Oireachtas Joint and Select Committees

Wednesday, 7 February 2018

Joint Oireachtas Committee on Health

Quarterly Update on Health Issues: Discussion

9:00 am

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

This is the quarterly meeting with the Minister for Health and the director general of the HSE. The purpose of this morning's meeting is to allow the Minister for Health, his officials and the director general to update committee members on key health care issues. The committee has flagged it would particularly like to have the issue of hospital overcrowding addressed during this session. On behalf of the committee I welcome the Minister for Health, Deputy Simon Harris, who is accompanied by the Ministers of State, Deputies Jim Daly and Finian McGrath. From the Department of Health I welcome Mr. Greg Dempsey, deputy secretary, and Mr. Jim Breslin, Secretary General. I also welcome the director general of the HSE, Mr. Tony O'Brien, who is accompanied by Mr. John Connaghan, Ms Anne O'Connor, Mr. Liam Woods and Mr. Ray Mitchell.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Any opening statements made to the committee may be published on its website after this meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

Before the Minister makes his opening statement, I note the lateness of its delivery to the committee. Replies to questions arrived at 8.40 p.m. last night and the Minister's statement arrived at 8.40 a.m. this morning. This point has been made on several occasions. Committee members have their own views on the matter, to which we will come, but I wish to put on the record that if we are to have a proper and meaningful engagement, it would be helpful to have the relevant information beforehand. I call on the Minister to make his opening statement.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank the Minister. I invite Mr. O'Brien to make his opening statement.

Mr. Tony O'Brien:

I thank the Vice Chairman and members. My team has already been introduced so I will go straight to my remarks, which are focused on the identified issue of overcrowding.

Each year our emergency departments, EDs, see close to 1.3 million patients and on average 25% of those patients are admitted. The total number of ED attendances has increased year on year while bed capacity has remained largely unchanged. This has created significant challenges for hospitals, which manifest primarily in emergency departments while challenge is also arising in terms of elective access. In the current year alone, ED attendances are up by 6.3% compared with the same period last year. This is on top of an increase in ED attendances of almost 3% during 2017 and 4.3% in 2016.

A key additional challenge facing our hospital and GP services is the sustained increase in the number of older patients presenting to EDs. During 2017 hospitals reported an increase of almost 6% in the number of older patients attending ED with some EDs experiencing an increase of upwards of 10%. This year to date, a further increase in this age group has been observed with the number of presentations up by a further 3.3% compared with the same period last year. Typically, patients over 75 years have more complex care requirements and are more likely to need to be admitted to hospital for treatment and will have longer lengths of stay. This means that the available capacity is under increased pressure as we do not have sufficient patient discharges every day.

The numbers waiting on trolleys at 8 a.m. fell by 3% during 2017 when compared with the full year of 2016. The number of patients on trolleys between October and December was consistently lower than for the same period 2016. These improvements were directly linked to increased capacity in a number of hospitals and sustained focus by hospital groups and community health organisations in reducing delayed discharges and improving patient flow. Targeted funding for emergency services in 2017 enabled consistent improvements in the wait time for funding under the fair deal scheme and an increase of up to 300 beds during the year. The trolley improvements were maintained to year end 2017.

The issue of overcrowding is a concern for both patients and staff, compromising a safe environment for assessing and treating patients. Of equal concern is the length of time patients wait in EDs. In 2017, the HSE sought to tackle both issues through investment in emergency departments, with University Hospital Limerick opening its new emergency department in June 2017 while upgrades were undertaken in St James's Hospital and at Mullingar. The major capital development in Our Lady of Lourdes Hospital, Drogheda, is opening on a phased basis in 2018. This development includes 80 beds plus theatres and an expanded ED.

The HSE has continued to focus on full compliance with no patient waiting over 24 hours and improvements have been observed in this during the year. Some 14 hospitals, including the three paediatric hospitals, achieved compliance of 98% or more in December 2017. Through our performance management process, we sought improvement plans from hospitals. A key challenge for most hospitals is the increasing requirement for isolation of patients to ensure that infection control issues are managed appropriately. The hospital system does not have sufficient isolation facilities or single rooms and as a result patients can wait for significant periods for suitable accommodation. In 2017, funding of €5 million was provided to support the cost of upgrades in EDs and wards aimed at addressing infection control, security and environmental issues.

In January 2018, the number of patients on trolleys increased due to increased attendances and the age and acuity of patients presenting. A key challenge this year has been the sustained increase in influenza cases with associated challenges in terms of providing appropriate isolation and consequential delays in discharge of patients to home and other community settings. At its peak this year the influenza rate was higher than last year and unlike last year, when it decreased sharply, it is expected that the high rates will continue for a number of weeks with continued pressure on hospitals. There have been two strains of flu present, which has meant that the isolation requirements are more complex and most hospitals have had to create cohort wards to ensure there is no cross-contamination.

This year a further challenge is the incidence of influenza in nursing homes which has prevented new admissions from hospitals during January. As of last week, it was estimated that more than 200 beds were out of use due to influenza cases in nursing homes. It is welcome and important that nursing homes are observing the national guidance on infection control but in the short term it means that fewer discharges from hospitals are possible.

A legitimate question that is posed by the public at this time of year is whether we make appropriate provision for winter pressures including the flu and other infections. It is important to emphasise that all hospital groups and community health organisations, CHOs, developed joint winter plans to ensure appropriate preparedness for winter surge. These plans included actions such as ensuring adequate medical and nursing staffing levels over the Christmas period; ensuring that senior decision makers are available to the greatest extent possible to support timely and appropriate admission, review and discharge of patients, for which a key requirement is to ensure that there is appropriate admission to emergency departments out of hours; increased access to diagnostics; staffing of surge capacity and targeting reduction in delayed discharges; vaccination campaigns and initiatives for staff and high-risk patient groups.

From daily engagement with hospital groups , it is evident that these measures did have some impact over the winter period and this is evidenced in the fact that while the overall attendances increased by 6% resulting in increased admissions, our rate of admission remained broadly the same. Hospitals highlighted that there were no delays in diagnostics and the number of delayed discharges fell from 580 to 450 between December and January 2018. All hospital groups put flu plans in place. Compared with the previous year, vaccination uptake rates are up in all categories, namely, health care workers, over 65s, and flu vaccinations by GPs and pharmacists. These combined initiatives have supported hospitals to address the sustained increase in attendances during this period.

Funding of €40 million was made available this winter to support surge pressures. Of this, €30 million was allocated to support additional home care packages, transitional care and aids and appliances. The main service areas include development of 30 additional transitional care beds in the Cork area; opening of the day hospital in Cashel; four rehab beds in Limerick; opening of six neuro beds at the National Rehabilitation Hospital; increase in funding for complex discharges; additional transitional care beds at the rate of 20 per week; additional home care packages at the rate of 45 per week. The remaining €10 million was allocated to support the opening of an additional 260 beds during 2018. So far, 176 beds have opened across the acute hospital system and a further 84 are planned to open during the year. As part of our winter exceptional measures, we have transferred 100 patients to private hospitals to alleviate pressures in public hospitals.

The key issue for our hospitals and community services is to develop sustainable solutions for access to services. The implementation of the Sláintecare report and the publication of the national capacity review by the Department of Health in January are critical in this context. The capacity review report acknowledges that our acute capacity is not sufficient to meet our current demands, with hospitals operating at almost 100% capacity. It also highlights the requirement for significant investment in the community to ensure that the aging population can have their needs cared for appropriately. The report sets out a clear plan for delivery of 2,500 beds, as well as sustained investment in primary and social care services. When it is considered in conjunction with Sláintecare, it offers a blueprint for the future delivery of hospital and community services over the next ten years. It also affords an opportunity for better streaming of emergency and elective services. The HSE is working closely with the Department to agree a robust implementation plan for core recommendations of the review with clear milestones for delivery of changes in the model of care delivery and investment in additional capacity.

This concludes my opening statement and together with my colleagues I will endeavour to answer any questions members may have.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank Mr. O'Brien. Before I invite questions, there are two issues I want to raise briefly. I also have some questions of my own, which I will hold until the end. The first issue concerns a letter I was sent yesterday by a psychiatrist who I will not name, although he is named in the press.

I was very disturbed to receive a letter under a HSE letterhead urging me to resist the pressure to yield to populism - specious arguments - and to give my support for the retention of the eighth amendment to the Constitution, Article 40.3.3o. I would like Mr. O'Brien to comment on that. I state for the record that I do not think anyone appreciates getting letters of this nature. We need to hear from Mr. O'Brien whether it was a breach of HSE policy. I have some passing familiarity with that and am reasonably sure it is. Perhaps, Mr. O'Brien could confirm that and advise the committee as to what will be done to follow up on it. This individual, who I am not going to name, is in the media now defending the actions. It is very distressing to be in receipt of emails of this nature which purport to come from the HSE.

My second point may be one for Mr. O’Brien and the Minister. It relates to the section 39 agencies. Are all of the representative bodies signed up to and involved in the process that was referred to? Can the committee have a timeline on that? As someone who was representing the bodies at the time, the Government moved nice and quickly to cut their wages and we would like to see the same sort of speed and attention with regard to pay restoration.

Mr. Tony O'Brien:

On the Deputy's first point, I thank her for forwarding that letter to me. Otherwise, I would not have been aware of it. Clearly, the HSE does not take a position on this issue as an organisation, neither would it be appropriate for it to do so. The use by an employee of both our letterhead and our email system to communicate a position, not just with Members of the Oireachtas, but more broadly, is not in conformity with our policies. The individual in question has already been met with and will be taken through the appropriate procedures. Normally, we do not issue the general guidance about not taking part in referenda and so on until a vote is called, but this clearly raises the issue of needing to do so more quickly. Obviously, the vast number of employees within the HSE are entitled to have and will have their own personal opinions and will take part as citizens in the process, but they may not represent themselves or use the corporate identity of the HSE in putting that forward. It is absolutely important that I be clear that the HSE does not take a position on referenda or electoral matters and must remain neutral. No member of staff may use the name of the HSE or its corporate resources to advance any side in any such issue. That individual is fully aware of that at this point.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I ask Mr. O'Brien to circulate that in writing to Members of the Oireachtas as we all were circulated with the letter. I thought it was only sent to me but that was a mistake. We were all circulated with it. As such, it might be helpful if Mr. O'Brien could share that with us.

Mr. Tony O'Brien:

We will. We got two references of it at approximately 3 p.m. yesterday and by the end of today we will have taken full action on communicating with Members of the Oireachtas.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I thank the Vice Chairman for bringing that issue to my attention also. I received the letter too. The Vice Chairman's comments are 100% correct. It is very important that our public bodies, in particular the HSE in this case, remain entirely impartial. Obviously, the health service will implement the laws of the land where any decision is taken by the Irish people. This is not the first example of this. We have seen situations where stickers have popped up in our various health care facilities containing various emblems and slogans relating to this emotive and complex issue. That has been brought to my attention. I welcome very much the comments and clarifications of the director general and it is important that they be transmitted across the health service. As citizens, everyone is absolutely entitled to their view, but not in terms of utilising the logo or name of our health service.

On section 39 organisations, I note that ICTU is leading the engagement on behalf of all the unions. Individual unions are also involved, however. I do not want to say too much, as talks are at a sensitive stage, but I note there are two timelines involved. On the first timeline, I would like an agreement to be reached before any industrial action is due to take place. The timeline for the subsequent process will be agreed as part of that. I do not want to say anything further than to note that there is ongoing engagement which ICTU is leading, albeit, obviously, individual unions are also involved.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank the Minister for allowing me to jump in there. I will take questioners in order; Deputy Kelleher, Deputy Murphy O'Mahony and Deputy Durkan.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

I welcome the Minister, the Secretary General, Mr. O'Brien and everyone else. We are here again at the start of a new year talking about potential difficulties in budgetary management and the stress under which the budget will find itself in the time ahead. In that context, there is no doubt that issues have been raised by the HSE, the Opposition and many commentators on the budgetary process, or how the budget is arrived at. If one looks back at the last number of years, it is evident that the HSE is almost always right about the shortfalls that will arise by the end of the year whereas the Department of Health and the Department of Public Expenditure and Reform are always wrong. That is a fact of life.

Is our process for budgetary arithmetic and assessment completely dysfunctional? Every year the HSE goes in and we accept that a certain amount of horse-trading is involved. The HSE goes in with a figure, outlines the reasons it was arrived at and the Department of Health and the Department of Public Expenditure and Reform insist on a reduced figure and the making of value-for-money savings and, perhaps, names other key areas where budget savings can be made. Almost consistently, that has proven to be a flawed policy.

If one looks back over the years, one had probity in terms of medical cards and other value-for-money savings measures which were farcical from start to finish. Let us be honest about that. It puts the HSE in a very invidious position very early on in every year. The HSE is planning to deliver health services knowing it cannot achieve that because sufficient funding is not in place. The Minister will point out that there is an additional €600 million being made available to health services this year and that this year's budget of €14.5 billion is the largest in the history of the State. Of course, that is true but there are also a lot of issues giving rise to additional funding requirements, including population increases, changing demographics, the complexity of health care and all the challenges that flow from that. Just because one has a larger budget does not mean it is, pro rata, a major improvement on previous years. When one looks at the changes in profile and the various clinical problems in our health services, it is clear we need additional funding in key areas.

I raise this because the Department of Health sent a letter to Mr. O’Brien on 26 January 2018 on issues which have been previously raised by him on the budget process and the funding of services. It refers to Mr. O'Brien's letter, received on 8 December, enclosing the HSE's 2018 national service plan and its view on the financial challenges for the year. The letter stated: "As we enter the new year and begin to implement the plan, it would be useful to set out my response to the comments in your letter."

The comments in Mr. O’Brien's letter were primarily about highlighting the major challenges ahead where the budget provided was, in his view, insufficient. Of course, he is right. We know that as we sit here on 7 February because he has been right every year. It is not because he is smarter than anyone else, it is because of the conflict between the process on his assessment and the agenda from the other side to contain public expenditure. It is Mr. O'Brien who is charged, fundamentally, with delivering health services in this country and ensuring we have a safe and improving health service. In view of its consistent failure to address and put together a budget in a meaningful way and have it approved by the Department of Public Expenditure and Reform for implementation by the HSE, I wonder sometimes whether that is the agenda of the Department of Health any longer. There are consistent overruns.

I am amazed that the letter was sent. Are there agendas undermining the budgetary process between the HSE, the Department of Health, the Minister for Health and the Department of Public Expenditure and Reform? The letter the Minister sent to Mr. O'Brien on 26 January was extraordinary. There seems to be some handwashing or pointing the finger of blame in anticipation, which is unhealthy in trying to arrive at a sustainable, fair and rational budget with which to deliver enhanced services. That has not been done in the budgetary process to date. The freedom of information requests published recently by The Irish Timesindicate that the process is flawed, does not serve the HSE well or its clients in long-term budget planning. The Department of Health seems to be playing both ways, in respect of the Government's request that it cap expenditure, but it is in no man's land in advocating for health services.

We do not want to see any industrial action or any impact on the clients of section 39 organisations. There seems to be almost a Machiavellian intent at work because the starvation of these organisations has been a very successful policy from the point of view of the section 38 organisations and broader health services which can now recruit large numbers of staff from section 39 organisations. Many section 39 organisation staff are opting to move to section 38 organisations and the HSE. The difficulties in retaining and recruiting staff, compliance with the Health Information and Quality Authority, HIQA, standards for the correct numbers of staff with the proper training in section 39 organisations have been flagged for a long time. How long will it take for the process outlined by the Minister of State to come to fruition?

In January approximately 12,000 patients were on trolleys, the highest number on record. There have, however, been some extraordinary achievements in Beaumont Hospital but huge challenges in Cork and Limerick. Has any assessment been made of what was done right in Beaumont Hospital and the challenges faced in other hospitals? Can there be cross-fertilisation of the good ideas that have an impact on patient experiences in the health service or are there silos which affect the impact decisions have on the roll-out of services? Beaumont Hospital was a serial offender for numbers on trolleys and waiting times. Why is it now a star? Why can the other issues not be addressed? It is hardly because the Minister of State, Deputy Finian McGrath, is the local Deputy.

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

I will be very modest.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

That is worth sharing with us and those across the health service who are trying to deal with the problem.

The bed capacity review and the Economic and Social Research Institute, ESRI, reports indicate that there will be extreme demands on health services in the years ahead and that if we do not enhance the capacity of the health service, as Mr. O'Brien predicted some time ago, we will effectively run the service on an emergency basis only and elective procedures will be a very rare experience. The bed capacity review recommends that there be 2,500 beds - intensive care and step-down beds - across the health service and a substantial increase in the numbers in nursing homes. Has there been any audit or will one be carried out of the 2,500 beds required? It would require approximately five new 500-bed hospitals. With the best will in the world, we will be waiting a long time for five hospitals to be built. Could an audit be carried out of what stock could be available through cheap conversions or upgrades of wards that may have been closed or changed to other types of facility to try to get some capacity into the system quickly? Does the HSE have the capacity to do this or would it need outside assistance?

It is extraordinary that 200 hospital beds were taken by patients with influenza. I assume that many of them were elderly people who are more likely to be badly affected by influenza. We seem to be incapable of dealing with patients in the nursing home setting. Figures, opinions and views vary, but many residents from nursing homes are being transferred or referred through out-of-hours services to an emergency department which is probably the wrong place for them to present. Has any consideration been given to enhancing and increasing community geriatric services in order that residents can be treated in the nursing home setting? Many of them require intravenous treatment. I am sure the competence and expertise are available, but they need to be deployed in the right area, with nurse specialists, geriatric nurse services and geriatricians to provide treatment in the nursing home, rather than transferring residents to an emergency department.

I have spent the past seven years observing the budgetary process for the Department of Health and the HSE and I am very disappointed that we have made no progress on how to assess and articulate the funding required. It seems to be a constant game of chess, draughts or snakes and ladders because there does not seem to be any coherent response to the HSE's requests when it points to the demands that will be placed on it in the years ahead. All of the funding sought will never be given, but I assume most accept that it is sought in good faith and that it is not a number plucked from the sky.

Photo of Margaret Murphy O'MahonyMargaret Murphy O'Mahony (Cork South West, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

The Minister of State said in his opening statement that there was a difference between what was predictable and what was avoidable, but surely predictability should help avoidability. This time last year Deputy Billy Kelleher predicted that January would be a crisis point in hospitals and, as he almost always is, he was correct. We knew that this would happen and that there should have been a better plan in place, with some simple moves such as making the flu injection available free to everyone or having a better public awareness campaign to highlight the advantages of having it.

I cannot sit in front of the Minister this morning without bringing up the case of Bandon district hospital. As the Minister is aware the issue is before the Labour Court today. This issue has been going on for a long time. I hope that underneath it all, a cost saving exercise is not under way as this issue has persisted for too long. This morning, 13 beds lay idle in Bandon district hospital, which is known locally as the cottage hospital. It is a term of endearment. The care given in the hospital, which the Minister visited himself, is exceptional. More serious than the beds lying idle is the fact that no respite has been available for nearly a year. If it all comes together and it opens, there will be four weekly respite beds. There is a huge need for that. The people of Bandon have been without respite beds for their loved ones for nearly one year. Many of them have reached crisis point with their own mental health because they need a break and the person who is being cared for probably needs a break. I cannot stress enough the seriousness of this situation. If there is no resolution today, the Minister should step in. I stress how important this is to the people of Bandon.

On waiting lists coming down, I have a submitted a parliamentary question and I do not expect the Minister to comment on an individual case. One of my constituents has Muckle-Wells syndrome. He attends a consultant every year and last month he was told that nothing more could be done and he was off the consultant's list. This man maintains that he needs monitoring and having googled the syndrome I agree, although mine is a non-medical view. He was told that another patient has taken his place. If this is the way lists are being reduced, then it is not fair. This may be something that could be looked into.

I welcome the fact that GP visit cards will be available for carers. They are our unsung heroes. It is not just a monetary thing; it is an acknowledgement of the wonderful work they do. Will the Minister indicate if he has a more definite date for when this measure will come in? Will the Minister outline what is being done to make it more appealing for positions in rural GP practices to be filled?

On the ratification of the UN Convention on the Rights of Persons with Disabilities some weeks ago the Minister of State, Deputy Finian McGrath, said it would be a few weeks. This time last year he told me it would be a few months, before that he told me it would be the end of 2016. Does the Minister of State have a definite date and what is happening in this regard? As the Minister of State is aware, under the Disability Act 2005 the assessment of need provision says that a person is assessed within three months of application and the assessment finishes within another three months. The Minister of State is aware that children are waiting years, not months, for this assessment. This is preventing early intervention. It will have long-term effects on children who are waiting. Is the Minister of State doing anything to speed up that process?

I also wish to ask the Minister of State about respite for those who are over the age of 18. I am aware that his office has been inundated with requests. Are there any plans in place for respite for people who turn 18? They go from getting a small amount of respite to hardly any. What are the plans in this regard?

I have a query for the Minister of State, Deputy Jim Daly - who is my constituency colleague. We were told about a year ago that 750 mental health services positions were approved between 2015 and 2016. I acknowledge this was before the Minister of State's time but the latest figures we received indicate that 667 positions were approved during that time. This means there are 83 positions that seem to have disappeared. I stress that hardly any of these positions were filled but they were approved. Where did the positions disappear to? Are they not now approved or what is happening?

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank Deputy Murphy O'Mahony. The Deputy asked a number of local questions which may be more appropriate to follow up in writing afterwards. I note that she also has submitted parliamentary questions on those matters.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I welcome the Minister and the witnesses from the HSE to the meeting.

Like Deputy Kelleher, from time to time I am askance as to how we cannot precisely identify the amount of money required to run the health service in any given year. This is especially relevant this year because the ink was not dry on the budget until somebody squeaked from the corner that there were insufficient resources to run the services. I cannot understand how that happens. It is particularly concerning recently because I have discovered that Ireland is among the highest spenders in the OECD in health services. There is some reason that I do not know and I cannot figure out what it is. I am sure the Vice Chairman would like to know what it is also.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I have my own ideas.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I have no doubt that she has, and I have some myself. One simple thing we could do is carry out an audit or a comparison with other countries that do not have the same problem. There must be one. Ireland is among the highest spenders and we know what we have to compare with. Can this be done? I am aware that the number of people on trolleys has been reduced and I am aware that the flu is a serious issue and it comes at this time and so on. Despite what people may think when they look at me, I remained standing in our household when everyone else got the flu. I do not go along with the general appraisal of the situation that Deputy Kelleher did that I should have gone down in the early stages. I am really concerned that it should be simple to find out where people have come from when they are sitting on trolleys, if we do not have the accommodation ready, if we should have the accommodation ready, if they should be treated somewhere else or if have they been treated or was there any attempt to treat them somewhere else such as primary care centres. There is not much sense in having primary care centres if they cannot do the job one would expect to be done in a primary care centre. There are a lot of them all over the country now, including a good few in my own constituency, and it does not seem to affect the numbers of people who are turning up in accident and emergency departments. I believe it should. If we cannot identify this information then all we are doing is duplicating services, in a very expensive way.

A simple audit needs to be done and I would love to find out why it cannot be done. RTÉ conducted an investigation some time ago on some of the things that were happening in the hospitals and it was able to find out information we did not know about or if we did, we did nothing about it. That is not being critical but it is something we have to answer. We must answer to the public and we must tell them outside what we are at. If it is not satisfactory, then the public has a way of very quickly dealing with us. I would like an answer to why there are deficiencies and whether they are permanent or are temporary. Are they theatre deficiencies or are they accident and emergency deficiencies? Is one overlapping into the other and if so, to what extent? Is extra capacity needed? The local hospital in Naas opened up 11 extra beds, a move which was very welcome and came at a good time. I thought we would have needed 20 beds at that time to eliminate peak time shortages. This is why I am concerned in this area. The Minister has pointed to the extra beds that are required between now and 2030 but I believe we need them before then. From my own observations, which I admit are not scientific, I believe we need the beds before 2030. Modern building methods will now very quickly bolt on extra accommodation to an existing hospital to high standards and the same as the rest of the building. This can be done very quickly, efficiently and cost effectively.

On the issue of spending, does an examination ever take place as to the cost-effectiveness of the service we provide at all levels in community care or in the hospitals and so on? There must be some way of identifying these. Deficiencies have been identified over the years and I am not suggesting these were simple; Ireland has come through a serious time in the context of the availability of finances.

However, we cannot go on with that forever. We have to move on, pick up the cudgels once again and simply ask ourselves why we seem to be chasing the game all the time. If we are always chasing the game, it is bad for the personnel in the hospitals and for all health personnel. We are always the subject of criticism. By "we", I mean all of those involved in the provision of services. Some time ago, a role in a local GP service was advertised. There was a great deal of furore about it beforehand, to the effect that the service was closing down. All the people who seemed to know everything announced publically that the service was closing down. What was the result of that? There was only one applicant for the position. Nobody wants to join a service that is closing down. I have never known that to happen anywhere. We must examine the impact of what we do and say about the services, and the effect it has on the confidence of those involved in them, particularly where emergency services are concerned.

My final point concerns step-down beds. A classic case of this issue is St. Brigid's Home, Crooksling, where we already have step-down beds. Somebody, who I will not name, wrote a letter to tell me that home was definitely closing down. I have news. That will be difficult, because I do not agree with closing it down. The reason is simply that the facilities there are state-of-the-art and are much sought after in this country at present. They are readily available beds of a high standard, with a high quality of nursing care, the use of modern technology to the greatest extent possible and a dedicated staff. What do we do with this asset? We try to make the bed situation worse by closing it down. The theory is that another facility will be opened somewhere else. I contend that we can open one somewhere else as well, because we need that too.

I cannot understand why people do things like that. The message I want to deliver is that nursing homes that are effective and well-run should not merely be kept but that we should continue to improve them. When somebody from the Health Information and Quality Authority, HIQA, tells me that I do not understand, that the building is falling down, my answer is that it is not. I know as much about buildings as HIQA does. Sometimes I get frustrated. Frustration leads to annoyance, and annoyance leads to reaction. At that point, something needs to be done.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank Deputy Durkan. I trust the witnesses were all taking very detailed notes but I can assure them that if they missed anything, the members who asked the questions will be sure to correct that.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I will take the queries in order. I thank Deputy Kelleher for his questions. I very much appreciated that when he said "Here we go again", he included the word "again". He spoke about observing HSE budgets for the last seven years. If one examines budgets since the HSE was established, one sees a recurring issue. In fact, looking at some of the progress we made on the HSE's budget last year, one can see that the demand-led schemes broke even. Moreover, the nursing home support scheme broke even, and the additional funding that I required was very small when compared with the additional funding other Ministers required in the past. This would have made their budgeting process blush. I am very satisfied that the phenomenon we are seeing in this country is not just an Irish one. Looking at health services throughout the world, including in our neighbouring jurisdiction, in Northern Ireland or in many European countries, it is clear that the challenge of budgeting for health services is genuinely a global issue. That is not to say that we should not continue to strive to do better. We absolutely should. However, it is too simplistic to state the HSE is always right or that the pesky old Department of Health is always wrong.

Of course the HSE has a job to do. I respect the job they do and take it very seriously. I read about rebukes and fraught relations. I do not see any such thing. What I see is a health service doing what it is meant to do, that is, advocating and highlighting what it believes are its needs now and in the future. I see myself as a Minister going to the Government table, putting forward a case for the health service and obtaining additional resources. I see the Government expecting to see demonstrable improvement in certain areas in return for those resources.

The people of this country voted, quite rightly, for a stability treaty that brought in fiscal rules by which we are bound. We are bound to a maximum amount the State can spend. If someone approached this objectively from the perspective of another jurisdiction, was apprised of the annual budget for Ireland and saw the proportional increase the Department of Health and the HSE received for the delivery of health services when compared with other public services, I would contend I had fought my corner very well. The Government has prioritised health yet again.

Perhaps the only mistake the director general and I have made is that we are too transparent. Excellent health correspondents use freedom of information legislation and find all our letters back and forth. I can assure the Deputy, who has been a Minister in Departments and has been around long enough to know, of one thing. There is no agency in this country that does not look for more money than the Government of the day is able to provide. That is the reality. Perhaps they do not all write letters back and forth to each other. Maybe we are guilty as charged of being too transparent, in that we put our discussions in writing so that they are available to read. If anything, the letter the Deputy describes as extraordinary is quite ordinary, in that a Minister wrote back to one of his agencies to state it must live within the budget it was given. It is appropriate for organisations to seek value for money. It is even more appropriate to seek value for money at times of economic boom and budget growth, in order that we do not slip back into mistakes of the Celtic tiger era. I emphasised in my letter that since budget 2015, the HSE's allocation has increased by €2.4 billion, or 20%, averaging an increase of about 6.6% per annum.

The point I was making in the letter is that there is a difference between a challenge and a shortfall. There are more things that the health service would like to do, and that I would like it to do. We are going to do them, together, on a multi-annual basis. However, that is different to a shortfall. The director general and his organisation have a legal obligation to produce and sign up to a service plan that they intend to deliver. I approve this plan, bring it to the Government and publish it. I am not going to speak for the director general, who will speak for himself in a moment, but when I launched the service plan I heard the HSE state clearly to the people of Ireland that this document outlined the services it would deliver this year. In every single case in that service plan, there is at least maintenance of last year's service level and in many cases, there is a significant increase in service provision, be it in respite care, waiting list funding, access funding, speech and language therapy or mental health services.

That is not to say that there is not substantial pent-up demand in our health service and indeed in our public services. I think the Deputy and I will agree on this. We have discussed some of these problems already in addressing capacity issues and we clearly have work to do there. I am excited about being able to grow the health budget again. I am excited to be able to build on the work of my predecessor, the Taoiseach, who also did so. However I think the committee would agree, as would the HSE and every citizen in this country, that it is not all about money either. If it was all about money, my predecessors would have solved this a long time ago. Our approach has to be about funding linked with progress. It has to be about targeting specific areas. We must not attempt to boil the ocean. Instead, we must pick certain areas of the health service to improve on in a given year.

I have proven already that when decent funding is allocated to the health service, as the Government did last year, the health service, with careful management, can provide many parts of its services within budget. The budgeting assumptions that my Department and the Department of Public Expenditure and Reform must make were proven correct last year where several parts of the health service budget are concerned. In particular, the nursing home support scheme, which received a budget of almost €1 billion, and the demand-led schemes in areas pertaining to the primary care reimbursement service, PCRS, have shown that we can budget correctly.

There are other parts of the health service we all know are a bit harder to predict and to budget for. That is not a uniquely Irish phenomenon. How many people will turn up at the door of a hospital? How bad is the flu going to impact this year? That is something on which we must continue to work. We can absolutely manage our processes better.

It is too simplistic to say that one agency is always right, that the other is always wrong and to try to paint it in a confrontational way. I am not suggesting that the Deputy tried to paint it in a confrontational way but some commentary does. We go through a very robust process, set out in law, which results in a HSE service plan being produced every year. My job is to make sure that the Government's priorities for the health service, which we often discuss here, are reflected in that plan. The director general's job is to deliver that plan. I would think that it is a job for both of us to continue to put forward new ideas on how we can do things better and continue to deliver services in a better way for our people. A number of building blocks which we have published and produced in recent weeks and will continue to produce, with the next big ones being the Sláintecare implementation plan and the Government's capital plan, will give real life to some of those ideas.

I take the Deputy's point about section 39 bodies. I visited, as I am sure the Deputy has, a number of section 39 bodies. They tell me that they have a situation where they try to recruit staff, such as nurses or health care assistants, or others, and find that a nearby State agency or section 38 body is able to pay those people a better wage. They tell me that the section 39 bodies therefore become uncompetitive and while they might be called a section 39, to the man or woman who comes in off the street and uses the services, they are a core component of the provision of public health services. We have to work out a way to address that. There are many section 39 bodies of different sizes, shapes, composition and even governance structures. The financial emergency measures in the public interest, FEMPI, saw a swift introduction of pay reductions back in the dark days, first with our public servants, then with fees to contractors. Section 39 bodies were also asked to make cost savings. There is no doubt about that. They subsequently took a range of measures, including pay reductions in many instances. Last summer, the public service pay agreement formed an agreed pathway for public service pay restoration. We saw the first benefit of that before Christmas with more in the new year. That will continue. We now have to seek to address our section 39 bodies. It is fair to say that the position relating to these agencies is more complex. We need an analysis. Each organisation might be different. We need to know if they applied a reduction, how they applied it, if they have restored it and when it was applied. I note, in correspondence from unions, that they are looking for a process to validate and interrogate the realities of the situation. I do not wish to be coy and not more forthcoming but I am conscious that discussions are ongoing with unions, which management is engaged in with a view to averting industrial action. I hope they can yield a positive outcome. As a part of that outcome, we need an agreed process and a timeline for that process. I have no doubt that at the end of this process, there will be a funding requirement for our section 39 organisations. It is a matter of how we get there, how we validate and verify, and the thought process that we put in place.

The Deputy's point about trolleys is one that I make all the time. A number of our hospitals perform well and a number perform very badly. I need to be careful not to be overly simplistic in suggesting that it is all down to one issue because there are certain challenges in certain hospitals. Looking at Limerick, for example, we know that there is a bed capacity shortage in the mid-west that goes back many years. There are issues with management and clinical leadership in every hospital, ensuring that discharges are done by the weekends, and other operational issues, but there is also a need for investment. My understanding of the issue at Beaumont Hospital is that we have seen excellent managerial grip and excellent collaboration with clinical leadership, but we also saw that on the back of investment, including investment in the hospital, which the Minister of State, Deputy McGrath, knows about from experience over the years, and investment in the community which serves the hospital with home care packages and transitional care. The audit of capacity in general is under way. I have made it clear that while the capacity review talks about the extra beds which will be needed by 2031, it also makes it clear that we need some of those beds now. I am not saying that this is a ten-year plan, and to come back to us in 2031 when we will have all the beds. We need to look at what we can do quickly. I have asked the HSE to identify and report back to my Department how, if coupled with investment, we could quickly open additional beds in advance of the next winter period. Beds are quite a big part of the answer but only if they come with reform. We have seen extra beds go in in some hospitals but have not seen significant improvements in trolley numbers. In Galway this winter, extra beds were received but the hospital made a number of changes to pathways which resulted in a significant improvement in Galway's numbers for a significant period of the winter.

The Deputy is right about the issue of nursing homes and referrals to hospitals. I was going to ask the Minister of State, Deputy Daly, to address it but he has had to go to the Seanad. That is an issue which can be dealt with in three ways. We can investigate what else we can do with the general practitioner, GP, contract and with GPs linking with our nursing homes to keep patients in what might well be a private room with an en suite rather than a busy emergency department. On nurse-led care, there is definitely a role for our nurses. Our Irish Nurses and Midwives Organisation, INMO, colleagues have clear views on that. There is also the integrated care programme for older people. There is no doubt that there are far too many patients who have to leave their nursing homes and go to hospitals. It is not a criticism of nursing homes but we have to look at how we can help to keep patients there where we know they will have better outcomes. The last thing one wants is to send a vulnerable older person into an overcrowded hospital if one can provide that person with an isolation facility. Equally, our nursing homes locally have to know that they have that support. The GP contract and a nurse-led service are the key ingredients for that.

Deputy Murphy O'Mahony joined the queue of everybody other than me as nearly always right. Deputy Billy Kelleher said he was told he was nearly always right. The Fianna Fáil position is that Deputy Kelleher and Tony O'Brien are always correct.

Photo of Margaret Murphy O'MahonyMargaret Murphy O'Mahony (Cork South West, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

Mostly.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

Maybe they are. The Deputy is right about predictability and avoidability. I will not play a word game and confuse everybody. The point I am trying to make is that everybody knows. If the Deputy was sitting in the chair I am in now, we would all know the pressures our hospitals come under. They are pressures our hospitals are always under but we know that tipping point is hit every January. I tried, my predecessors tried and my successors, in time, will try to handle it. Unless we take some big, fundamental actions, that will be repeated each year. I genuinely believe that the capacity review is a big part of that. There is also the issue of trying to keep people out of hospitals in the first place. Sometimes, in January, there is a bit of misinformed commentary. If people are on a hospital trolley, a clinical decision has been made that those people need to be admitted to an acute hospital. It is not a case of people who could go to see a GP, take two antibiotics, and be home in bed, resting. The bigger question is, if those people had access to chronic disease management in the community and so on whether we could have avoided that acute incident ever happening. That is where I think the GP contract has a role to play.

I am sure our colleague, the Minister of State, Deputy Daly, would be delighted to answer the question about Bandon District Hospital if he was here but he is not so I will give it a go. The Deputy is right. I visited Bandon District Hospital and it seems to me to be a wonderful, very special place. I was struck by the warmth of the staff and the patients. I am conscious that there are issues before the Labour Court and it would be inappropriate of me to comment but I hear clearly from Deputy Murphy O'Mahony about the importance of the facility, specifically the respite facility, and the burden that the lack of the facility is placing on people in the Bandon area. My Department and the HSE are watching developments with interest.

The director general might want to comment on the waiting list issue in a moment. I am not a doctor and the Deputy pointed out that she is not one either. The decision for people to be removed from waiting lists who no longer need to be on one is a clinical one. There is no edict, nor should there ever be one, that a person is taken off a list unless a clinician believes that there is a better way to care for a person. If the Deputy wishes to send the details of that individual case to the HSE, I am sure it will look at it.

A GP card for carers requires legislation. I said it would come in quarter two of this year so I expect we can have this in place by summer. Let us work together on that to try to get the legislation passed. We have a very busy legislative agenda ahead, as we all know, from my Department in the coming weeks. I would like to get that passed and in place by the summer. Supports for rural GP practices, building on what my predecessor, the now Taoiseach, Deputy Varadkar, did, will be looked at in the context of the GP contract.

Deputy Durkan rightly makes the point, as many of my colleagues also rightly make, that we are among the highest spenders on health care in the OECD. Even when one strips out the proportion of private health care included in that figure, we are still at the high spending end of that league table at OECD level.

We have to look at what we are spending the money on. I have previously used the analogy at this Committee of an old car which can be terribly expensive to run. A neighbour up the road can have a newer, flashier car which is actually cheaper to keep on the road. There is an issue here about the system we are pumping the money into. It is no disrespect to the system, but politicians and HSE management have acknowledged that it has to be reformed and changed. Patients are being treated in more high-cost locations - places they would rather not be - than is the case in other jurisdictions.

The point about people on trolleys is important. We have to remember that we are talking about people and not get lost in figures. The people on trolleys are those who clinicians have decided need to be in hospital. The reason they are on a trolley rather than a bed is because there is not enough bed capacity in that hospital. That is the straightforward part of the answer. The more complex but equally important part relates to the possibility of making reforms in the community health sector and keeping those people well and living in the community so that they do not have to come to the hospital in the first instance. That relates to some of what Deputy Kelleher referred to in terms of nursing homes. It also refers to things such as the diabetes cycle of care and how we look after people with asthma and chronic diseases in general. These have to be key priorities for us if we are to invest more in primary care. We know that there is a benefit in that regard.

The Deputies spoke about primary care centres. We have built a very good primary care infrastructure now. We are still building it; I am opening another centre in Limerick on Monday and there are a number of them coming on stream in the coming weeks and months. That is good. The State has invested a substantial amount in primary care centres. The conversation now has to move on to what is in those centres. These centres require staff and diagnostics. I opened a primary care centre in Castlebar recently and the X-ray and ultrasound machines are now in situ there. Patients who would have had to go to Mayo University Hospital are now having their X-rays and ultrasound examinations done under the governance of the hospital but under the direction of the primary care centre. That has had a very positive impact on those lists. We have to investigate how many more primary care centres we implement that system in. We have plans for a number of them in that regard.

I agree that we need extra beds by 2031. The evidence also shows that we need a number of the beds now.

We should acknowledge that activity based funding has given us a greater sense of what we are spending money on and what we are getting in return. We have to look at that in terms of the community.

I am aware of the issue concerning Crooksling nursing home. I look forward to visiting it in the near future. We certainly should not be reducing capacity anywhere. When a facility is being decommissioned it should be replaced by a facility with not just the same amount of beds but more. We also have to look at how we keep those facilities for the use of older people. A local group has a number of ideas in that regard, and I am aware that the HSE in South Dublin County Council is engaging on that as well.

Mr. Tony O'Brien:

On the issue of nursing homes, in my opening statement, I was referring to situations where nursing homes were now following the guidelines so that patients with flu were being retained there. Consequently it was not appropriate to discharge into them. They were being supported both by public health teams and community intervention teams. This is part of the emerging and developing integrated care programme for older persons. We are seeing a reversal of the previous pattern where patients were automatically sent into hospitals. We have to get further down that road, but it means that the nursing home, even if it has two or three empty beds, is otherwise effectively regarded as a flu ward into which we cannot discharge patients directly. Overall, that is a better place to be.

I will ask Mr. Connaghan to comment on the performance issues relating to trolleys when I am finished because that is an area within his brief.

I do not agree with the committee's perception of the correspondence or the budget process as it relates to the service plan for 2018. We have had the pleasure of discussing a number of service plans across this floor, and the spectre of the famous medical card probity issue of 2014 was raised. We are nowhere near that territory. The committee must know that if I had concerns of that nature I would express them, as I expressed them previously. Within this service plan a number of risks to its successful delivery are spelled out. The service plan in its full form was approved by the Minister, having consulted Government, with those risks taken into account. Every service plan and every budget has some element of risk associated with it, and it is appropriate for a public body proposing a service plan for ministerial approval to be transparent with that Minister about what those risks are. The 2004 legislation, combined with freedom of information legislation, makes our service planning process extraordinarily transparent, especially when added to the performance reporting process, which I would contend is more transparent in the HSE than in any other public body in the State. That does not mean that from time to time we do not have some crunchy conversations where we share our different perspectives. We are not living in North Korea; we can have good discussions. We all accept the fundamental reality that, ultimately, the budget for the HSE is decided and announced on budget day. Our task then is to construct a budget in the shape of a service plan which we can propose to the Minister and the Minister can subsequently approve. We then publish that and make every effort that we possibly can to deliver that service plan in the way that we framed it. That, essentially, is what this service plan is about.

The correspondence is the ordinary correspondence that goes on between Ministers and their officials. I would not agree with the proposition that the Department of Health is not a strong advocate for the health system. I believe it is. I have worked within it and alongside it. I have had the opportunity to work with every Minister of Health going back to Deputy Micheál Martin, and every one has been a strong advocate for the health system in their day. The difference between the past, when we were in the most difficult of economic circumstances, is that we now see targeted investments around specific improvements that were not possible in the past. Matched against that, we seek - as outlined in the value improvement programme which Mr. Connaghan might say a word about - to use better the relative small proportion of the total resource we have, and stretch those resources to get the best possible range of services we can. The overriding priorities are patient safety and access. That has been clear in all of the correspondence from the Department and back to the Department. The Minister has been very clear about it. We will make our best efforts on all parts of the service plan, but nothing will take away from those priorities the greatest possible quantum of service to improve access in a way that supports the highest level of patient safety that we could possibly achieve with the resources we have.

On the variable performance regarding trolleys, as the Minister has said it is probably too simplistic to take the trolley count in a given hospital and reach a conclusion about the overall performance of that hospital. It has to be adjusted for the size of the population it serves, for the resources it has and for the quality of the infrastructure it has in its emergency department versus the balance of the hospital. I can give two examples of that. Kilkenny and Limerick, hospitals which have had particularly challenging trolley counts this winter, are locations which have recently had the benefit of new acute care buildings with modern, first class, contemporary accommodation, versus ward accommodation which in general is of the "nightingale" variety. Consequently the clinical decision is more likely to be to hold the patient in an individual room - which often has an en suite, climate control and environmental control - rather than transfer the patient to the ward, even though that will add to the trolley count in that particular hospital. There are a variety of factors, and I will ask Mr. Connaghan to expand on that.

Mr. John Connaghan:

I will make some comments as someone who has recently joined the Irish health system from a different jurisdiction who has the benefit of being able to compare and contrast in some respects. In common with most modern health economies, the Irish system has witnessed significant changes in bed use over the past ten years, characterised by a significant drop in length of stay for medical beds. In recent years, that process improvement has begun to stand still. In fact, we have flatlined over the past couple of years. That points to a system where some of the process improvements we could make have begun to bottom out.

That is an important point in comparing the relative efficiency regarding the use of our resources, as Deputy Durkan pointed out.

The increasing elderly population is also an important factor. Over the course of 2017, we have seen an increase in admissions of people over 75 of approximately 5.7%.That drives a longer length of stay. Patients tend to be sicker and elderly patients tend to have increased comorbidity of a number of conditions, which means that the stay in hospital is more complex. That makes discharge more difficult. This is another material factor in considering where we stand regarding trolley waits.

One of the issues that strikes me about the Irish health care system is that our ability to discharge effectively and efficiently in the evenings and at weekends is hampered by our ability to have diagnostics readily available. That is a simple fact in terms of the number of consultants and support staff that are available to man operate facilities on a 24-7 basis. We need to consider what we can to do alleviate this as part of any consideration of expansion. We cannot simply expand bed capacity without considering what needs to wrap around that to make the expansion more effective.

There are things we can still do in terms of pursuing process efficiencies. This links in to value improvement. There are a number of elements we need to consider that are perhaps not entirely in balance, such as the number of acute assessment beds we have, the number of beds in the system, and where we are in terms of community resources. When we consider the differences in performance between Limerick and Beaumont, for example, which have been mentioned already, we can do some very simple maths. What is the population we need to serve? What is the expected rate of admissions and discharges and how does that lead to our bed base? We can readily see that some parts of the system are more stressed than others. We need to consider where we would ideally like to have beds in the longer term versus what is opportunistic and what we can invest in the short term.

We also have what I would call failure demand in the system, which is another reason that drives matters regarding people on trolleys. Failure demand is where we cancel electives for a considerable period, which is what we do in extremisduring the first part of January, and where they then reappear in the system as emergencies. We need to avoid driving failure demand. The long-term plan in Sláintecare to separate elective and emergency care is perhaps something we really need to pursue quite quickly. It would also allow us to enhance what we are doing in terms of efficiency and effectiveness regarding elective care.

I will pause there and can say a word or two about the value improvement programme if the Vice Chairman wishes.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank Mr. Connaghan. A specific question was addressed to the Minister of State, Deputy Finian McGrath.

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

There were three questions on disability concerning the UN convention, assessment of need and respite care.

I thank Deputy Margaret Murphy O'Mahony for her question. I feel very strongly about the UN convention. The Deputy is absolutely right that it is a very important issue for the disability sector in Ireland. We have 645,000 people with some form of disability. I also feel very strongly that we cannot hold back on ratification until the ink is dry on every remaining item of legislation. We have made major progress in the last weeks, particularly up to Christmas. We got the €3 million to start up the decision support service and there is wide consultation in train on the deprivation of liberty; the Deputy may have seen the advertisements in the paper over the Christmas period. I want to make sure every disability group and organisation as well as every organisation that advocates for senior citizens is involved in the process. That is partly the reason for the delay.

The important thing is that we have a clear plan now. On 30 January, the Government decided to authorise the ratification of the UN convention. That is phase 1. I am hoping to have a resolution before the Dáil in the next two weeks. My target in that regard is mid-February. For the deposit of the instrument for the ratification, my target date is the end of February. In the meantime, I will be looking for support from all the political parties to allow me some space in respect of the deprivation of liberty issue, the disability Bill and some of the other instruments that have to be put in place. My objective is to have the resolution before the Dáil in the next week or two and to ratify the convention by the end of the month. I totally accept the criticisms of the delays. A lot of complex issues arose, particularly around deprivation of liberty, and we want to get the legislation right. We have it at the moment and are waiting for final consultation.

The UN convention sends out a strong message to every person on this island that we care about them and that we care about the rights of all people with disabilities. More importantly, as well as caring we are putting in place the services to support them. On jobs, for example, the UN convention should improve the economic prospects of people with disabilities. In respect of gender equality, the convention will be of benefit to all persons with disabilities including women with disabilities. Article 6 of the convention deals specifically with the position of women with disabilities. Another issue that is important for people with disabilities and their families is that of poverty. Implementation of the convention should improve the lives and chances of people with disabilities in reducing the incidence of poverty, particularly among people with disabilities but also in rural communities, which is an issue that arose this week. The convention puts inclusion at the top of the political agenda.

As stated, I am aiming to have a resolution before the Dáil in mid-February and ratification by the end of February. Hopefully nothing will go wrong this time.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

Is that February of this year?

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

This year, absolutely.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

It is important to be specific.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

I heard something similar last year.

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

I explained the reasons for the delays. The matter is very complex. I want the disability sector and those dealing with senior citizens to be involved in the process. If it takes another few months to do that, so be it. I will take the hits and deal with it.

On the assessment of need issue, Deputy Murphy O'Mahony rightly said this is a provision under Part 2 of the Disability Act, 2005. There has been a steady increase in the applications. I totally accept that. The recent figures I have in front of me are in the region of 6,000 applications. We know we are facing huge challenges in meeting the statutory time frames. There are many complex cases but we have set out and are planning to act on the delays. We are doing three major things. We have put in place a comprehensive plan with individual measures for each CHO area to deal with this issue. A new standard operational procedure for assessment of need is being implemented by the end of 2018. This will improve efficiency in the operation of the assessment of need process and the compliance rates. The reconfiguring of the disability services is taking place. It is part of the Progressing Disability Services for Children and Young People programme. Integrated teams are operating well and the assessment of need process is running more smoothly than in other cases. A policy review is taken place in respect of assessment of need, with the ambition to extend it to adults in 2020.

Photo of Margaret Murphy O'MahonyMargaret Murphy O'Mahony (Cork South West, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

What is the date for the policy review?

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

It is happening as I speak, by the end of 2018.

Photo of Margaret Murphy O'MahonyMargaret Murphy O'Mahony (Cork South West, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

Another date. Okay.

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

The final issue raised was respite services. I appreciate the support I have received from the committee and other colleagues, as well as the strong support I have received from the Minister the Department of Health and the HSE. We accepted before Christmas that there was a huge crisis in respite services.

This is why we got together with our colleagues in government and in opposition to look for extra funding. We received an additional €10 million on top of this year's budget to enhance the respite service and the disability sector. Of this, €8 million is for an extra 19,000 nights respite care on a full year basis. These are to be provided in ten new dedicated respite houses throughout the HSE community health organisation areas. There will be three in the greater Dublin area. The other €2 million has been put away in a special pocket for innovative respite solutions, such as home sharing or extended day services, to provide assistance where people need it most.

Photo of Margaret Murphy O'MahonyMargaret Murphy O'Mahony (Cork South West, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

How many of these houses will be in west Cork?

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

I do not have the particular figures for west Cork. I will come back to the Deputy with the details.

Photo of Margaret Murphy O'MahonyMargaret Murphy O'Mahony (Cork South West, Fianna Fail)
Link to this: Individually | In context | Oireachtas source

It is very important.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Will the Minister of State come back to us with a detailed breakdown of the picture in the State rather than on a county by county basis?

Photo of Finian McGrathFinian McGrath (Dublin Bay North, Independent)
Link to this: Individually | In context | Oireachtas source

There will be 19,000 extra nights nationally, and if the committee wants a detailed breakdown I will provide it. Three new community houses will be in the Dublin area. It is an issue we take very seriously. There is agreement in the Department and the HSE that when we invest in disability services we must deal with priority cases first. I have a budget for this. Do we need more money? We absolutely do, but we have started building. As I have said previously, our key objectives are to invest in services, reform services and, with the new momentum for the UN convention, to put the person with the disability at the centre of the services. This is what I hope for 2018.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

We will now move on to the remainder of questions from Deputy O'Connell, Senator Colm Burke and Senator Conway Walsh after which I have a few questions that I might throw in if I can.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I apologise for being in and out between this meeting and the meeting of the justice committee. I also apologise if I ask questions which have already been asked. I know from Twitter that certain things have been asked. If I duplicate questions I ask the witnesses to let me know and I will look back later.

This morning, there was an article in the Irish Mirrorby Mikie O'Loughlin about the alleged refusal of the morning-after pill in a community pharmacy setting to a girl who claimed rape. As a community pharmacist I never realised it was my role when dispensing the morning-after pill to judge or to have any role with regard to how the unprotected sex happened. My understanding as a community pharmacist is our role is specifically on seeing whether the product is suitable and making sure that patient gets the service required. Perhaps whoever feels they are most qualified might comment on this. Perhaps it is a once off, but if it is going on in our community pharmacies it would be prudent for the HSE to have an advertising campaign, particularly in light of the Minister making the morning-after pill available at the weekend to medical card holders, which I do not believe was ever advertised. Perhaps there is an advertising campaign to be done on accessibility to emergency contraception. It is topical in light of recent discussions on the eighth amendment and some parliamentarians' views on self-certification or justification of termination of pregnancy in the case of rape.

The Minister is aware we spoke at the eighth amendment committee on the availability of free contraception, and it was raised by the Irish Family Planning Association that 18% of women, which is almost one in five, who are non-medical card holders have an issue with a price barrier when it comes to contraception. I thank the HSE for its response. Approximately €90 per year on contraception is the average amount reimbursed by the State per woman. Will the Minister let me know whether he is considering rolling this out and whether we have a timeline?

Another issue has come to my attention and I ask the witnesses to correct me on it if I am wrong. People used to get a medical card if they had cancer and this was taken away some years ago. I know from my previous role it was a great comfort to cancer patients and primary care providers that if someone had a bad diagnosis the GP could just write a prescription and the pharmacist would dispense it, and we would sort out the medical card payment element when we had dealt with the patient in a caring manner. It has come to my attention that it is now a discretionary card and there appear to be issues with people having to prove they have cancer. I am not big into anecdotal evidence, but I have heard that people are being required to justify getting the card by having to state they might definitely die, or they are definitely terminal or definitely at stage four. To me, particularly in the case of children with cancer, this is just not humane. It is not humane to ask parents to guarantee their children will be dead in 12 months so they will definitely be given a medical card. This is not the way to approach things. Can this be streamlined? Can there be a nicer and more holistic way of doing it? The way it used to happen four or five years ago worked really well. We all got paid and the patient got fixed up. I never heard as many complaints as I have heard recently.

The Vice Chairman raised the issue of a letter sent on HSE headed notepaper to Members of the Houses by Ciaran Sean Clarke, and I know it has been dealt with to some extent. Perhaps the HSE could let the committee know under what cases can staff employed by the HSE use headed notepaper. As a parliamentarian I am very conscious of what I put on personal and on headed notepaper.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I ask the Deputy to refrain from using names.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
Link to this: Individually | In context | Oireachtas source

It is here in front of me. It came to my email and I have a printed copy of it.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I appreciate that.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
Link to this: Individually | In context | Oireachtas source

The Vice Chairman has dealt with the initial aspects of it. What are the actual rules? There must be a list of rules somewhere on when people can use headed paper and when then cannot.

Do we have any news on the roll-out of the male HPV vaccine? Do we have any new data on the uptake? We were up at 61% recently.

Yesterday in the Chamber, Deputy Clare Daly raised the case of the lady who died during an intervention into an ectopic pregnancy in Holles Street hospital. The Taoiseach, Deputy Leo Varadkar, stated he was disappointed by the hospital which, I understand, is threatening to injunct the Minister for Health. Will the Minister comment on this situation? How does he see it moving forward? The committee has spoken previously about dragging people through judicial processes when they have been through extreme trauma. Is that really the way to treat people?

I welcome the trauma centres proposed by the Minister. Will the witnesses comment on the integration of this plan with the Sláintecare report? We are back to the structures of the HSE and how these trauma centres might fit into any proposed realignment of community health organisations and the training hospitals in each area. Is there any intention on the part of the HSE to educate people on the pathways to follow once they have a trauma or injury? I have long felt that many children in the accident and emergency departments in children's hospitals have not had a serious accident. They may just have a broken bone.

People in the community are not aware of some of the primary care centres, especially the centre in Smithfield for minor injuries. That is a really good set up. Many people in Dublin city do not know that is available.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

With regard to the issue raised about the email, Mr. O'Brien has indicated he will be circulating a response to an email I sent him yesterday, which may answer the Deputy's questions.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I thank the Vice Chairman.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

I thank all those who made presentations this morning. I apologise if I go over some of the ground again. I had to deal with a Commencement Matter in the Seanad.

I am grateful for the comprehensive reply to my question on the availability of drugs. There is a question mark over short supply of some medication, some pharmaceuticals. I have got a comprehensive reply and I appreciate that. There are two issues. The reply confirms that there is a short supply in some areas and the HSE is dealing with it. The Sunday Business Postrecently had a report on overprescribing. The usage of one particular drug has gone up by more than 1,000%. That huge increase in the use of medication is a major cost to the health service. In one case it went from slightly over 100,000 people taking an item to more than 600,000 using it. There is also a big budgetary problem with orphan drugs. Is it time to look carefully at the availability and use of drugs? On the one hand we seem to have overuse and on the other hand we do not seem to have funding to provide for particular drugs. Do we now need to have a full review of how we are managing the cost of pharmaceuticals and drugs?

As part of my question I also raised the issue of the effect of Brexit on the availability of drugs because we are very much tied to the UK market in many ways. We need to plan for that adequately. In fairness, the reply deals with that. That is another issue we need to plan for.

I know people may be tired of me raising the issue of the increase in administration and administrative staff. I was given figures this morning indicating an additional 2,605 administrative and managerial staff in the HSE since 2014, which I calculate to be a 17% increase. I know the argument will be put to me that there were cutbacks in difficult times and this needs to be made up. However, the HSE now has 17,715 people in administrative and managerial roles. That is an increase of 17%. The number of staff nurses has increased by 3.65%. The number of public health nurses, who are to the forefront of helping us keep people out of hospitals, has increased by 3.69%. People on the front line in section 39 organisations are having difficulty because we have not restored the cuts they suffered.

While I know there is more paperwork related to health care, there has been a disproportionate increase in administrative and managerial staff. A 17.2% increase does not sit right with me. I raised this question 12 months ago and I raised it two years ago. Where is the cut-off point? The HSE now has 17,715 people. Is the cut-off point 17,800? Is it 18,000? Is it 19,000? Surely the HSE has a plan. If we go down this road, we will not have the funding to sort out the people in the section 39 organisations. We will have a difficulty in recruiting public health nurses. The whole job in health care is to keep people out of hospitals. The only people who can do that are the people who work on the front line - out in the community. I ask for a detailed reply on that issue.

I also raised the issue of elderly care. I am grateful for the reply on that. I suggested we need to have a forum involving all the focus groups, nursing homes and the care providers. We have a huge change in the demographics with a greater number of people living longer and therefore greater demand. Many nursing homes are experiencing difficulty in getting GP cover at weekends. How will we deal with that? I am talking about dealing with that immediately because that cannot be parked.

Many people need to go from nursing homes into hospitals because our health service does not provide the care for them in the nursing home. A simple example is with dieticians. Dieticians employed by the HSE will not attend nursing homes because they are not covered for travel expenses. If a patient needs to see a dietician, someone has to go into the hospital with them. It takes up time in the hospitals and there is an issue with value for money. The private sector is coming into many nursing homes and prescribing supplements giving rise to a huge cost to the health service. Those are simple examples. That is why we should have a forum. There are 23,000 or 24,000 people in nursing homes. We need to see how we can create efficiencies in dealing with people in nursing homes rather than putting them through accident and emergency departments, but it needs to be co-ordinated.

Those are the issues I want to raise. I again thank the people who dealt with the questions I submitted. I raise those issues on foot of those replies.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank the witnesses for their presentations. It is really good to have all the decision makers in the room at the same time. Sometimes it feels a bit like Wimbledon, going back and forth from one to the other. I am really happy they are all here this morning.

I wish to raise the issue of the Versatis patch, which affects 25,000 people. Since 1 December, I have been contacted by many people who are really concerned about this. It goes right through the lifecycle, and includes older people and younger people with arthritis. All of them have one thing in common; they are all in chronic pain. I know the witnesses will have been contacted by a large number of GPs who have said that this is the treatment their patients require. I am baffled over why it has been withdrawn. The message it sends out is that people who have the money will not be in pain but those without the money will have to continue in pain. The alternative treatment for that type of chronic pain is either morphine or paracetamol. The patients are telling me that the paracetamol and other drugs that are given are not working. They really do not want to go on morphine because of all its side effects.

Has the HSE done a cost-benefit analysis of that decision? I am really concerned about the escalating mental health impact even over the short time since it has been denied on the medical card or the drugs refund scheme. The amount of additional money the HSE will end up spending on antidepressants and other drugs that do not work will far outweigh the €30 million being spent on Versatis.

That is outside the cost of the isolation and what it does to patients. For example, I have a 31-year-old constituent with chronic arthritis who is in much pain. She was able to get out and drive around the community, leading a somewhat independent life. She cannot do so now and she is confined to her bed. All the calls I get from her are made from her bed. I am extremely worried about her and other patients left like this.

For somebody like that, the option is to go to a pain management clinic and ask what to do because he or she is immobilised. People must ask how they can be helped. The patient I mention has been on the waiting list since July 2016. When Vertsatis was no longer available and she contacted the relevant people, she was told it would be at least another 15 months on the list. There is nowhere to turn for these patients other than their GPs. Those GPs are advocating in the best way they can. What is the process for looking at this again? I know there are other drugs. The witness might tell me this was designed especially for people in the aftermath of shingles but there must be other drugs in the system that treat multiple conditions. This is one such drug.

My second issue concerns physiotherapy services. In Mayo - I am sure it is not unique to the county - there are people waiting months, including children with disabilities. I am glad to see the man with a plan here and what he is working towards. At this moment we have children with disabilities who are supposed to be getting clinically assessed for weekly physiotherapy but they have not had physiotherapy since September. It is a fact and there is no way to hide it. What plans are in place for that? I have asked colleagues to submit a number of parliamentary questions in this regard. In Erris the physiotherapist is back again and I hope that will somewhat reduce the list within that confined area. It is a serious problem that must be examined now.

I must also ask for an update on Translarna. The Minister has met Lewis Harte-Walsh and I thank him for that. He knows how time-sensitive is the approval of Translarna. I am not sure where Mr. Connaghan has come from or the jurisdictions in which he has served. I was trying to pick up the accent but whether it is Scotland or any of the other 22 countries, he would know Translarna is approved there, albeit conditionally in some parts. We need to have it approved here quickly. There are only five children who need this drug so we are not talking about huge amounts of money.

The Castlebar primary care centre is an excellent service and I look forward to increased services within that. There is an issue around Castlebar and I ask for it to be taken into account when planning the other primary care centres. We should not be in a position where the primary care centre physical structure is built and we then start looking for staff. We should do it much earlier, possibly at the planning stage. There is also an issue with transport. The primary care centres must be careful of working in isolation. There is a primary care centre outside the town but people on very low incomes and dependent on social welfare may have to pay for taxis to get in and out from those centres. It is cost-prohibitive. There must be a process with the community transport system to help patients get in and out and make the centre accessible.

Could I get an update on staffing for Coolock, Darndale and Dungarvan? The Taoiseach's maiden speech mentioned that everybody would looked after from Dungarvan to Doohoma. I would also like an update on Limerick city, Boyle and Westport and Claremorris in the Mayo area. I am concerned that if no new staff is being put in place, staff will be dragged in from surrounding areas. That is fine but I am really concerned about the surrounding areas, again because there is no public transport. I cannot see how this will increase capacity within these communities unless there is additional staff. Perhaps we can get an update.

I must ask the Minister again about a case that I raised with him in 2016 concerning a man waiting for a spinal operation. He is still waiting for it. He had an operation but could not have another one because of capacity issues in Galway. He is now in the Mater hospital.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I have already pulled up other members of the committee-----

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I can ask about it separately.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

-----as this is a policy forum. If there are individual matters, I am sure the witnesses would be happy to follow up directly.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I will ask the broader question. If somebody is waiting, in dire pain and display suicidal tendencies and behaviours, where do I go? I am at a loss. There are cases across the board and I really need to know what to do in those cases when somebody is presenting with suicidal behaviour.

There has been much discussion of capacity in hospitals and step-down beds. Are there plans to provide more services through the district hospitals, perhaps looking to reverse some of the Fianna Fáil decisions to close the beds in these district hospitals? Is the reversal of that policy being considered, with investment being put into district hospitals and particularly hospitals like that in Belmullet, which saw half of its beds cut in 2010? I will leave the rest of the questioning to somebody else but I look forward to the answers.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

There is only one other person left to come in, which is me. I will throw in my questions, although we normally take them in sets of three. The first question relates to the neuro-rehabilitation strategy. I would like an update on that and also information on whether the people who deliver the specialist community care can be included as part of the implementation group. That is not the overall umbrella group but rather people with direct experience of delivering that community care.

I have raised the matter of doctors getting paid for a qualification they do not have. I have done this repeatedly and there is probably a nicer way of putting it. It is entirely the fault of the HSE and the witnesses know as well as I do how contracts of indefinite duration work. It can leave things like this open. Nothing has been done to stop this from happening and I am definitely not convinced of the idea that people who are already busy and overstretched are now supposed to monitor their colleagues.

Will the Minister update us on the Comhliosta, the integrated hospital waiting list management system? Mr. O'Brien mentioned that 100 beds were purchased in private hospitals. This relates to the budget, and we all appreciate that peace has broken out between the parties here, whether or not it is normal to be otherwise. Was this purchase budgeted for at the beginning of the year or was that extra? Will it happen again? What is the cost per bed night? How was the decision made? Does it come directly from the hospital budget or is there a special emergency budget? Will the witnesses outline that?

The Minister referred to waiting lists and said nobody is taken from a list unless a clinical decision is made. My understanding is sometimes people are taken from those lists without a clinical decision being made. A letter or text message is sent asking if a person still wants the appointment. If the person cannot or does not reply - there can sometimes be very good reasons - the person is taken from the list. That would not be a clinical decision but one effectively made by an administrator.

With regard to early intervention, the Minister of State, Deputy Finian McGrath, mentioned the assessment of need. I have been informed that in the CRC the speech and language therapist, SLT, is on maternity leave, the occupational therapist has another job and has left, and the physio, likewise, is not around. Are there any plans to recruit these staff? How will they be replaced? Parents from all over the country, specifically, from my area, have presented themselves to the CRC only to be told that the wherewithal is not there to help them.

I refer to the use of PPS numbers as a unique identifier. My colleague, Senator Warfield, has written to the Minister in this regard. We understand that instructions have been issued to hospitals to use the PPS number and that it is necessary for PCRS reimbursement. When we discussed this here, we had a long conversation about how the PPS number could not be used because it did not have sufficient protections to protect the anonymity of the patient. The Minister might comment on that.

The issue of transvaginal mesh products has been raised with me. I was very disappointed, not with anyone in this room - they all will be delighted to know - but with the Taoiseach, who stated that he did not have an answer on the day because he had not been briefed about it. It is not the habit - of anyone in my party anyway and I do not know about others - to brief the Taoiseach on what is coming up on Leaders' Questions but it was the subject of a "Prime Time" programme the night before. I was surprised. I am aware that those who are suffering as a result of complications were very disappointed. I note that Deputy O'Connell had also raised this issue as have others. It is very concerning.

My last issue relates to a letter the Minister sent me. It is in regard to the Minister examining the possible extension of the reimbursement scheme for those who are living donors. I want to put on the record that I welcome that letter. We are hopeful of a positive outcome for a very small number of people, but people who give something unique and good. The Minister might expand on that a little.

There is a significant number of questions but health is a very important issue.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

Absolutely. I thank the Cathaoirleach.

I thank Deputy O'Connell for raising a number of important issues, as always. On the issue regarding the morning-after pill, I obviously do not have enough facts to comment with any degree of certainty other than to say I want to live in a country and see a health service that provides women with access to the supports that they are legally entitled to, such as the morning-after pill, without any degree of judgment, cross-examination, interrogation or anything else. While I do not know the facts in that case, I would suggest that there are a number of avenues open to anybody in highlighting that with the regulatory authorities. Everybody has a professional responsibility in terms of discharging the law of the land. As the Deputy correctly points out, in my time as Minister for Health I have made a number of policy decisions to try to help improve access to that, most particularly, the fact that a person with a medical card can now access it directly through her pharmacy, as a person without a medical card could always do, without her now needing to go to her general practitioner. I take the point the Deputy makes about the need to ensure that information is publicly available and I will certainly undertake to do that.

On access to contraception and free contraception, I am very much of the view in reading the report of the Oireachtas Joint Committee on the Eighth Amendment of the Constitution, of which the Deputy was a member, that it is not all about terminations. The report is not all about abortion and anybody who represents it as such has not read it correctly or at all. If one reads the report, while it obviously makes a number of recommendations on termination in Ireland, and the committee's view that the eighth amendment should be repealed in full, a view which I support, it also addresses a number of things the State and the health services must do to protect pregnant women, to support pregnant women, to support people in crisis pregnancy, to increase access to counselling, and to improve sex education and access to contraception in general. As the Deputy will be aware, I have set up within my Department, as a response to the Oireachtas committee's report, a working group chaired by the Chief Medical Officer to work through what I refer to as ancillary recommendations. I nearly think it is unfortunate that they are called "ancillary" recommendations as no doubt they are core to the broader and wide debate that is already under way in this country. We will examine it in that context.

On the issue of medical cards, I will ask the director general to comment in a moment but I would just make two points. First, we have seen a massive increase, rightly, and thankfully, in the number of discretionary medical cards in this country. On 1 January 2014, there were 50,294 discretionary medical cards. One year later, there were 76,665. Another year later, there were 99,396. Another year later, on 1 January 2017, there were 116,362. On 1 January of this year, the number was 131,160. We had 50,294 people with discretionary medical cards at the start of 2014 and have 131,160 now. I hope that is reflective of a compassionate system, that when somebody does not qualify on means grounds there is a compassionate approach in that regard.

On the issue of children with cancer, the director general prior to my time in the Department of Health took a decision on their automatic eligibility which was the right decision. For children with cancer, there is automatic eligibility. I will ask the director general to comment on that in a moment.

Regarding the issue of the HPV vaccine for boys, as the committee will be aware, I have asked HIQA to carry out a health technology assessment, HTA. We will know the final outcome of that by the autumn. We may begin to have an indication of the likely outcome of that a little earlier than that. Obviously, I will be guided by that. Instinctively, I see great benefit in it. However, I need to be guided by the HIQA HTA as well.

On the issue of a case before the court, I need to do something I do not like doing which is bite my lip. I will say as long as I am Minister for Health I will always take the approach of trying to put systems and structures in place to ensure that people who suffer a bereavement who loose of a loved one through the maternity services can have access to all of the facts and all of the information and that the system can learn from such tragedies. It is a matter of public fact that I met Mr. Thawley and when I sat in a room with a grieving widower who has lost his young, beautiful and healthy wife, I told that man we would establish the facts. I intend to honour that commitment. As the committee will be aware, we have made a policy decision that all maternal deaths will now be subject to an external review. That is appropriate. It is good practice. It is something that should be welcomed by the maternity services in general in terms of ensuring learning across the system. We have established in the HSE a women and infants' health programme and we have Dr. Peter McKenna, the clinical director, there as well. We are making positive strides in that regard. On matters before the court, I am happy to let them play out but, instinctively, my view is we should not be finding people in court in these situations.

I thank the Deputy for her comments regarding the issue of trauma policy. As Minister for Health, I have the honour of bringing it to Government and publishing it. The only reason I am able to do that is because of the incredible work of clinicians of the HSE and of patients and patient groups over a sustained period of time since 2015. This is something that every doctor will tell one will save lives and will improve outcomes. It is something we badly need in this country. We cannot have a situation where we can stand over a system where almost 30% of patients are ending up effectively in the wrong location when they suffer a major trauma and are being transferred to other locations. I have heard commentary that simply is not true about ED reconfiguration. It is really not about this. Approximately, 1.2 million people attend the emergency departments each year. We are talking about a cohort of major trauma patients of 1,600. When one divides that up, it amounts on average to four a day. We are talking about getting those patients to the right place. There probably is not an Oireachtas Member who has not been in contact with the HSE over his or her years as a public representative about a patient in a hospital who really needs to get to Beaumont or CUH. I have heard the Chair on this and she is correct. There are issues of connectivity and that is why this is a plan that will not be implemented overnight. We have published the plan now and we will implement it.

I really believe that, despite all the difficulties our health service faces, we have shown as a country that when we publish a policy plan in key specialties, we can make real differences. We have seen this with cancer. We are now beginning to see it with our national maternity plan, and I believe we can also see it regarding trauma. The point made was entirely correct. The plan emphasises heavily the fact that it is not just about treating the major trauma incident in the hospital; it refers to a five-step pathway. One is obviously prevention. How do we prevent and reduce major trauma? I particularly welcome the support of agencies such as the Road Safety Authority in this regard. There is a need for us to make our workplaces more safe and to minimise the number of workplace accidents. There is a need to continue with the mental health agenda to reduce the incidence of self-harm. All of these can cause major trauma. There is a very important piece on rehabilitation. The idea is not to put all the patients in the major trauma centre and say "Job done." The point is that a patient who requires a major trauma centre should be able to get there quickly and receive the expert care needed and then be transitioned back to the community, or local hospitals, thus freeing up space in the major trauma centre. Therefore, there has to be a full continuum of care. We have a lot of work to do in that regard.

On Senator Colm Burke's point, I will ask the director general of the HSE to talk about over-prescribing and what the HSE is doing in that regard. Much of the data associated with the excellent work done by The Sunday Business Postprobably came from the HSE's medicines management programme. It is very important work that Susan Mitchell put into the public domain.

The point the Senator made is a very interesting one. When I talk about value improvement programmes in the health service and the idea that the Irish health service, like most other health services in the developed world, should have value improvement programmes, which view is shared by the HSE, I do so in the belief that this is an area we have got to consider. We must consider how we can achieve better value and clinical outcomes for our patients. We all know that over-prescribing of medication is a challenge in this regard. I hope to be in a position very shortly to make a significant announcement on Ireland's participation in international collaboration on drug pricing. We have been working quite hard on this for quite a period, and we are almost at decision point in terms of formalising our involvement in international collaboration. I will ask the director general, as the employer of the administrators and others referred to, to comment on this.

My Department received almost 12,000 parliamentary questions last year, which is good. Almost all of them, or very many of them, get referred to the HSE because they refer to operational matters. Those questions are answered by administrators. I take Senator Burke's point absolutely that there needs to be a plan and an understanding of the appropriate level to be reached. That is a very well made point. I differ slightly on the assertion that only front-line staff can produce a direct patient benefit. Bearing in mind much of the Healthy Ireland agenda, if one goes to see a hospital consultant today one notes the man or woman managing the files outside that consultant's door is making sure the waiting list continues to decrease. Therefore, I very much see a role for administrators. In fairness, the Senator acknowledged in his contribution that we saw, during the recession in particular, significant reductions in administrative roles in an effort to protect the front line, but to the point where it may now be having an adverse impact on the front line. Nurses and doctors are asking me who should answer the telephone when it rings in the ward. Therefore, there is a need to get this right. I take the Senator's point. It is right that he has highlighted the matter. I shall ask the director general to comment on it.

With regard to the idea of having a forum on nursing home care and how we interact with the nursing home sector, I appreciate the director general's view but I am positively disposed to the idea and instinctively believe it is good. We will not be able to deal with all the challenges facing the demographic trends in this country on our own. We already know that the nursing homes sector, including both public and private elements, plays a major role and is likely to play an even more significant one in the years ahead. Structured engagement on best practice and the exchange of ideas are a good use of everybody's time.

I thank Senator Rose Conway-Walsh for her questions, most of which I will ask the HSE to answer. I will start the answers on some of the questions.

With regard to the Versatis patch, the decision was made by the medicines management programme on clinical grounds. I have heard people's concerns. I have been listening to people expressing concern. As Professor Michael Barry stated eloquently in recent days, there is a process whereby a general practitioner can say to the medicines management board that a certain patient needs the patch. It is important to point out that there is already an appeals process in place. The director general might expand on that.

On the issue of Translarna, I had a meeting with the Senator in Castlebar. I thank her for facilitating that. I very much understand the sensitivities and the importance of this issue. The Senator is talking about a mother who wants to keep her son out of a wheelchair for as long as possible so he can have as much quality of life as possible. I understand his condition affects quite a small number of patients in this country. As a result of the meeting in Castlebar, I had a meeting with representatives of Muscular Dystrophy Ireland in Dublin. They brought along a clinician, from Temple Street, I believe. At that meeting, we had a good discussion on the process that is still under way and the importance of the relevant company and the HSE engaging of this matter. I am conscious of the various legal aspects, on which I will not comment.

On the issue of smaller hospitals, I have two points. The capacity review makes it very clear that we do need to increase capacity significantly. It also makes it very clear that all the capacity does not need to be in major acute hospitals. The step-down, transitional-care and elective facilities have a role to play. I envisage a very secure, sustained role for our smaller hospital network now and in the future. I believe it is likely that bed stock in a number of smaller hospitals will have to increase for clinically appropriate purposes in those locations. All of this will be determined by my working through the capacity review with the capital plan on which I am engaging with Government colleagues.

It is important to refer to the idea of setting up hospital groups and of having hospital group boards. We now have such boards for all our hospital groups The idea is that the centre does not dictate to everybody. We do not say a certain hospital must do a certain thing now. The hospital groups come up with strategic plans and ascertain how best they can use the health infrastructure available within their area. I look forward to receiving strategic plans from all the groups this year.

Most of the questions of the Vice Chairman are more appropriate for the director general. On the neurorehabilitation strategy, the idea that there would be an inclusive process of involvement makes sense. The HSE is undertaking that body of work so I will ask it to respond.

The Vice Chairman asked about the position on the specialist register. Comhliosta is a matter we have talked about for quite a while. The NTPF has a body of work on this. There are two parts to advancing any body of work. One involves the e-health agenda, on which I am hoping to make good progress in our capital plan. The second concerns the operational aspect. Mr. Liam Woods might be in a position to expand on that. The director general can talk about the cost of the private beds.

With regard to the administrative validation of waiting lists, the point I was making in response to Deputy Margaret Murphy O'Mahony was based on a patient who was told they no longer needed their treatment. The patient was told by a clinician, not an administrator. Even when we do administratively validate lists, there is a role for the general practitioner in terms of reinstating someone's position on the list.

I am very positively disposed to the idea on living donors. We have made some changes in that regard. I have asked officials to examine the Vice Chairman's suggestions-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I raised this more to draw attention to a good news story, or as something to be grateful about.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I always appreciate the Vice Chairman highlighting good news.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

It is a small thing but it will mean a considerable amount to the people concerned.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I am sick and tired of the Deputy highlighting all the good news around this place. To be serious, I appreciate her comment. She is correct on this and I hope we can do something about it.

I have written down a word that I cannot read so if I have forgotten a question by the Vice Chairman, she might tell me.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Does it relate to mesh products?

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I have the response on that. I have asked the chief medical officer to do a body of work on this. I saw the programme in question and have heard about the experiences of women who have had very debilitating conditions and who face very upsetting circumstances. I have noted the impact on their families. I have to balance this with the comments of the clinicians on the programme. They said that, in some cases, they believe the treatment in question is appropriate. From my perspective as Minister for Health, I believe the most appropriate thing I can do is ask the chief medical officer to consider international practice. The Deputy and I have discussed on the floor of the Dáil the point that the HPRA is the appropriate point of contact for any complaints or concerns in this regard. As the Deputy knows, it is processing a number of them. I will keep in touch with the Deputy on this.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I thank the Minister for his answers. With regard to the HPV vaccine, I welcome the fact that HIQA is due to report by the autumn. Some 30,000 boys will not be vaccinated this year, because of the loss. I could hazard a guess that it will probably be September 2019 before we seek to start vaccinating. Perhaps I am wrong; perhaps it will be six months earlier. While we are on a roll here and while we have managed to reverse from 50% or 51% up to 61%, there might be an opportunity to move things on a little faster.

Mr. O'Brien mentioned the ancillary or core recommendations that we would like to change. I remember a pie chart from the recommendations. The split was 44% to 56%. However, give or take, 50% of crisis pregnancies are due to no contraception and 50% are due to contraception failure. I fully support the position on accessibility to contraceptives to bring about a reduction of crisis pregnancies - I know the Vice Chairman shares my view in this regard. In the first instance, this should happen through sex education. Furthermore, adult contraception would seem like a good place to start.

I am conscious of the medical view on the vaginal mesh. It seems to be used to treat various conditions and there are various ways of going about it. This is relevant for the maternity strategy. To a great extent, incontinence, especially in women, was a taboo subject for years. It was seen as a side effect of having children. The thinking was that women would get over it and it was not spoken about. I maintain the lack of pre-natal and post-natal physiotherapy as well as the quick through-put of women through hospitals are relevant factors. A woman is seldom in hospital longer than three or four days after having a baby. Indeed, we hear of some people being out after three or four hours. I acknowledge the great work that public health nurses do but I have found that it tends to be focused more around the baby rather than the mother. It is a pity the Minister of State at the Department of Health, Deputy Daly, is missing. One of the primary reasons for admission to nursing homes is incontinence. When it is not dealt with at maternity level, it goes into later life for women and causes problems. Incontinence can lead to urinary tract infections and this outcome is a common cause of confusion and falls in older people.

All this feeds into neglect of our maternity services. There is a major lack of investment and neglect of women in this country. It is all linked and it has an effect on quality of life. I know the Minister for Health is worn out from listening to me talking about incontinence pads, but there is significant expense on people as a result of this. Furthermore, there is the green aspect of the disposal of same.

I welcome the increase in medical cards for children. I hope children are getting them easily. We need to ensure that, in cases where adults are diagnosed, we make it as easy as possible for applicants to fill in the form and get medical cards.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

That is interesting. I will comment first and then pass over to the director general.

I do not disagree with a word Deputy O'Connell has said on the issue of our maternity services - I doubt anyone present disagrees either. The fact that we did not have a national maternity strategy in Ireland until 2016 tells us all we need to know about it being the proverbial Cinderella of the Irish health service. We are now on the cusp of being able to advance plans to build new maternity hospitals, relocate maternity hospitals and advance our anomaly scans.

Reference was made to the human papilloma virus vaccine. We have done something great in this country. I am proud of the work of the HSE and the political leadership from many people in this room and in these Houses. I am proud of the work of all the clinicians who have supported this as well. We have managed to do something that other countries have not managed to do, that is, reverse a concerning trend in HPV prevalence. We need to continue on that track. There can be no room for complacency. We continually need to call out those who profess to be medical experts, but who are not, and who put forward dangerous misinformation, often on social media.

Deputy O'Connell asked about the expansion of the vaccine to boys. Deputy O'Connell, as a scientist, will appreciate that it is appropriate for me to follow the scientific advice from the health technology assessment process. That is why I asked HIQA to get that process under way. I expect to be better informed of the outcome shortly.

Mr. Tony O'Brien:

I wish to be clear about the position of medical cards for children. Any child below the age of 18 years who has been diagnosed with cancer is automatically entitled to a medical card for a subsequent five-year period. That has been the case for two-and-a-half years. The standard process for a person above the age of 18 years has not changed in recent times. Discretionary medical cards are available for those with cancer. Should there be a diagnosis of terminal cancer – there is no crude timeline – there is an emergency medical card application process. There has been no policy change in that regard. If committee members are experiencing individual exemplars of some procedural change then we will look at them.

A question was raised about staffing numbers. Since October 2013 figures for medical and dental nursing are up by 9%, health and social care professionals are up by 21%, other patient care staff numbers are up by 24% and administration management is up by 17%. The administration management category ranges from the most junior grade, grade III, right up to senior managers. Some 85.7% of the total are in front-facing roles in care delivery settings. That reflects to some extent what the Minister was saying.

I made a journey around the health system, especially during the period when there was significant reductions in clerical and administrative posts. One of the key points made to me by health professionals, who were often in short supply themselves, was that what they most needed was someone to lift the administrative burden in order that they could focus more on the direct provision of patient care.

The number of senior managers represents only 1.4% of the total workforce. That is comparable with other health systems. Clearly, we need to have an overall strategic view on the right balance between the various grades. We go through a process each year that involves ourselves, the Department of Health and the Department of Public Expenditure and Reform. It centres on what is called the funding workforce plan and it seeks to address those concerns. The broader workforce planning process has been outlined and published by the Department of Health.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

The number of public health nurses has only increased by 3.69% in that period. We talk about trying to keep people out of the hospital system, but if we do not have people working in the community, then we have a problem. That is the point I am raising.

Mr. Tony O'Brien:

I thought the point Senator Burke raised was that we have too many administrators. We have significant increased our public health nursing workforce in the past year. We have not quite reached the objectives sought, but we will seek to increase our nursing and other front-facing health professionals in line with our ability to recruit. The only thing that holds us back is our ability to recruit in that area. There is no question of an agenda of not recruiting to refill posts in those areas. We increase the workforce in line with the funded workforce plan.

Senator Conway-Walsh asked about the patches. It is important to emphasise that there has been no withdrawal of reimbursement for those patches. There has been the introduction of a secondary layer of approval. On a three-month basis, it is possible, on application by a general practitioner, for approval to be granted for a continued prescription under the medicines management programme.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I wish to clarify that and I want to make sense of it. If a person goes to the GP today, and he has heretofore prescribed the Versatis patches, can the GP write out the prescription today?

Mr. Tony O'Brien:

This new system came in last September. At that point, a patient could be started on the patches for a three-month period. Within that three-month period, if the GP wanted to continue prescribing, then the GP would need to register that on the application system. In other words, what is being introduced is a higher level of clinical supervision for the prescribing of the patches.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Once the GP has the patient registered on the system, then there is no problem. It is as it was prior to September. Is that correct?

Mr. Tony O'Brien:

It subject to three-month review or renewal.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

That is not what is happening.

Mr. Tony O'Brien:

I have in front of me the exact guidance from the medicines management programme. That is the system in place. General practitioners can apply using the online system, which they are familiar with, for approval to continue to prescribe for a three-month period. That does not mean that in every instance such approval will be given, because clinical judgment must be made. However, where it is given, it is given for three months and is subject to renewal.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Who makes the clinical judgment?

Mr. Tony O'Brien:

The medicines management programme, which is staffed by clinicians.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Is the GP's submission or recommendation taken into account?

Mr. Tony O'Brien:

Yes. The only basis on which the medicines management programme makes a consideration is following referral from a GP.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

What is the timeline?

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I have a question on that point.

There has been a fair amount of discussion of this issue recently, but Mr. O'Brien appears to be suggesting nothing has changed since September. Have a large number of applicants been turned down? Could it be the case that GPs are not aware of the programme? It would be quite worrying, if that was the case, but I do not think it is.

Mr. Tony O'Brien:

I do not think it is the case that GPs are unaware of it. I do not have data for the proportion of applications which are approved. The reason the programme was introduced was there a strong sense that the patch was being prescribed inappropriately, both by condition and duration. The clear intention was to have greater clinical supervision of patients who would otherwise have gone on to receive the patch for an overly extended period for conditions which were not indicated. Consequently, it is inevitable that some patients will be switched to other medications. That was the intention of the programme.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Two members are indicating on the specific issue - Senator Rose Conway-Walsh and Deputy Kate O'Connell.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I have to tease out what has been said because there is a need for clarity. The GP has to register the patient on the list which will then be approved. What is the timeline for approval and is the list open indefinitely such that there is no closed period before which the GP has to register the patient?

Mr. Tony O'Brien:

No.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

If someone who today becomes aware that the patch is no longer available under the medical card or the drug refund scheme and the GP makes the assessment that he or she needs to continue using it because the other drugs will not work and morphine is unsuitable, what will happen? I ask Mr. O'Brien to talk me through the process for the patient whom the GP will register online. How long does it take to get approval?

Mr. Tony O'Brien:

I do not have the precise data, but normally the online processes work seamlessly.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

We had a discussion at the start about the timing of responses to questions. Mr. O'Brien could have anticipated that this issue would come up. Notwithstanding that, perhaps he might provide the committee with the information sought. Clearly, our experiences as people who are contacted by constituents do not seem to tally with what Mr. O'Brien is saying to us. There is obviously a disconnect.

Deputy Kate O'Connell has indicated. Does Senator Rose Conway-Walsh want to finish?

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I just need to know what the timeline is. Is it a day, a week, a month or longer before approval is given?

Mr. Tony O'Brien:

We can find out for the Senator.

On what I might or might not anticipate the committee might ask, questions were coming in from members as recently as Monday. There is a wide breadth of questions that could be asked. As the Vice Chairman said, we could deal with specific issues in follow-up correspondence. However, I do not want to provide members with information that is not necessarily accurate. We can get back to the committee on this issue.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

The point I was making was that this was one that could have been anticipated. On the timing of questions, I fully appreciate what Mr. O'Brien said. Equally, the HSE could time its responses according to when it received questions. I hold up my hands as I suspect it was my questions that went in on Monday morning. However, there were others which were received long before then. I do not see why everything has to be left to the last minute. Responses could be sent according to when questions were received. It will not be news to Mr. O'Brien that we have considered and discussed the timing of responses to our questions on more than one occasion.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

On that housekeeping issue, we should agree or agree again what the protocol is in order that questions will go in in a timely manner. There is a real need for clarity on this issue. The director general has tried to bring clarity to it. I suggest we provide a written brief for the committee, today if possible, in order that members can best advise their constituents and bring clarity to the matter. I have been told very clearly that GPs can apply in the first instance and appeal a decision. The Medicines Management Board must approve a patient in that regard, but let us try to provide as much clarity as possible for the committee on what the process looks like and set out the timeline for it. I ask the HSE to revert to the committee secretariat.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Deputy Kate O'Connell is indicating, as is Senator Colm Burke. On a point of order, I note that there is not just an issue with the timing of the submission of questions; there is also an issue with the timing of responses.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
Link to this: Individually | In context | Oireachtas source

That is what I meant. I meant how we got back to the committee.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I hold up my hands as a person who probably got questions in last night, for which I apologise.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
Link to this: Individually | In context | Oireachtas source

With regard to the Versatis patch, over 90% of applications are being rejected on appeal. That is what I am told at home. The issue is that it has been licensed for use to treat post-shingles pain. In the past five years I have seen us go from having one box on the shelf to 20. It was being used for literally everything and there is a huge cost. I think the Minister said it was the second highest pull on the reimbursement budget. Someone said it. It is at the top cost-wise. The issue with which we have to deal involves the patient who has been using it for five months to treat back pain and then lands into a pharmacy with his or her medical card only to be told it is going to cost, I think, a couple of hundred euro a box. The issue is that someone might be without an alternative during the approval period. While it is fine for the HSE to tell us stories about the price and the reasoning when it is drawing up its briefing note, what we are looking for is a solution for patients. On the ground, the prescription is being run off by the GP; the pharmacist says the patient cannot have it; the approval process starts and there is a gap in treatment for the patient. A worry is being put on the patient because of the price of the product. When the HSE is preparing its briefing, I would appreciate it if that element for the patient is covered.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I call Senator Colm Burke.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

If the Vice Chairman wants to deal with that issue, I will come back to the issue of staffing levels.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

The Senator can raise it now.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

I still have a concern about staffing issues and I am sorry for raising the matter now. If one looks at the 2015 annual report, the number of managerial staff was down as 4,700 because grades 7 and 8 were listed under the heading of managerial capacity. We have changed this and taken them out of the managerial capacity category and listed them under the administrative capacity category. The issue I have relates to public health nurses. The public health nurses I meet tell me that nothing has improved for them. Mr. O'Brien tells me that they are now doing a lot of the administrative work with which those on the front line were previously dealing, but the staff on the front line are telling me otherwise. That is my concern.

I have also asked where is the cut-off point. Over 500 administrative staff were taken from the HSE and assigned to Tusla. We are now at a figure of 17,700 administrative staff, which is a higher number than we had before 2010. On top of this, we have to take the 500 staff who went to Tusla, which means that, technically, we are at a figure of 18,200. Where is the cut-off point for administrative and managerial staff, given that in other areas there has not been a pro rataincrease?

I also raised an issue about section 39 organisations in which those who work on the front line have not received the appropriate increase in remuneration which others received. That is why I am referring to the disproportionate changes which have occurred. That is what I am concerned about.

Mr. Tony O'Brien:

I understand the concern about section 39 organisations, but that is a separate and distinct issue which is related to a policy position. The Minister has outlined what is being done in that regard. All I can do is reiterate that there is a workforce planning process that has been elaborated on. There is an annual, funded workforce planning process. There is a a live discussion between the Department and the HSE to seek to provide for an appropriate balance. I am also aware that this issue was raised with Ms Rosarii Mannion when she was before the committee last week to discuss the section 39 organisations issue and that she agreed to engage with the Senator on it. I propose that she continue to do so.

On the issue of specialist registration, what is happening is that in each location where a person is employed in a consultant post and who is not on the relevant specialist register, his or her individual clinical director is carrying out a review to establish what issues arise to provide us with a full picture of what we do or do not need to do. When the review is completed, the relevant action will be taken.

On issues to do with neuro-rehabilitation, Comhlista and the 100 private beds, I will ask Mr. Connaghan and his team to respond.

On the issue of text message validations, I understand text messages are used only in relation to specific individual appointments, rather than in relation to validation lists. They would not result in a person being taken off a list. Failure to respond to a text message might, however, result in the individual appointment being reallocated to ensure it was not lost to the system. That is the standard process.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

If a person receives a letter asking them if they are still waiting for a procedure but they do not open it or do not respond-----

Mr. Tony O'Brien:

The person would no longer be active on the list but if they respond subsequently, for example through their GP, they can be reinstated.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Are they reinstated to their original position or at the end of the list?

Mr. Tony O'Brien:

They are reinstated where they were. If they are not opening or answering letters, however, we would be concerned that they would not open an appointment letter either.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

There is sometimes a dispute and people say they do not always get letters. On the subject of consultants no longer on the register, is it the case that the clinical director at each site is conducting a review?

Mr. Tony O'Brien:

That is the case.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Why has it taken so long? It was raised well over a year ago. Is the HSE not concerned about this? I am quite concerned about it but Mr. O'Brien may be able to put my mind at rest on the matter.

Mr. Tony O'Brien:

It is an issue of concern but it is important to stress that a proportion of those doctors will be persons who have been in practice as consultants since prior to the time when it became necessary to be on the specialist register. There are others whose cases arose as a result of the extended dependency on them, leading to contracts of indefinite duration. The underlying issue is how we get to a position where this will not arise in the future. The current review is to establish whether they are practising in appropriate areas, having regard to oversight by the clinical director on the relevant site, given that these posts are distributed-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

We know how contracts of indefinite duration work. From the day a person starts on a fixed-term contract the clock starts ticking and the person begins to accrue an entitlement under the law, and I would not stand in the way of anyone who has that entitlement. I asked Ms Mannion about this and it struck me that the HSE does not have a handle on how many people are embarking on a journey towards a contract of indefinite duration. If we have only got as far as clinical directors conducting a review, it strikes me that it is not a priority and not urgent. I believe it should be an urgent matter and I have not heard what is going to be done to ensure it does not keep happening.

Mr. Tony O'Brien:

It is a risk which is a by-product of the challenge we have in filling a number of consultant posts at the moment. We have a dependency on a number of persons in this category. Ms Mannion is very focused on this. I do not regard it as appropriate for any publicly-funded body in the health service, whether it is a section 38 organisations or otherwise, to seek to fetter the Minister's discretion and rights with regard to requesting a HIQA review. In questioning the Taoiseach, Deputy Clare Daly is reported to have indicated that the HSE had, at one point, taken a court action to prevent the publication of a HIQA report.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Deputy Daly is not here.

Mr. Tony O'Brien:

The issue was raised and I wanted to say that this has never occurred.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Perhaps Mr. O'Brien will raise it directly with Deputy Daly.

Mr. Tony O'Brien:

This is the Joint Committee on Health.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I know but she is not here.

Mr. Tony O'Brien:

I will raise it with her.

Mr. Liam Woods:

A question was asked about how beds in private hospitals were being used and where the funding was coming from. Specific funding was provided for surgical capacity during the winter. This was additional to the underlying budget and was referred to in the director general's opening commentary.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

The surgical capacity issue related specifically to seasonal factors.

Mr. Liam Woods:

Yes.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Does that mean if the sun was shining it would not happen?

Mr. Liam Woods:

We would hope the need would not arise. It was an extraordinary measure, which we would not want to take too frequently. Public hospital capacity is the underlying point and it is important to get that right. The Vice Chairman asked about individual prices. I do not have them in my head but they may, in any case, be commercially sensitive so I will have to be alert to that. The rate for the HSE, in terms of average price per night, would be around €850.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I specifically wanted to know the amount the HSE is spending on private beds.

Mr. Liam Woods:

We can come back with the total quantum if that is helpful.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

It would be very helpful.

Mr. Liam Woods:

The Vice Chairman asked about the use of PPS numbers. An arrangement has been in place for a number of years to reimburse high-cost drugs on a named patient basis through primary care reimbursement service, PCRS, drugs prescribed through hospitals. It has been working very successfully and has been expanded into a new area of care recently. There was some dialogue around the use of a PPS number for that purpose but it is not yet in use and no decision has been taken at this stage.

The point about waiting lists was addressed. We hear the comment about representation on the neurorehabilitation group, which has a manager in place and is a key piece of the overall trauma strategy to which the Minister referred earlier. The National Rehabilitation Hospital and Peamount Hospital in Donnybrook are engaging in a networked approach as a part of the strategy. We will take away the Vice Chairman's comments on representation on the group. I am not familiar with the full details of its representation.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I ask Mr. Woods to respond directly with me.

Mr. Liam Woods:

The question of validation was addressed.

Mr. John Connaghan:

There was a question about the decision-making process over the use of private beds. Over the winter period, and on a continuing basis, we have been holding twice-daily assessments of where we are nationally. This assessment is done by senior HSE members involved in operational management and during the day it is extended to CHO chiefs and hospital group chief executives. The assessment tells us we are running out of capacity inside the public system and we need to do something in extremisto extend it into the private sector. We make judgments on a day-to-day basis but we also look ahead by up to four days to anticipate pressures on the system. It is addressed on a tactical basis.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

Can I ask about the overprescribing of drugs?

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Yes, but we have kept people here for quite a long time.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

I did raise it.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I appreciate that but I ask for brevity.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

I raised a question on the overprescribing of drugs, which was not answered.

Mr. Tony O'Brien:

Sorry, but I was distracted by the question on patches. The medicines management programme is systematically examining each area, by volume and cost, where there appears to be evidence of overprescribing. It is working on an educative basis with prescribers and putting in place new processes, such as with patches, to create appropriate controls. In the phenomenon known as "polypharmacy", it is very easy to have drugs added to a formula but not so easy to have them removed and the medicines management programme is an active targeted campaign, particularly in the area of repeat prescribing, which is systematically addressing the issue. There have been a number of initiatives in the past and this is part of a rolling programme to limit overprescribing.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

We have a problem in some geographical areas and there seems to be a reliance on some medication. In my own constituency, up to 20% of people are on antidepressants. What has the HSE put in place to deal with such issues?

Mr. Tony O'Brien:

Using data analytics based on the prescriber database in the primary care reimbursement service, the medicines management programme systematically examines prescriber patterns, seeks to identify issues of concern and establish the causal factors and what the remedial factors might be. Perhaps the term "overprescribing" might be too general. Data analytics are certainly being used to identify all sorts of areas of concern where there are either regional variations or national patterns by comparison with other jurisdictions that look out of line in terms of prescriber and drug consumption.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

What action is taken once the cause of the problem is established?

Mr. Tony O'Brien:

That varies from case to case, but we can certainly provide the Senator with details on a number of initiatives taken by the medicines management programme that are illustrative of the type of actions taken.

Photo of Colm BurkeColm Burke (Fine Gael)
Link to this: Individually | In context | Oireachtas source

That would be appreciated.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I had asked a question of the Minister of State, Deputy Finian McGrath, but I am happy to have it responded to in writing in the interests of time because we have kept our witnesses for quite an amount of time.

On behalf of the committee, I thank the Minister, Deputy Harris, the Ministers of State, Deputies Jim Daly and Finian McGrath, Mr. Jim Breslin, Mr. Greg Dempsey, Mr. Tony O'Brien, Mr. John Connaghan, Ms Anne O'Connor and Mr. Liam Woods for appearing at today's quarterly meeting, for their open engagement and for the time they have given us. Perhaps for our next engagement we will all endeavour to get our questions and answers in in a timely manner.

The joint committee adjourned at 12.30 p.m. until 9 a.m. on Wednesday, 14 February 2018.