, in the reform of the operation of the medical card service in the aftermath of the probity debacle. The quality and patient safety enablement programme has been established, as outlined in the service plan, with a distinct and appropriate focus on quality improvement, on the one hand, and quality assurance verification on the other. We are learning from the past in this regard.

A confidential recipient has been appointed as a means of empowering workers, service users and family members to highlight the most serious shortcomings in health services and to rebalance the power relationship between the health service, its users and their representatives. These are important steps in the right direction and the directorate is committed to building upon them, working with Ministers, to ensure that the health service is fundamentally reformed and improved.