Oireachtas Joint and Select Committees
Wednesday, 9 June 2021
Joint Oireachtas Committee on Health
Update on Sláintecare: Department of Health
I welcome our witnesses to this meeting. They will provide us with an update on the implementation of Sláintecare. I should also mention that the Sláintecare Implementation Strategy and Action Plan 2021-2023 was published last month and makes for interesting reading. I welcome, from the Sláintecare programme implementation office in the Department of Health, Ms Laura Magahy, deputy secretary; Ms Caroline Pigott, principal officer; Ms Rosaleen Harlin, principal officer; Ms Sarah Treleaven, principal officer; and Mr. Bob Patterson, principal officer. I also welcome, from the Healthy Ireland division of the Department of Health, Mr. Tom James, head of the unit; Ms Fiona Mansergh, assistant principal officer; Mr. Greg Straton, assistant principal officer; and Ms Ursula O'Dwyer, assistant principal officer. From the e-health and health information systems division of the Department of Health, I welcome Mr. Niall Sinnott, principal officer.
Before I ask our guests to deliver their opening statements, I need to point out to our witnesses that there is uncertainty as to whether parliamentary privilege will apply to evidence that is given from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by me to cease giving evidence on a particular matter, they must respect that direction.
I call Ms Magahy to make her opening remarks. Following the presentation, I will call committee members to ask particular questions. Ms Magahy is very welcome.
Ms Laura Magahy:
I thank the Chairman, Deputies and Senators. We appreciate this opportunity to update them on Sláintecare. I am joined by colleagues from the Sláintecare programme implementation office and the Healthy Ireland office, both of which are parts of the Department of Health. Am I able to share slides?
Ms Laura Magahy:
That is fantastic. As the Chair mentioned, two strategies have just been approved by the Government in the past month. The Sláintecare Oireachtas report's fundamental principles underpin the Sláintecare implementation strategy and action plan. Healthy Ireland is the key prevention pillar of Sláintecare reform and hence we have brought our colleagues from Healthy Ireland, with whom we work hand in glove. We have made steady progress since the office was opened just over two years ago, as is outlined in the strategy. We have had targeted support for integration and innovation programmes. A decision was made this year to fund Sláintecare to the levels in the health capacity review, which is welcome. A substantial Sláintecare communications and citizen engagement programme has occurred. There has been a significant move to the community, which was a key part of Sláintecare, with additional staffing coming into place this year as a result of all the funding. I will also highlight the key foundational decisions of the establishment of the HSE board and the approval of the geographies for the six new regional areas.
There has also been steady policy progress which underpins everything we do. That progress has included the Healthy Ireland outcomes framework, the national healthy positive indicators for ageing, an independent patient advocacy service and other key policies that have underpinned everything we do and everything that is being rolled out in the new strategy.
We have focused on two priority programmes for implementation over the next three years. The first programme is about improving safe, timely access to care and promoting health and well-being. The second programme is around addressing health inequalities. My colleagues and I will take the committee members through the 11 projects which form these two programmes. We will then be very happy to take comments etc., and elaborate on anything that is in the plan.
The first programme is about improving safe, timely access to care, promoting health and well-being. It is underpinned and enabled by staff engagement, public engagement and, critically, funding. The overall objective is to achieve the waiting time targets of 12 weeks for inpatients, ten weeks for outpatients and ten days for diagnostics for public patients across the system. It is a complicated set of projects. There are seven in total and they are interrelated and interlinking. They involve implementation by the Department of Health policy sections, HSE operations and many other stakeholders across the system. We are not starting from scratch. Many of these have begun and have made progress in the past two years, but by the end of the next three years they will see substantial implementation.
Ms Caroline Pigott:
Good afternoon Chairman, Deputies and Senators. There are seven projects to improve safe and timely access to care and promote health and well-being. The first project is to implement the health service capacity review 2018. The three key work streams in this project relate to healthy living, enhanced community care and hospital productivity. It is about keeping people well in their homes and shifting care from acute hospitals into the community.
The second project is about scaling and mainstreaming innovative projects. The third project is about streamlining care pathways from prevention to discharge. The fourth project will develop elective centres in Dublin, Cork and Galway.
The fifth project is implementing a multi-annual waiting list reduction plan, project six is implementing the e-health programme and the seventh project relates to the removal of private care from public hospitals. That is implementing the Sláintecare contract.
The first project in programme one relates to the implementation of the recommendations of the health service capacity review 2018. This review projected to 2031 the staffing and physical infrastructure that would be required to meet the growing demands in the healthcare service. It factored in unmet needs, demographic and non-demographic pressures and reducing waiting lists over a four-year period. Three key reforms scenarios underpin the health capacity review. These are healthy living, enhanced community care and hospital productivity improvements. Implementation of these reforms reduces the need for an additional 7,000 acute beds to 2,600 acute beds. The increased acute bed capacity that is being funded in budget 2021 tracks the reform scenario outlined in the health capacity review.
Implementation of these three reform pillars involves the complex mix of interrelated projects that, when aligned, will collectively move towards providing safer and more timely access to care and promoting health and well-being. Can Ms Magahy read the slides?
Ms Caroline Pigott:
Significant investment has been provided in budget 2021 for enhancing community care. On the next slide, the model illustrates the provision of integrated end-to-end care in the community, ranging from keeping people well at home to primary care provision, community care services and acute care. The healthy living workstream focuses on prevention and decreasing the prevalence of unhealthy behaviours. It empowers people in their own health, and it facilitates people to live well at home and within their communities. A key aspect of the Health Service Capacity Review 2018 was the shift of care out of acute hospitals, into the community, and closer to a person's home, where safely possible. The community healthcare networks will focus on the healthcare needs of a population of 50,000. Some 96 of those will be rolled out. They will provide the foundation and organisational structure that will enable integrated care between the primary and acute care providers. Specialist ambulatory hubs will incorporate integrated care for older persons and chronic disease management. They will also link to acute hospitals to facilitate early supported discharge. I will now hand over to Mr. James, who will talk about the work undertaken by Healthy Ireland.
Mr. Tom James:
The healthy living workstream encompasses a broad range of health and well-being initiatives and programmes, through Healthy Ireland. As mentioned, Healthy Ireland is the key prevention arm of Sláintecare. It focuses on decreasing unhealthy behaviours that contribute to chronic disease. Our aim is to ensure maximum impact for citizens in terms of avoiding hospital admissions, reducing the need for primary care services, and helping people to lead healthier lives and to stay well for as long as possible. A number of key policies and initiatives form part of Healthy Ireland. Policies include the national obesity policy and action plan, national physical activity plan and national sexual health strategy. We have a big focus on evaluation, for example, through the Healthy Ireland outcomes framework, the Healthy Ireland survey, and the Health Behaviours in School-Aged Children, HBSC. I will now hand over to my colleague, Dr. Mansergh, who will talk about some of the current priorities.
Dr. Fiona Mansergh:
The national physical activity plan aims to have more people meeting the national physical activity guidelines - 30 minutes a day, five days a week - enabling more people to be more active, more often. It is implemented in collaboration with a range of other Departments, agencies and the academic sector and, in particular, the Department of Tourism, Culture, Arts, Gaeltacht, Sport and Media, who are the co-leads, and Sport Ireland. The national sexual health strategy focuses on promotion, education and prevention, and includes sexual health services, such as the STI clinics. Recent initiatives have included, for example, HIV Ireland's Fast-Track Cities, pre-exposure for prophylaxis or PrEP, and the expansion of the national condom distribution service.
Healthy Ireland has been running a series of information campaigns since 2018. Latterly, these have been adapted to take account of the challenges posed by the Covid-19 pandemic, aiming to support everybody’s resilience through this difficult period. The latest campaign, Keep Well, is now wrapping up. It provided supports for keeping active and being outdoors during the winter, supports for individual activity, staying connected with people safely, addressing isolation, supporting volunteerism and initiatives that support person-to-person connection. A community call helpline was available to those most in need.Switching off and Being Creative, in partnership with Creative Ireland, helped to learn something new, to get back to nature, relaxation and to take up a new hobby. Eating Well is supported by the HSE,safefood and others. I should mention our support of RTÉ’s Operation Transformation this year, which reached out to approximately 400,000 to 500,000 people with advice on exercise and healthy eating. Finally, the Managing Your Mood campaign supported positive mental health and gave people supports on where to go if they were in distress. It linked to relevant information points, for example, the HSE’s mental health service, Your Mental Health, Jigsaw and SpunOut. I will now hand over to Ms Harlin to talk about scaling and mainstreaming integration innovation.
Ms Rosaleen Harlin:
Scaling and mainstreaming of integration innovation is a second project outlined under reform programme 1. The next slide contains a map, which outlines the large number of projects funded in round 1 of the Sláintecare integration fund. The goal of these projects is to promote the engagement and empowerment of citizens in the care of their own health, share best practices on processes for chronic disease management and care of older persons, and encourage innovation in shift-of-care to community, or provide hospital avoidance measures. The goal of round 2 will be to enable safer integrated care between settings through audit-informed, research-driven, or process improvement projects. Integrated patient pathway improvement projects and integrated wider determinant stakeholder partnerships will focus on improving outcomes for communities of particular needs. We have funded projects such as SMILE in Carlow, COPD projects, diabetes, heart failure, and a community oncology project in north Dublin, which are on the next slide These projects support the delivery of integrated care. They shift care into the community and help reduce and prevent hospital visits. They support the ultimate goal of reducing waiting lists and waiting times. We have great examples of projects doing wonderful work out in the community that have been funded through Sláintecare.
Ms Laura Magahy:
Project 3 is about streamlining care pathways from prevention to discharge. Many of these examples have been demonstrated well over the past two years through some of the samples on which Ms Harlin spoke. Developing integrated care pathways that are based on delivering the best outcomes for patients can help drive streamlined integration between the care settings. Pathways will be agreed between GPs, primary community care providers, community specialist teams, and hospital-based specialists. They will provide better links across these care settings, ensuring resources are used to provide care for people in a timely way. This has been recently proven in New Zealand in an innovative way. It will be enabled by a decision support tool and other e-health projects, and backed up by a services directory. There is great demand for this, particularly in areas where there are problems of referral, for example, in mental health. We will work with colleagues to implement that over the next three years.
Our next project in reform programme 1 is on developing the elective centres. As members will know from our previous meeting, the development of elective hospital facilities in Dublin, Cork and Galway is in line with the National Development Plan 2018-2027 and health service capacity review and it was recommitted to in the programme for Government. The goal of the project is to develop elective hospital capacity with a ten-year horizon of need. This facilitates the separation of scheduled and unscheduled care. It will provide quicker, higher quality, safer care for selected elective patients. It will create capacity for acute hospital sites and reduce or eliminate outlier orders, that is, people waiting on trolleys. It will help drive down waiting lists, reduce cancellations and reduce acute hospital footfall. The project continues to work at the moment under the previous implementation strategy. The elective hospitals oversight group, which is under the joint governance of the HSE, the Department of Health and Sláintecare, is guiding the development of the elective hospital sites. We followed the process outlined in the public spending code. We have completed a strategic assessment report. As of last Friday, we had invited sites for selection. They will be considered by the oversight group in the next phase of the implementation of the elective hospitals. The goal is, in accordance with the public spending code, to bring for a Government decision before the summer the selection of sites for the elective hospitals.
We have been working closely with colleagues in Cork and Galway in particular to make sure their requirements can be met within this programme. The next slide is on implementing a multi-annual waiting lists plan.
Ms Laura Magahy:
We will forward the slides afterwards. For anybody watching at home, we will put them on our website.
This is an important programme around waiting lists. Waiting lists have been exacerbated by the Covid-19 experience. We report on waiting lists monthly and they have been getting worse as a result of cancellation of operations due to Covid-19. Together with our colleagues in the HSE and the National Treatment Purchase Fund, NTPF, we are developing a multi-annual waiting list plan to get rid of waiting lists over a four to five-year period. It will not just be about hospital waiting lists. There are waiting lists in the community as well. It will be about acute, community, social care, disabilities, mental health, palliative care, rehabilitation and any other waiting lists that exist. We are at an advanced stage and will present our project to the Minister for Health to see if the Government will commit to a multi-annual plan to get rid of waiting lists once and for all. Traditionally, waiting lists have been dealt with on an annual basis only. We need a longer-term view in order to drive these down. It is what people care about most. It will be the barometer for the success of Sláintecare.
Over the last four months, we have put a lot of work into developing this plan. It is complex and there are a lot of moving parts. It will require joined-up thinking. Some of the projects to which we alluded form part of this plan. I am happy to come back to the committee to discuss the details of the plan, once it has been approved by the Government.
On the next slide, the e-health programme is a critical part of reforming the health service. Through the pandemic we saw the impact of some positive initiatives in e-health, for example, remote consultations and, to a limited but successful degree, electronic prescribing. The benefits of e-health have been demonstrated, as have the risks through the recent cyberattack. It is necessary to invest into the basics of our e-health programme, as well as into the more advanced pieces.
The projects listed on this slide are an example of some of the key health solutions and electronic health record, EHR, component parts, which will be needed to deliver an electronic health record for every patient in Ireland. In the middle, there is the citizen portal, the individual health identifier interoperability, the shared care record, and the integrated referral and wait lists hub. These will be facilitated on one side by e-prescribing, immunisation, home support and community programmes. On the other side, it will be supported by our hospital-based programmes.
We have some very good examples of EHR in the maternity newborn programme. We also have advanced level EHR in hospitals such as St. James’s Hospital. The National Forensic Mental Health Service Hospital and Children's Hospital Ireland will have one in due course. This slide underpins everything we do in Sláintecare. Some key advances have been made in recent months. In particular, everybody who has had a vaccination has now been allocated an individual health identifier. This is an essential part of the shared care record. They will soon form part of general practice and the hospital patient administration system, which is necessitated to deliver a summary and shared care record.
On the next slide, the project on removing private care from public hospitals is a key part of Sláintecare and the original Oireachtas committee report. The new Sláintecare contract with an increased salary over existing new entry levels will support the expansion of the public health service in line with Sláintecare. It is a key step in the move towards the long-term goal of universal single-tier healthcare, with public hospitals exclusively used for the treatment of public patients. That has been a long-standing aim. It is the first step on the road to separate private and public health care. The OECD, in its analysis for the de Buitléar group, whose report gave rise to this, concluded that removing private practice from public hospitals would eliminate the unequal treatment of public and private patients in public hospitals. We are at the stage of entering discussions with the representative bodies and we look forward to concluding those in the coming months.
We have just described reform programme 1. Everything within reform programme 1 has been designed to reduce waiting lists and improve access for public patients. On the next slide, reform programme 2 takes a slightly different slant, which is about addressing health inequalities. We need investment in the public system, but there are also pockets of places where people have unequal access. Therefore, the four projects that are listed here are designed to ensure that resources are more equally distributed and are targeted to address and reduce health inequalities. This is like the Delivering Equality of Opportunity in Schools, DEIS, school idea. There are four projects here. The first is developing a citizen care master plan. The second is rolling out healthy communities, which is a very exciting initiative. The third is developing regional health areas. It was parked last year during Covid-19 but it is on the cards again. The fourth project is about implementing the obesity policy and action plan. I invite Ms Treleaven to outline the citizen care master plan project.
Ms Sarah Treleaven:
In the original Oireachtas committee report on Sláintecare in 2017, a population-based approach to service planning and funding was championed. This will take the form of a citizen care master plan. By using a population-based approach for service planning and funding, we hope we can address some of the health inequalities that exist around the country. First, we will profile our population to assess their health needs in a formal way. That evidence will then be used to develop a population-based resource allocation model, and a review of eligibility entitlements specifically. We will also look at frameworks for capital planning and workforce. Many of these work streams will be done concurrently. Mr. Straton will now address the area of healthy communities.
Mr. Greg Straton:
The Sláintecare healthy communities programme aims to reduce health inequalities by addressing the social determinants of health in the most deprived communities in the State. Some 22.5% of our population is exposed to some form of disadvantage. In these communities, the prevalence of chronic illness such as stroke, coronary heart disease and diabetes is higher than the population average and significantly higher than in affluent communities. As an example, in self-reported health rates for men in the 65 to 74 age cohort, 57% report good health in deprived areas, as opposed to 91% in affluent areas. The Sláintecare healthy communities programme will be designed to bring together key policies, strategies and fields aligned to the social determinants of health. It will involve 12 Government Departments working in close partnership with local authorities. The first phase of the programme will be delivered in 18 areas, aligned with the social inclusion and community activation programme, SICAP, areas and will cover all 51 SICAP areas by phase 3.
In these areas the HSE will deliver evidence-based programmes that will provide targeted supports in the identified communities, such as parenting programmes, stop-smoking advisers, the We Can Quit programme, social prescribing link workers, nutrition supports and Making Every Contact Count training programme. I will hand back to my colleague, Ms Treleaven.
Ms Sarah Treleaven:
Once again I am here to talk about the regional health areas. As people may recall, the geography of the six regional health areas was approved by the Government in July 2019. The Government decision directed us to develop a business case and a change management programme. We are doing that at present in line with the Department of Public Expenditure and Reform's public spending code. The key objectives of the implementation of regional health areas are: to further define clinical governance pathways, in particular where they cross between community lines; to reinforce our corporate governance and accountability structures; to enable a population-based approach to service planning and funding; and to promote the integration of services between community and acute sectors. I will now hand over to Ms O'Dwyer to talk about the obesity programme.
Ms Ursula O'Dwyer:
Members can see on the slide the reference to Ten Steps Forward, which is the obesity action plan for Ireland for 2016-2025. As all members know, obesity is a major public health problem. Two out of three adults and one in five children are overweight or obese. Since 2016 we know that the levels have been stabilising, but they remain significantly higher in socially disadvantaged communities. One figure to illustrate that is the incidence in a first-year class is a DEIS school is 24.6% versus 15% in a non-DEIS school in the general population. We know that is a problem.
The ten steps in the action plan show the Government's commitment to reversing the obesity trends and they set out the actions required across a range of Departments and sectors. They aim to reduce the overall burden for individuals, their families and the health system. A wide range of steps are being actioned and a mid-term review by the school of public health at University College Cork, UCC, is currently under way. Step 9 is a key step. The model of care is shown on the other side. It was launched in March 2021 and provides for an integrated delivery of early intervention, weight management and obesity treatment across the lifespan. There are five levels of care. It sets out how healthcare for children, young adults and people living with overweight and obesity in Ireland should be organised and resourced both now and in the future. I will hand over to Ms Magahy.
Ms Laura Magahy:
That is the overview of the 11 projects which comprise the two programmes for the next three years for Sláintecare. We will report on them on a regular basis. We have just completed our quarter 1 report and everything is broadly on track, which is really great. We will be providing an evaluation programme, as discussed earlier, and making sure that everything is aligned and reported on properly. We are working in tandem with the HSE and other colleagues right across the system to implement this very complicated programme and making sure that everything is running in the right direction.
We are very pleased that everything the members have seen in the report is funded, other than the areas that are highlighted, for example, with the elective hospitals, where it has to come back to the Government for specific approval. All the elements such as beds, community staffing, diagnostic care, social care expansion, etc., that were outlined in the budget, which we went through with the committee at our last meeting, have been funded. We are very pleased with that.
I thank the committee for bearing with the technical issues. Sláintecare is about working together across the system. We are acutely aware that it has had the support of all of the parties, for which we are very grateful. We value the input of all the public representatives, as well as our colleagues across the public, private and voluntary sectors in the health system. We look forward to discussing the report with the committee and to coming back and updating it later in the year on how we are getting on.
I thank Ms Magahy. I again apologise for the technical hitches that interfered with the meeting today. We usually have ten minute and seven minute slots, but I ask members to curtail themselves to eight minutes and six minutes, respectively, if that is possible. We will try to make up time. If there is a chance, I will try to bring members back in.
I thank the witnesses for their presentation and for all the work that has been done on this area. I wish to focus on two areas. The first is elective hospitals. My understanding is that the South/South West Hospital Group was a bit surprised with the presentation made to it on 4 March because it set out that it would be an elective hospital, which would be open six days per week, 50 weeks of the year. There was a clear indication that there would not be inpatient beds there. It might be helpful if there was some clarification on that. My understanding also is that the head of the South/South West Hospital Group has written to Sláintecare since the meeting. What level of engagement has occurred since the meeting of 4 March with the hospital group?
Ms Laura Magahy:
I can take that question. The elective hospitals were designated as elective ambulatory hospitals in the national development plan. We have devised a national model for ambulatory elective hospitals. We understand that it is not everything that is required either by Cork or Galway, or other areas around the country. We have had substantial engagement with the South/South West Hospital Group as recently as last Friday. We are coming together to get an understanding of how we can make sure that its requirements and those of the elective hospitals can be done in tandem. When we went out looking for sites we made sure that we were looking for a site that was big enough to accommodate both the elective hospital's ambulatory requirements and the inpatient and overnight stays, which I know is the wider ambition of the South/South West Hospital Group. I am in weekly contact with the group. Its consultants, KPMG, and our consultants, PA Consulting, are talking together about how to make sure that the two requirements dovetail and overlap.
Is Ms Magahy saying that the new elective hospital will have inpatient beds, because that is the issue. What is being said to me is that if one takes hip or knee operations, people with diabetes or other underlying health conditions would not be suitable candidates for a day hospital. Is Ms Magahy saying there are going to be inpatient beds?
Ms Laura Magahy:
No, I am saying that they are two projects which need to be done side by side in due course. The elective ambulatory project, which is the one that we have been pursuing looks at very simple day surgery where a person goes in and out and will not be delayed or cancelled due to other issues impacting on them.
Does Ms Magahy accept that we are confining ourselves to a very low number of people who can use the facility? This facility will not be a suitable place for anyone with an underlying condition who wants to go for minor surgery.
Ms Laura Magahy:
I am sorry, perhaps I have not been clear. It is designed specifically for minor surgeries and simple procedures. I refer to the operations that are being cancelled at the moment that constitute most of the waiting lists. These are large elective centres, one in Dublin, one in Cork and one in Galway, that will be able to facilitate thousands of people who are-----
Does Ms Magahy still accept that anyone with an underlying condition will not be able to have surgery in these centres? Someone who has diabetes will not be a suitable candidate for a centre like this.
If the person is going in for minor surgery that is not related to diabetes, he or she is still not considered a suitable candidate. The same is true of a person whose body mass index, BMI, is above what it should be, he or she is a not a suitable candidate for a day facility.
The day facilities will be managed in two different ways. Surgical procedures will be done in the elective surgery centre and procedures for medical conditions will be done in the primary care centres or by the GP.
The point I am making is that those with an underlying health conditions are not suitable candidates for a day hospital that is doing surgery. For example, if they are going in for a minor surgical procedure, that facility will not be able to accommodate those people.
But if they have underlying conditions, they cannot be accommodated. That is what is stated in the evidence that has been provided to me. The medical advisers and consultants have told me that if they have a patient with an underlying condition who is going into a day hospital for a minor medical procedure, the advice is that it is not a suitable facility for them.
I want to move on to the issue of sites. I understand that there has been a consultation on sites. However, is it not also the case that the HSE already has a number of existing sites? What level of engagement has there been with the South/Southwest Hospital Group about using the sites that are there already?
Ms Laura Magahy:
There has been extensive engagement. We issued a public invitation for submissions for sites in the last few weeks. The closing date was on Friday. The invitation for submissions includes HSE sites, Land Development Agency sites and indeed, private sites. There will be an evaluation process that will assess which are the best sites and the best value sites. It will also ensure that the sites are big enough for future development. Our HSE colleagues helped us to design the invitation that was issued, so they have been part of that whole process. We have been in discussion with our HSE colleagues in Cork.
I want to return to the beds issue. Taking the two voluntary hospitals in County Cork, the Mercy Hospital and the South Infirmary Victoria University Hospital, the South Infirmary Victoria University Hospital has been there since 1756. The Mercy Hospital was established in 1857. Therefore, the two hospitals are facing many challenges in trying to meet updated requirements. Particularly after the pandemic, there are even more requirements on them in respect of the new challenges that they face.
Together with the Cork University Hospital, CUH, how are they going to cope with the demand for inpatient care if there are not going to be any inpatients in the new facility? That seems to be what Ms Magahy is saying.
The South Infirmary Victoria University Hospital is just doing elective surgery. There is a huge level of co-operation between the CUH, the Mercy Hospital and the South Infirmary Victoria University Hospital. I am not sure that any further merger between the Mercy and the South Infirmary Victoria University hospitals will gain any extra capacity.
Ms Laura Magahy:
The Deputy is correct. There are two issues. From the findings of the health capacity review, we know that extra capacity is needed and in any event, new beds need to be built to cope with future demand. We also know that some of the existing stock is not up to scratch. That was demonstrated particularly during the Covid-19 pandemic, when we did not have proper infection control and had Nightingale wards. Therefore, there must be a substantial investment in our health infrastructure-----
Ms Laura Magahy:
There can be elective inpatient beds as well as elective outpatient and day surgery beds. We are working with the South/Southwest Hospital Group to look at how the two plans can complement each other. We have deliberately chosen a site that is big enough to accommodate both the day surgery and inpatient overnight beds and the future plans of the South/Southwest Hospital Group which, as I have said-----
I thank the Chair for letting me substitute for Deputy Cullinane. I welcome the witnesses. There are a few issues that I wish to raise. If I run out of time, written responses will suffice.
A lot is made of care in the community and we hear about it often. Despite the constant references to how important it is to care for people in their own communities in rural Ireland, district care has been stripped away from localities on a continuous basis. In my own constituency in Country Tipperary, the district hospital, St. Brigid's, was closed down temporarily during the crisis. We were told this was for Covid reasons. Before the decision was made to close it, it had a short-stay unit with palliative, respite and convalescent beds. In the following months during the crisis, there was increased public concern over whether the hospital would reopen at all and if it was being closed by stealth. As it turned out, it was.
It has since been confirmed that the unit will not reopen due to alleged concerns over the suitability of the premises and the standard of care for people. It had been providing this care for decades. This means that the people of Carrick-on-Suir, south Kilkenny and north Waterford and the surrounding areas, who had great affection for St. Brigid's, now face the prospect of having to travel further afield for the services that were provided in their community, as stated in the reports. Despite their best efforts, the Minister has refused to move on the issue. The people of Carrick-on-Suir have been demonstrating every weekend and they will continue to do so. I have no doubt about it.
I wish to ask a number of questions about the decision and how it was arrived at. Despite numerous freedom of information requests being submitted by the community in respect of the engineer's report upon which the decision is said to have been made, we are still waiting for the information to be made available. We have received some reports that it was made available today. In 2018, the HIQA report gave a clean bill of health to the hospital. When was the engineer's report commissioned? I ask that a precise date is provided, if possible. Was it commissioned before the assurances were given last summer? Deputies were given assurances that the hospital would reopen. If the report was commissioned before that, then we were lied to. If it was commissioned after that, I wish to know the precise date on which it was commissioned and who commissioned it. I also request a copy of the report.
How are the hospice beds that were in the hospital going to be replaced? Where are they going to be based and whey will they be available? Have contracts been signed with nursing homes in the area? It seems to us, who have been campaigning on the issue, that it is all about privatising beds and taking from the community. Every one of the reports mentions community-based care, but the beds are being taken away from the community. I am interested to hear if the Minister for Health spoke to officials before the decision was made on the closure of St. Brigid's. A Deputy and a local councillor publicised on social media and the local media in Tipperary that the hospital was going to open, but that decision seems to have been thrown out.
The mental health services aspect of it is another issue of concern. I am sure that is it the same all over the country. However, the provision of mental health services in Tipperary has been affected by the stripping of services away from local communities. St. Michael's was a huge psychiatric unit, which closed in 2012. People were told to go to the overcrowded St. Luke's General Hospital in Kilkenny if they were from the south of the country and those in the north of the county were told to go to Ennis Hospital. I do not know if people realise how large a county Tipperary is to be without any beds. It has since emerged that the HSE itself is willing to pay €300,000 over the next seven years to transfer patients from Clonmel to St. Luke's. Around €700,00 has been spent on the facility as part of the Covid-19 response, and still, no beds are available. With all this money being made available for these purposes, is it not time to invest money in mental health services in a county the size of Tipperary and reopen St. Michael's to some extent so that we have a proper mental health unit in Tipperary? Some people seek to think that mental health issues stop at 5 p.m. and do not affect the patient until 9 a.m. the following morning. Something needs to be done. With that kind of money being spent, something has to change.
Another issue that I wish to raise concerns the Dean Maxwell Nursing Home. It is another facility that has been closed in County Tipperary. We are beginning to wonder if the Department has something against the county. All of these decisions have been made. Everything is being stripped away . All the reports are about community-based care. It is not being delivered. -----
I would like direct answers to the following questions. How long will it take to deliver each of the three elective centres? What capacity will they have? What will each centre actually cost?
How will the integration of primary and community care work through the community healthcare networks? How will the networks work in practice and what services will they provide?
Finally, has there been any progress on the new Sláintecare consulting contracts? Will there be no negotiation or will they just be just imposed unilaterally? Gabhaim buíochas.
The difficulty for the Deputy is that he has asked ten different questions and our witnesses have approximately two minutes left to respond to him. I do not know if we will receive written replies because of the-----
Ms Laura Magahy:
In fact it may be the opposite, and I do not mean to be smart, but I do not know anything about the operational piece at that level. We can find out, however, from the HSE.
Ms Laura Magahy:
Yes, there are three issues I can deal with. I thank the Deputy for his questions. The first is how big the electives will be. The thinking at the moment is that there will be nine theatres in Cork, eight in Galway and 21 in Dublin. That might change as we are still in the middle of developing the model and the final business case.
The consultants contract has issued to the representative bodies. We are hoping that there will be a substantial engagement process, which we have asked them to engage in. There is a great deal to discuss within it. There are two fundamental issues that Government decided upon. One is not to have any private practice off-site and the second is the salary levels but there are plenty of other issues that can be discussed and engaged upon in a meaningful way. We are hopeful that that will be happening over the next very short time.
Finally, on the community healthcare networks, the Deputy asked what kind of population level they will cater for. These are for populations of approximately 50,000 people each and there will be 96 of these. These will be substantially implemented and rolled out by the end of this year. Staff are actively being hired for these at the moment and they will provide primary care.
That was a whistle-stop tour. We could have used twice the time and it was a very pleasant attack on the senses. I want to express my appreciation to our witnesses for all of the work that is going into these projects. Each programme probably deserved a separate session in its own right. I feel a little overloaded after it. This is nonetheless exciting stuff which I appreciate.
I have just a couple of questions and I do not believe I will use up all of my time. Something that has often intrigued me is the VHI SwiftCare model of emergency intervention. Why has that never been considered? It would significantly alleviate the pressure on emergency departments and hospitals more generally.
Ms Laura Magahy:
That is a very interesting question. There is a parallel in the public system, which are called minor injury units, and there are 11 of these associated with the main public emergency departments all around the country. In Dublin, there is one in Smithfield and one in Mallow, County Cork. I will miss the names of the others as I do not have them off the top of my head. These are brilliant, are open between 8 a.m. until 6 p.m. seven days a week, mostly. These are minor injury units and do what it says on the tin by providing care for minor falls, small X-rays, are very good and are becoming more and more used to taking pressure off the main emergency departments. It is interesting that the Deputy should raise these units because I am not sure that they are as widely known about as-----
Yes, these are just for minor injuries. VHI SwiftCare has managed to grab the corporate name. Perhaps a renaming of the public facility might be in order. That is useful to know. I was aware that there were minor injury clinics but I did not appreciate that they were fulfilling the same function.
Respite care is an issue that is coming down the tracks. I was very interested in what Ms Magahy said about returning care to the community and what she might have to say resulting from the nursing home experience. Public nursing home experience is often pooh-poohed by some people. For example, I know that one of the big advantages that public nursing homes have over private nursing homes is the presence of GPs on-site pretty much all of the time. This is something that is open to private nursing homes but is something that could be significantly improved upon. What does Ms Magahy believe the public mood is around the nursing home experience and what can Sláintecare learn from that?
As constituency politicians, respite care is an issue that comes up a great deal. I want to float, however, a different idea. Politicians will have charted the increased number of children with autism who have now entered their teenage years with the condition and who are becoming adults with it, depending on where they are on the spectrum. There will be demands on society for some of those who are on the extreme end in respect of social housing provision and so on. However, has respite on the home site ever been considered? I know that there are parents, for example, who would like to access something like a seomra for their house or back garden where, if there is an outburst or where everybody needs a break, there is space on site. The respite, therefore, does not then have to take care out of or away from the family home in some instances but it is still being taken care of within the community. This is going to become a greatly increasing demand from within communities. There are multiple other questions I could ask but I will leave it at that because I would like to receive some responses on these questions, and I thank our guests.
Ms Laura Magahy:
I may need to come back to the Deputy on some of his questions and I thank him for his kind observations at the outset.
On public nursing homes and the public response, it is interesting that HIQA was going to do a consumer survey on that and it was paused due to Covid-19. It was one of the things that we are very interested in getting citizens’ feedback on what they think about it.
We are slight outliers in that we have more people going into nursing homes than in other countries. One of our main goals is to increase the number of people who can stay well and be enabled to stay well in their own homes. The Deputy may have seen some of the programmes referring to healthy communities as outlined by Mr. Straton earlier. Another one that we did not have a chance to talk about is Age Friendly Ireland's healthy homes programmes. We have funded 11 age friendly co-ordinators in each of the local authorities on a pilot basis to have a conversation with people who are deemed to be vulnerable to identify what supports they may need to stay in their own homes. This may involve rightsizing, a warmer home, occupational therapy requirements for the home and how can people be enabled to stay longer in their own homes. It has just started and the co-ordinators are in place. We have set ambitious targets to see can we reduce these needs by putting the requirements in upfront in a co-ordinated way so the people can stay well in their own homes for longer. This is an inter-agency approach, which involves the housing Department, local authorities, Sustainable Energy Authority of Ireland and, obviously, the HSE from a clinical perspective. We are very interested in this project because we are outliers in respect of institutional care as opposed to trying to keep people well in their own homes.
The Deputy’s proposition on respite on the home site is very interesting and is one I will take away and talk to colleagues in the Department about to see what the thinking is or could be on that. If there are examples of other places in which this has worked, we will be very interested in hearing about that. He is correct in that people want to stay well in or near to their own homes and, indeed, that people who require care are also looked after near to the family residence. We would be very interested in hearing more about that if he has any suggestions around that idea.
It is an innovative piece and I am not claiming credit for it. A grant seems to be what is stopping it at the moment. There are some families who cannot afford this but would like to do this on site. All that is stopping this then is a grant but I will follow this up with some more detail. That concludes my questions. I thank the Chairman and the witnesses again.
I thank everyone for their presentations. I fully appreciate the complexity and breadth of the work involved, however I am concerned as it is hard to establish from the presentation whether the work is almost complete or still at a theoretical level. If there were funding allocations attached to each project and a timescale, it would be more helpful. Much of this seems like name-checking from the original report. It may be that or there may be work well under way but we do not have a sense of that from the presentation.
I have six very quick questions. Who will do the Sláintecare contract negotiations? I thought the citizen care master plan population profiling was almost done the last time the witnesses were in contact. When do they expect that will be completed and published? I was very disappointed to hear the elective hospitals will be day hospitals. That is not what was envisaged at all. The witnesses say that is how they went into the national development plan. Can that be changed in the review of the NDP, because it is clear that we will need a lot more than just day hospitals? On the regional health areas, I note the name has been changed. Has the objective changed in any way in terms of a single management structure for all health services in each of the RHAs, as they are being called now? Can we have a note on the detail of the healthy communities and what exactly Sláintecare is doing and how it is going to bring 12 Departments together? I am interested in hearing about that. Finally, where is the work on entitlement versus eligibility?
Ms Laura Magahy:
Each action has a set of deliverables in the plan. We could not go through it now, sorry. Everything that has been named has a budget. Many of the things that are in place are at an advanced stage. By the end of the three years we will have the multi-annual plan substantially implemented to reduce the waiting lists, so we will be well on the way to having the waiting lists down, we will have begun construction of the new elective hospitals, we will have rolled-out the Sláintecare consultant contract, we will have hired 7,000 new community-based staff, delivered 31 new primary care centres, invested in 32 community specialist hubs, and provided the next stage of the healthy communities. I will return to that. There will be 57 healthy communities in due course covering 250,000 people, with 18 happening this year. We will have mainstreamed access for patients to direct diagnostics, created the six new regional health areas, and established the new community healthcare networks. All this work has been enabled by the budget. Since last October's budget, we are in the position of being able to hire the right staff to put in place the infrastructure and properly get everything in place. It is substantially advanced. We will publish the quarter 1 report in the next couple of weeks. I want to assure the Deputy about that.
The intention on the RHA has not changed. It will be single budget. I will ask Ms Treleaven to come in on the regions.
Ms Sarah Treleaven:
That is the intention. We are scoping potential options and engaging with our stakeholders to ensure that we are incorporating lessons learned from previous exercises such as this. We are looking to create structures that will allow a single population-based resource allocation per region that will bring together community and acute sectors at a much lower level of management than at present, bringing decisions closer to the ground and bringing integration closer to the front line.
Ms Laura Magahy:
We would love to provide the Deputy with a note on the healthy communities and Mr. Straton will give more detail. It is very exciting. In the last five months, we have got agreement from the local authorities to roll this out at a really local level through the local community development committees, LCDC, structure. We will appoint a healthy communities co-ordinator for each LCDC structure that are aligned with the social inclusion and community activation programme, SICAP, areas. At national level, we have the agreement of each of the Departments that they will meet and ensure that their respective resources, whether in housing, education, social care, and children, and work together, somewhat like the DEIS model, to focus on healthy outcomes for the people in those communities and ensure that all the resources are being targeted. It is really exciting. It is a good example of what population resource allocation can do. We have the funding for it and the staff are being hired now. We have the agreements of the Departments, local authorities and all the pieces are ready to roll-out. They will start on the ground, in real life, in September.
Ms Laura Magahy:
There will be a team from within the Department and the representative bodies, and the HSE which is implementing the contract. It will be a team approach.
On the question of entitlement and eligibility, I am a little concerned because a major element of Sláintecare was the removal of cost as a barrier to accessing healthcare. I am not hearing that much about that from the witnesses. What is the status of that?
Ms Laura Magahy:
It will be part of the work that Ms Treleaven referenced which is to examine the whole eligibility entitlement and what is a barrier for people to access care. That is part of the work that is being done this year that Ms Treleaven is rolling out. It will be budget dependent and decisions on the budget will not be made until October but we will make proposals into the budget for consideration by the Government then.
Ms Laura Magahy:
I do not know how it came about as it was written before I joined but it was there that they were day surgery and that was the urgent requirement for the very simple in-and-out procedures that were required. The next stage can be considered in the NDP review happening at the moment. As referenced earlier by Deputy Burke, there are wider requirements around the country for more inpatient beds and for better quality inpatient beds with more privacy and better infection control, which also needs investment through the NDP. It can be considered in that context. The sites are big enough, even as a first phase, if we get the day surgery going which will really help the waiting lists. Then we can bolt on or have additional in-patient elective work at the same time.
To what degree have the witnesses been satisfied by the availability of funding for the implementation programme so far? What are their expectations for the future? To what degree has Sláintecare been able to interact with GPs, consultants and nurses, that is, the front-line workers over the difficult last 12 months or more?
There are two major trauma care centres, one in Dublin and one in Cork. I understand the need for both but is it sufficient to cover the country?
I got a hint somewhere recently of a comparison with the population of the greater Manchester area, which is correct. However, there is a vast difference between the delivery of services to an area the size of greater Manchester and an area the size of this country as the logistics in terms of geographic cover are vastly different. I would like clarification on that point.
With regard to residential mental healthcare for child and adolescent patients, residential places are non-existent at present and there is a huge crisis in that area, in particular for severely affected patients and those with emergency needs. Extraordinary things are happening and have been brought to the attention of my office. While I do not want to delay the meeting, there is an urgent and pressing need to deal with that situation to ensure the patients in question have a place to go in terms of residential care, and we must recognise that the problems become even more complex as patients get older.
That is enough for the moment. If I can ask more questions later, I will try to do so.
Ms Laura Magahy:
I thank the Deputy. There is a lot in that. We are very pleased with the availability of funding this year but there will need to be substantially more investment, particularly if we are to get the waiting lists down. As I referenced, it is a multi-annual plan. What we are doing now is putting in place the capacity to deal with the increase in population even since the Oireachtas report was written. That has brought us up to a level playing field and the staff are being hired for that as we speak, as I referenced earlier. However, there is a backlog and it has to be invested in, so that will have to be considered by the Government to see if the appetite is there to do that. That will be a separate application.
In terms of liaising with the front-line people, and not just during the pandemic, it has been incredibly difficult, although we have had substantial engagement with general practice through the pandemic in establishing a general practice research hub.
Ms Laura Magahy:
Absolutely. I just meant we were not going out into the hospitals or meeting them in communities during the pandemic.
There are to be two major trauma centres and we know the Government recently decided on that. This will require substantial investment and that is in line with the policy outlined by the trauma review. That is the policy that is being followed and invested in, which is good news.
We require more residential care but, again, there has been investment through the national development plan for residential placements. We can come back with the detail of where that is happening or being proposed.
What role does Ms Magahy see for healthcare assistants in the future? Does she see them as part of the plan? A project was undertaken and a report produced by UCD. Has it has been progressed?
I am concerned about the two major trauma centres. The point was made by previous speakers in regard to elective care. I think there is a problem, from my experience as a public representative. Obviously, the ambulance services will have to be involved, and they will be. However, invariably and inevitably, there will be situations where two or three urgent cases require attention at the same time and it is not going to be possible to deal with all of them. I ask that this be looked at again because I foresee the need for another major trauma centre. It is a long way to the south west or the north west, and we have the Northern Ireland situation as well. I ask that this be done.
I welcome Ms Magahy and her team. I want to touch on issues similar to those raised by Deputy Colm Burke with regard to the elective centre for Galway. Is it correct that there are no agreed plans for an overnight unit or overnight beds?
Outside of what is carried out in a minor procedures unit such as at Roscommon hospital, what additional procedures will take place in this elective centre? For example, will hip and knee replacement surgery, non-prostate cancer surgery or hernia treatment take place?
What we need is clarity on this. What has been talked about and promised by Saolta and others is overnight or inpatient beds. In Ms Magahy's presentation to the South-Southwest Hospital Group, she mentioned orthopaedics and a wide range of services. I find it hard to believe all of those could take place on a day-only basis. Realistically, will there be hip and knee replacement on a day-only basis without having an overnight stay, for example?
Ms Laura Magahy:
I have found the list. It refers to general surgery, orthopaedics, urology, oncology, ophthalmology, gynaecology, plastics, pain medicine, gastroenterology and vascular surgery. It will include day surgery, endoscopy, non-surgical therapeutic day procedures and non-radiological diagnostics procedures. Our group is led by Professor Frank Keane and we have had a lot of input from the surgical community in that regard. I am happy to furnish more details of what is envisaged.
Ms Magahy said there are weekly meetings with Saolta. Senior Saolta officials have commented to me that the plans Sláintecare has presented were not what they envisaged or what is required for Galway or the region. Have they expanded on that? I presume they have. What issues do they have with the proposals Sláintecare has made?
Ms Laura Magahy:
We met Saolta officials as recently as yesterday and, as I said, we are meeting weekly. There is an acknowledgement that day surgery is required, so there is no denying that we need more day surgery happening all around the country and that that will help waiting lists. The issue is that the larger capacity requirements that Galway and, indeed, Cork have are outside the day surgery proposal. Therefore, they need to be considered as part of the national development plan. It is not that one model is wrong and one model is right. There is a recognition that what is being proposed in elective day surgery is additional to what is there at the moment, and that it will create capacity and free up capacity in existing hospital theatres, for example, and free up existing day surgery beds. However, it is not everything and we are not saying this is everything that is required. We recognise there is a need for additional investment in both Cork and Galway.
As I said, the first action was to ensure the site chosen is big enough. We are trying to ensure the proposal being offered by Cork and Galway, which is a different idea, can progress in tandem if the funding is there with the elective surgery proposal. They should not be seen in competition but rather as complementary. We have reached that level of understanding, I suppose, with both Galway and Cork and the discussions are proceeding in a good way.
Over the next number of weeks we are trying to prepare the plan for the consideration of everybody, including the funders, Oireachtas Members, the Government, etc.
Okay but there are proposals relating to the elective centre. What is the difference between an elective hospital and an elective centre? Will the witnesses provide a list of procedures above what is provided in a minor injuries unit? The diagram indicates that selective day surgery plus minor see and treat, which is the chosen model for Galway, Cork and Dublin is one place above a minor injuries unit and three places below a full service elective hospital. There is a bit of confusion in terms of what that means or what will or will not take place.
Ms Laura Magahy:
To be absolutely clear, these are fully operational theatres requiring anaesthesia. These are not simply minor injury units. They are elective centres where anaesthesia is required but not an overnight stay. They would include cataract procedures, for example. There are approximately 400 different procedures proposed to be undertaken here. I can send on those details. To be very clear, these are fully operational theatres with the full specification. This is not about minor injury clinics or units.
Ms Laura Magahy:
There are no overnight stays. It is not three places down anywhere. These will be fully functional elective hospital centres but there would be no overnight stays in their current form. As I say, there is no problem if we can come up with an additional project dovetailing with our project, subject to funding, Government agreement, etc.
There are a couple of eHealth Ireland initiatives with European funding, including the ePharmacy programme. What other technology or plans are in the pipeline related to Sláintecare? Has there been any change in plans or strategy as a result of learning from the Covid-19 pandemic? The conversation has sped along when it comes to telemedicine. Have the witnesses any further thoughts on that?
I will follow up Deputy Shortall's question around user fees as I know the witness was tight on time. She might want to elaborate on that. There has been quite a lively outcry online relating to consultant Sláintecare contracts, so what is the plan to deal with that? I have certainly been contacted by a number of people who have expressed concerns around them. What will happen in that area?
A question has arisen a couple of times when speaking about Sláintecare, which is supposed to be a public health service model for all, but there will still be private health insurance. How do the witnesses envisage these living together? I am struggling somewhat to see how we will have a Sláintecare model working to the effectiveness we want it to if there is a private health insurance sector also pushing and shoving in that space.
Ms Laura Magahy:
The first question concerned telemedicine and the eHealth Ireland programme. The Senator is correct that during the Covid-19 pandemic these have been fast-tracked and demonstrated to have worked extremely well. There will be no going back from that. The original plan holds firm as we need a shared care record and systems in place in hospitals and the community to contribute to the shared care record so that no matter where somebody goes, he or she can have a record. People should not be asked the same question over and over. That original plan still holds true and, as I said, some of it was fast-tracked as a result of Covid-19 requirements for remote consultations and not meeting people in public, etc.
We have details of our eHealth programme if the Senator is interested in following up. I apologise as we expected our eHealth person, Mr. Niall Sinnott, to join us but he is speaking about the vaccination certificate as we speak. We need to excuse him for not joining us. If any follow-up is required, I am very happy to take that.
The second question concerned the consultant contract. We have issued the contract to the representative bodies and we are really hoping for dialogue, as I indicated earlier. There is room for movement on the non-Government policy decision areas and for substantial discussion or engagement. We really hope people will see the benefit of that. We have had feedback from many consultants who are positively disposed to the contract that this will give more security and it is a comparative rate internationally. They have indicated there are good supports with the basic salary. We really need the support of the consultant body and would really welcome further engagement with It.
On the question of the separation of public and private services, there has never been an argument with Sláintecare that there should no private care. Deputy Shortall is more versed in this than I but the framework was that there should be clear separation of private and public so there is no conflict. That is the question behind the consultant contract and that there should be no real conflict between treating somebody in the public hospital in six weeks or treating the same person in a private hospital tomorrow. That is the real issue at stake. The goal of Sláintecare is to separate public and private and not to eliminate private care. It is about ensuring there is no conflict and that public patients can be prioritised in public hospitals.
I do not have a headset so I hope everybody can hear me. The presentation was really interesting and I, like others, would love to have had more time to listen and get a bit more detail. The witnesses are doing phenomenal work so I thank them for that. I am particularly interested in the treatment of alcohol harm. I worked closely with others on the Public Health (Alcohol) Act 2018 and alcohol has had major public health implications in Ireland. The harmful use of alcohol is a causal factor in more than 200 disease and injury conditions. These include diseases like liver cirrhosis, heart disease and cancers. Three people per day die from alcohol-related issues, amounting to 88 deaths per month or 1,000 per year. There are 900 people in Ireland diagnosed with alcohol-related cancers each year, which is quite shocking, and 500 people die from these diseases each year. One in eight breast cancers is alcohol-related. That may only be the tip of the iceberg. One in every two pedestrians killed on the road dies as a result of an incident involving drink-driving.
There is a major cost to health arising from alcohol. Alcohol-related discharges from hospitals cost the Exchequer €1.5 billion in 2012, which is quite shocking.
I have another question after my next one and it, too, will be on alcohol. From Sláintecare's point of view, what will be put in place? There is a lot of focus on obesity, which is fantastic. The question of eating disorders also needs to be examined. What can be put in place to deal with the major impact of alcohol harm on public health? I am concerned that alcohol harm done to family members of alcohol abusers is not often visible. It can have very serious consequences for the safety and well-being of family members. Children in particular are very vulnerable. Alcohol is a significant contributor to child neglect, for example. Parental drinking has been identified as a key child welfare issue. It contributes to many assaults, including sexual assaults, and rape, domestic violence and manslaughter. It can go on and on. One thousand five hundred beds are taken up every day because of alcohol-related harm. I did not hear anything about this. Does it fall under mental health services? Where does it fit in?
Ms Laura Magahy:
I thank the Senator. It crosses several areas. One of the biggest opportunities is within the healthy communities context. We are working at local level with community groups and across agencies. For example, we are working with Tusla and social welfare colleagues, especially in respect of children and vulnerable families. Within the healthy communities context, we have an opportunity because we will have co-ordinators at local level who will link with the relevant agencies to focus on prevention. It has to be done really carefully, however, working with communities and families and through agencies and local bodies. That is where the opportunity lies. We can certainly consider specific initiatives in that regard.
Mr. Greg Straton:
Ms Magahy said most of what needs to be said. The key is working with the alcohol and drugs task forces locally but also creating multi-agency responses. We are aware that alcohol contributes to adverse childhood experiences that can have a significant health impact across the life course. It is definitely about finding the preventive focus before alcohol becomes an issue in the family and home.
I am talking not so much about addiction as alcohol harm and the unhealthy relationship we have with alcohol. It is a matter of keeping that in mind. One thousand five hundred hospital beds are taken up every day because of alcohol harm, not addiction. That is a very high number. It is shocking.
The main aim of Sláintecare is to provide universal access to timely, quality integrated care for everyone in Ireland. The lack of investment in and funding for our Sharing the Vision policy has been heavily criticised. How do the delegates believe we should strategise for the increased need for timely and early interventional mental health services after Covid? We are aware of the mental health impact of Covid and the restrictions. We are heading for a tsunami in the future. What has been put in place in this regard?
Ms Laura Magahy:
I thank the Senator. Ms Pigott might refer to the oversight work. Investment is one aspect. I will not be popular for saying the siloed nature of funding in some of the mental health services is also contributing to some of the issues. We fund mental health services in primary care. We fund through prevention and secondary care. I am told by those in general practice that the path between general practice and where a patient is directed is not always clear. Therefore, we have some work to do on pathways of care for people with mental health issues, from the early talk therapies right through to psychological interventions in the community and psychiatry, etc. A body of work has to be done on the pathways so it will not simply be about investment, although investment is needed also.
Sharing the Vision is committed to. It is in the programme for Government. Ms Pigott, who is on my team, is on the oversight group. Does she want to add anything to that?
Ms Caroline Pigott:
Yes. The oversight group was set up at the end of 2020. Of the recommendations in Sharing the Vision, 83 are HSE-led. The HSE is drafting an implementation plan for the period 2021 to 2023 and wants to hold workshops in June. The focus of the implementation committee is on monitoring and making sure we see the impacts of the investment made in implementing the recommendations in Sharing the Vision. The other recommendations in Sharing the Vision are linked to either Healthy Ireland or other areas and voluntary sectors. They are all being progressed. That work is going well. We meet monthly to consider progress and to steer in respect of what else needs to be set up, including specialist subgroups, to progress various actions.
Does Ms Magahy believe that progress in community-based mental health services is needed? How does she see it all playing out? Community-based mental health services will be vital. What is Ms Magahy's view on this in light of the current crisis?
Ms Laura Magahy:
They are absolutely needed. Through the enhanced community care fund, allied funds and the community care networks, there is funding for community services. There has been a bit of a lack of focus on the earlier stages, such as the talk therapies, which we would like to see scaled up. We invested in the likes of Jigsaw and other talk therapies, especially for young people, LGBTQ people, etc. I would like to see them scaled up. We are determining how they might be mainstreamed through the next phase. They showed very good results. Young people absolutely appreciate and need an instant response rather than being told to wait for a week or whatever for a more in-depth service. These approaches have been shown to work. We have embarked on scaling them up right across the country.
The Rise Foundation, for which I do work, is an organisation that supports family members who have somebody they love with an alcohol, drug or gambling problem. It does not get any Government support whatsoever. It has six to eight therapists but it also has a waiting list. There is something not right about that picture at this time. This needs to be addressed. The organisation does phenomenal work. It is more of an intervention organisation. It stops the intergenerational trauma caused by addiction. I will leave it at that.
I, too, thank our guests for the update. I realise that there were IT issues but the update was comprehensive. We appreciate that.
I have two questions. The first is on the mid-west region, where I am from. As our guests will know, there has been an ongoing difficulty with the accident and emergency unit at University Hospital Limerick. A 60-bed modular unit was built there in the past 12 months or so. It has helped somewhat. A new 90-bed accident and emergency facility has been committed to for Limerick. Could we have an update on this project? When can the people of Clare, Limerick and the rest of the mid-west region expect the facility to be up and running to deal once and for all with waiting lists at the accident and emergency unit at Limerick hospital?
My second question is on waiting lists and prevention.
I would like to focus on the issue of sight loss in this regard. The statistics tell us that for 80% of people who lose their sight in this country, it can be prevented. For four out of every five people who go blind or suffer serious vision impairment in this country, it can be prevented with early intervention. Has Sláintecare done any work on ensuring that there is early diagnosis and early intervention? I refer to both education and early intervention because it is known that people do not get their sight checked often enough and sometimes, conditions like diabetic retinopathy and so on are diagnosed when it is too late and interventions will have only a limited, if any, effect.
Ms Laura Magahy:
No problem at all. I am pleased to say that the chronic disease management programme has been substantially funded. When we talk about the enhanced community care programme, two major parts of it are the integrated care programme for older people and the chronic disease programme, of which diabetes control and, therefore, the retinopathy programme is a key part. We referenced earlier 96 community healthcare networks. What is being put in place as a key part of that are 32 specialist hubs for the integrated care programme for older people and chronic disease management, specifically, between the hospital and the community, in order that they work between the different settings on those different pieces.
It is interesting. There has been a lot of proof through the integration funds projects about the necessity for early intervention and, as I say, putting that in place. The Senator referenced retinopathy. Another downstream effect of diabetes is, for example, investment in podiatry and the diabetic foot. There is a whole load of individual initiatives happening around diabetes control and chronic disease management that is funded and that one will see in place by the end of this year.
That is fine. In terms of waiting lists in general, obviously, we are getting information through our offices that there will be a chronic problem with waiting lists and that they are increasing dramatically because of the pandemic and the lack of movement for significant periods over the past 12 to 18 months. Has Sláintecare specific targeted measures to try to deal with the waiting lists? Is there anything happening through Sláintecare, based on the experience of the pandemic, to deal with waiting lists in general?
Ms Laura Magahy:
There is. Maybe the slides were not great at the beginning. We were saying that there is a waiting lists programme in place that is targeting hospital waiting lists, community and all kinds of waiting lists to make sure that they are driven down over the next four years. We have, literally in the past two months, done a call-out to every community healthcare organisation asking it to show us your waiting lists, asking what are the plans, whether permanent capacity is required, what is it and whether a temporary injection is needed to drive them down. I stated earlier that we would be bringing up a multi-annual waiting list programme to Government for consideration.
Finally, in terms of people who were diagnosed with various conditions, and I specifically refer to eye conditions and sight loss because my office receives a considerable amount of queries in that particular area, there has been a pilot programme involving the role of eye clinic liaison officer, ECLO, that is run in partnership with the National Council for the Blind of Ireland in the Dublin hospitals. They are looking to roll that out to hospitals around the country. Has Ms Magahy any information on where we are with that because I understand the HSE has committed to funding these ECLO officers, basically, officers who give advice to people on step-down supports and services after they have been diagnosed with sight loss?
I have two questions. To follow-on on the waiting lists, I am told that there are almost 900,000 people on the waiting lists at present. That is down to Covid, certainly. It has tested our healthcare system and pushed it to the brink. We have also seen embargoes on staff recruitment, pay issues, a specialist retention crisis and a lack of investment in physical capacity all contribute to a weakened health service. We need to invest in capacity, in beds, theatres, equipment and staffing levels and some of the things we have covered here today.
The stated objective of the Sláintecare implementation plan for the next two years is to have no outpatient waiting for more than ten weeks for a procedure. How likely is it that we will reach that target? While Ms Magahy stated earlier on that it is over four years, that target was two years.
It was mentioned by a number of the members today that under a Sláintecare recommendation, the Government set a target for overall mental health funding of 10% by 2025. That is four years away. Mental health receives less than 2% of Sláintecare funding and the budgetary allocation of €50 million for mental health care is only 1% of the overall health budget for 2021. Many would say that it is a failed opportunity to significantly increase the funding for mental health services. What practical evidence has Ms Magahy that the Government will come close to the 10% target? Is Ms Magahy aware of or has she seen any plans on how we would reach this 10%? We as a committee have set up a sub-committee on mental health because of the overall challenges that we face as a committee in that regard, not only from Covid but, as other members have said, from other challenges in society as well. Covid has put everything related to services under pressure with staffing being allocated to different areas etc. Is there a particular plan for that?
Lastly, Ms Magahy made the point about Mr. Niall Sinnott not being able to attend today as he is doing something on the vaccination certificate. One of challenges we have faced as a committee is a result of the malware situation. We were hoping to have the HSE in. We had been hoping to have the Department of Health in, possibly tomorrow. It will not happen. Is there a briefing available? If Ms Magahy could forward that on to us, it would be helpful.
As public representatives, but also as a committee, we are being asked constantly. People want to travel. As regards the travel certificate, what will be put in place? There is a complete lack of information available and anything that we could put through our own system would be helpful.
If Ms Magahy could answer those two questions, I would appreciate it.
Ms Laura Magahy:
We can certainly get the committee as much information as we have on the Covid certificate. I will ask Mr. Sinnott to forward that on, if that is okay.
On the 10% of the overall funding, what we would need to do is double-check that we are comparing the right percentages. At the back of the Sláintecare report, it shows what the additional funding for Sláintecare was but we did not include what is in the base for mental health. To make sure that we are comparing like with like, I would like to run the figures and come back to the committee on that to see what mental health spending is as an overall percentage of the total budget for health, as opposed to only the additional piece that was invested in. It is fair to say that there was a focus on community staffing in this year's budget because it had been so chronically underfunded. That is not to say that mental health should not get additional funding as well. Let me come back to the committee on the percentage issue, if that is okay.
On the waiting list numbers, there are approximately 600,000 waiting for an outpatient appointment and 90,000 people waiting for inpatient or day-case procedures, and scopes make up the balance.
There has been a deterioration in the waiting list numbers as a result of Covid-19 and the fact many of the operations were cancelled. Before Covid-19 hit, substantial inroads had been made in reducing the inpatient waiting list - significant progress had been made - by the tens of thousands. Obviously, that was paused due to Covid-19. The Chair is right in that many of the staff were diverted, especially from regular community interventions, so those have been exacerbated as well.
Going back to the beginning of the meeting, that is why we have put such an emphasis on the access and multi-annual waiting list programme, which is about increasing supply of staff and facilities and reducing demand by putting a focus on prevention and trying to get people the care at an earlier time, rather than it hitting the crisis point. It is an ambitious plan which is just reaching finalisation.
The final point is the waiting lists, bad and all as they were as a result of Covid-19, have again been exacerbated by the cyberattack, because many of the outpatient appointments were cancelled. It has compounded the issue and is even more reason to put a focus on it, which we have done and are doing. When we come to Government looking for multi-annual support, we would greatly appreciate the committee's support on that.
The last point Ms Magahy made in her presentation was on age-friendly homes. The question we all ask is whether they are being built. There was little talk on the role of local authorities. It is the basic things that people in hospitals need, such as a ramp, a door widened, a shower, a possible extension and so on. This is where the joined-up thinking comes in, so people do not have to wait three months for a ramp and even longer for a shower or an extension. One could be waiting years for a lift to get someone up and down the stairs.
We have been dealing with elected representatives and in many cases, people are only getting these when they are at end of life. They are not getting the opportunity. We need champions on that. That is all part of Ms Magahy's work, but I do not believe we are building these age-friendly homes and what has been thrown up throughout this city and many parts of Ireland is not age-friendly and we are not building for the future, we are building for speculators and others, certainly not long-term investment in our population.
Ms Laura Magahy:
I would like to reassure the Chair on the local authority involvement part. He is absolutely right in that it is a key part of every part of Sláintecare. We have funded the age-friendly piece, in particular, through the local authorities. Its position is sponsored by Meath County Council. We have put in place 11 - Mr. Straton can correct me - age-friendly housing co-ordinators. Their job is to go out to see if the existing houses fit for purpose, for older people in particular and to put in place the infrastructure needed, in advance of somebody falling, ending up in hospital and waiting to come home and if he or she cannot come home, having to go into a nursing home.
This is exactly why we have put this in place. It will have a proper impact on ordinary people's lives. We had a report this morning from the man who is managing the programme to say it had already received 600 references from within the local authorities, for people who want the services. The services can be retrofit from the perspective of energy or the suitability of the house, or a link to the integrated care programme for older people to give people clinical services, if they are needed.
The local authorities are a key part of what we are doing and the work Mr. Straton, my colleague, is about in the Healthy Ireland team. We have Healthy Ireland co-ordinators in every local authority and the healthy communities will be housed by representatives through the local authorities structure, because we can see health is only a tiny part of the impact of how well somebody is. It is the wider determinants, such as housing, education and all of that stuff we talked about, which has an even bigger impact on how well somebody can live in their own community, so we are linked-in with the local authority structure. I would like to assure the Chair on that.
I appreciate the witnesses' contributions today. It was useful and has certainly helped the work of the committee. That concludes our business for today. The meeting now stands adjourned, until we meet again in public session next Wednesday, 16 June, at 9.30 a.am.