James Reilly (Dublin North, Fine Gael) | Oireachtas source

Gabhaim buíochas leis na Teachtaí as ucht a gcuid ranníocaíochtaí sa díospóireacht seo. I thank the Deputies for their contributions to the debate. Mar is eol do Theachtaí, tá an Bille mar chuid de chomhthéacs níos leithne. Tá an Rialtas ag tabhairt faoi chlár athchóirithe mór ar an gcóras sláinte, agus é mar aidhm aige córas sláinte sraith amháin a chur ar fáil le tacaíocht ón árachas sláinte uilíoch, áit a bhfuil rochtain bunaithe ar riachtanas seachas ioncam. Creidim go bhfuil an Bille seo ina chéim ar an mbóthar athchóirithe sin. Tá dhá chuspóir aige. As Deputies are aware, this Bill is part of a wider context. The Government is embarking on a major reform programme for the health service, the aim of which is to deliver a single-tier health system supported by universal health insurance in respect of which access is based on need, not income.

The Bill is a step on the health reform road and its purpose is twofold. Ar an gcéad dul síos, forálann sé do dheireadh struchtúr bhoird an HSE agus le haghaidh stiurthóireacht a bheith ar an gcomhlacht nua rialaithe don HSE in ionad ag an mbord, faoi cheannas ard-stiurthóir. Ar an dara dul síos, forálann sé do socruithe freagrachta breise don HSE. Baineann siad seo le athchóiriu a dhéanamh chun deireadh a chur leis an gcóras dhá shraith, chun é a dhéanamh othar-Iárnach. Beidh mar thoradh ar seo ná coinníollacha d'othair a bheith mar thosaíocht i ngach a dhéanfaimid. First, it provides for the abolition of the board structure of the HSE and for a directorate to be the new governing body for the HSE in place of the board, headed by a director general. Second, it provides for further accountability arrangements for the HSE. It is about reform to end the two-tier system to make it patient centred, and it will keep outcomes for patients as its priority in all it does.

Tá dul chun cinn suntasach feicthe againn cheana féin. Bunaíodh an t-aonad seachadadh speisialta i mí lúil 2011. Ag an am sin, bhí 2,732 othar ag fanacht níos mó ná bliain agus 6,277 othar ag fanacht níos mó ná naoi mhí ar chóireáil cónaitheach nó ar chóireáil lae. We have already seen significant progress. The special delivery unit was formed in July 2011. At that time, 2,732 patients were waiting more than a year and 6,277 patients were waiting more than nine months for inpatient or day case treatment. Faoi Nollaig 2011, bhí titim tagtha ar líon na ndaoine fásta ag fanacht níos mó ná naoi mhí le haghaidh cóireáil cónaitheach nó cóireáil lae go dtí 3,706. Faoi dheireadh mí na Nollag 2012, bhí an líon sin tite go dtí 86. Léiríonn sé sin laghdú de 98%. By December 2011, the number of adults waiting more than nine months for inpatient or day case treatment had fallen to 3,706, and by the end of December 2012 the number was just 86. This represents a decrease of 98%.

I gcás páistí, is é an sprioc gur cóir nach mbeadh aon pháiste ag fanacht níos mó na 20 seachtain mar othar cónaitheach nó ar obráid máinliachta mar othar lae. Faoi mhí na Nollag 2012, bhí an líon ag fanacht nios faide ná 20 seachtain síos go dti 89, le titim de 95% ar an 1,759 páiste a bhí ag feitheamh níos faide ná an sprioc i mí na Nollag 2011. For children, the target is that no child should be waiting for more than 20 weeks for inpatient or day case surgery. By December 2012, the number waiting longer than 20 weeks was down to 89, representing a decrease of 95% on the 1,759 children waiting longer than the target in December 2011.

In the area of emergency departments, despite the winter pressures, including increases in the incidence of influenza and respiratory illnesses, the year-on-year improvements continue nationally. The number recorded on trolleys at the end of 2012 showed a marked improvement, namely, 23.6% fewer than in 2011, which equates to 20,342 fewer people lying on trolleys. Progress continues to be maintained in 2013. On Friday, 1 March 2013, the number on trolleys for the year to that date totalled 12,283, representing a reduction of 2,116 patients, or 14.7%, on the improvements already made in 2012. We have much more to do and we will continue to make progress.

Let me turn again to the Bill. The Bill is about a new governance structure for the HSE and increasing the HSE's accountability to the Minister for Health and, ultimately, the Oireachtas and the people. Contrary to what has been suggested during the debate on the Bill, it is not about the Minister for Health taking over the HSE's functions, nor does it give sweeping powers to the Minister. The HSE has responsibility for managing and delivering health services, and that does not change under this Bill. The Government has responsibility for policy. Any State agency must have regard to the policies and objectives of the Government to the extent that those policies and objectives may affect or relate to its functions. A State agency must be accountable to the Minister concerned and, therefore, must explain its actions and decisions.

The Health Act 2004 and this Bill provide for this accountability.

The board of the HSE is the current governing body for the HSE. The abolition of the board structure and the increased accountability measures are intended to help prepare the service delivery and funding systems for the next phase of the reform programme. As the HSE board structure is to be abolished, it is necessary to replace the board with an alternative governing entity. The proposal in the Bill is to have a directorate as the governing body, comprising the director general and senior employees. The directorate will have collective responsibility as the governing authority for the HSE.

Issues were raised in the debate about the detailed governance mechanisms and inter­relationships for the directorate members under the Bill. In practice, the directorate model will involve a combination of a senior management team working together on major corporate issues but with the usual operational line of reporting for the specific service functions.

Deputies asked why members of the directorate must be appointed from HSE employees. The establishment of the directorate is about more direct accountability, whereby the governing body of the HSE is drawn from people in senior positions within the organisation itself. I should clarify that this means that appointed directors are not limited to current employees but may be drawn from HSE employees irrespective of when the employee was appointed.

There will be new administrative structures in the HSE which, while in support of the Bill, are separate from it. The HSE has begun the process of putting in place the new administrative management team. The recruitment process for five new national directors has now commenced through a competitive process to be run by the Public Appointments Service. One of the new posts is director of mental health. Deputies asked if there could be specific reference in the Bill to a director of mental health with specific functions. While I am very glad to say that the director of mental heath post is one of the posts included in the competitive recruitment process I mentioned, I do not believe that the legislation should specify the functions of particular grades within the HSE.

The appointment provision for the first director general was raised. There are legislative precedents providing that the first person appointed to a new office be appointed as envisaged under the Bill, and this is the most practical way to advance the new governance arrangements.

The Bill is a transitional measure and is part of a much larger plan. I said at the beginning that the Government is committed to fundamental reform of the health care system with the objective of delivering a single-tier health system, supported by universal health insurance, where access is based on need, not income.

Deputies have asked me to state clearly my plans for the changes that are coming for the health system. In November 2012, I and the Ministers of State, Deputies Kathleen Lynch and Alex White, published Future Health: A Strategic Framework for Reform of the Health Service 2012-2015. This document sets out the major health care reforms that will be introduced in the coming years as key building blocks towards the introduction of universal health insurance, UHI. I intend that further detailed actions will be built on the foundations of the document as the reform process proceeds.

I have identified an overall governance structure for the programme of reform. The new structure includes a strong programme management office in the Department of Health to drive and oversee implementation of the health service reform programme in line with the public service agenda, and a systems reform unit in the HSE. The Government recognises that effective consultation and collaboration with stakeholders will be crucial for the successful implementation of the reform programme. In the two weeks following the launch of the framework, I met some 1,500 local clinical and administrative staff and management, as well as regional health forums at 14 different events across the four HSE regions. Consultation will continue throughout the reform process. The progress to date underlines this Government's commitment to health service reform and the implementation of universal health insurance. We are confident that with the involvement and support of all the main stakeholders in the health system, we can deliver on our objectives in the best interest of patients.

Deputies asked about universal health insurance. Preparation is key to UHI and the new governance arrangements for the HSE under the Bill are intended to play a part in preparing the system. Under UHI, every individual will have equal access to a standard package of primary and acute hospital services, including acute mental health services. A new insurance fund will subsidise or pay insurance premiums for those who qualify for a subsidy.

There are a number of important stepping stones that are necessary to pave the way for the introduction of UHI. Work is under way to advance these initiatives which will bring benefits and drive efficiencies in advance of implementing universal health insurance. They include the strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients, the work of the special delivery unit in tackling waiting times and establishing hospital groups, and the introduction of a more transparent and efficient money-follows-the-patient funding mechanism for hospitals.

In February 2012, I established an implementation group on universal health insurance to assist in developing detailed and costed implementation proposals for universal health insurance and in driving the implementation of various elements of the reform programme. We must learn from other countries and build on best international experience. This is reflected in the membership of the UHI implementation group. The UHI implementation group comprises a mix of those with executive responsibilities within our health services and external expertise, including international experts working with the World Health Organization and the European Observatory on Health Systems and Policies.

In addition, my officials have been examining the experience of health reforms in a range of countries, including the Netherlands and Germany. This analysis is vital to enhancing our knowledge and informing policy. A prerequisite for designing the UHI model for Ireland, however, is that it meets the needs of individuals in Ireland and that it achieves the best outcomes for patients. This requires that we have regard to our starting point, that we carefully plan and sequence the reform programme and that we give detailed consideration to the most appropriate structures for delivery of different services. Ultimately, the Government is committed to introducing an Irish model of universal health insurance that best fits the Irish system.

The Department is advancing work on drafting the White Paper on universal health insurance which will outline details of the UHI model in addition to the estimated costs and financing mechanisms associated with the introduction of universal health insurance. Preparation of the White Paper is a complex and technical process requiring significant research and financial modelling to support analysis and costing of different design options. My Department is engaged in a process to ensure availability of the necessary expertise to support work on preparing the White Paper in 2013.

In the meantime and in advance of the White Paper, my Department published a preliminary paper on UHI. That paper provides a succinct update on work on universal health insurance as well as providing further details on the path ahead. The reform programme is a major undertaking that requires careful planning and sequencing over a number of years. The implementation group will assist, advise on and oversee different elements of the reforms as they are being put in place. It is also my intention to consult widely as part of the reform implementation process.

Several Deputies referred to medical cards and, in particular, individuals with very serious health conditions. More than 1.8 million medical cards have been issued to individuals, the highest percentage of the population covered in the history of the State. Medical cards are provided to persons who, under the provisions of the Health Act 1970 are, in the opinion of the HSE, unable, without undue hardship, to arrange GP services for themselves and their dependants. Under the legislation, determination of eligibility for a medical card is the responsibility of the Health Service Executive. The assessment for a medical card is determined primarily by reference to the means, including the income and expenditure of the applicant and his or her partner and dependants.

Under the legislation, there is no automatic entitlement to a medical card for persons with a specific illness such as cancer. There is, however, a provision for discretion by the HSE to grant a card in cases of undue hardship where the income guidelines are exceeded. The HSE set up a clinical panel to assist in the processing of applications for discretionary medical cards where there are difficult personal circumstances.

Most importantly, the HSE has an effective system in place in relation to the provision of emergency medical cards for patients who are terminally ill, or who are seriously ill and in urgent need of medical care that they cannot afford. Emergency medical cards are issued within 24 hours of receipt of the required patient details and the letter of confirmation of the condition from a doctor or a medical consultant. This can be initiated through the local health office by the office manager who has access to a dedicated fax and e-mail contact within the primary care reimbursement service.

While it can take a day to produce the plastic card physically and a further day to allow for its arrival in the post, the medical card number can be provided to the local office or social worker within 24 hours, if requested. Once approved, any primary care contractor can validate the entitlement of a client through the online system.

With the exception of terminally ill patients, the HSE issues all emergency cards on the basis that the patient is eligible for a medical card on the basis of means or undue hardship, and that the applicant will follow up with a full application within a number of weeks of receiving the emergency card. As a result, emergency medical cards are issued to a named individual, with a limited eligibility period of six months.

The arrangement is slightly different for persons with a terminal illness. No means test applies to an application by a terminally ill patient. Once the terminal illness is verified, the patient is given an emergency medical card for six months. Given the nature and urgency of the issue, the HSE has appropriate escalation routes to ensure that the person gets the card as quickly as possible.

Some Members mentioned the backlog of medical card applications. The major backlog of last year has been cleared. Furthermore, in the case of discretionary medical cards, there was the backlog towards the end of last year and that has been reduced, from 3,500 to only nine cases today. Contrary to some of the contributions and common belief, the centralisation of medical cards has resulted in an €8 million saving to date. The PCRS can be commended on the work it has done to address the issue of backlogs and in bringing in a more efficient system.

The issue of free GP care was also raised. The Bill to allow for the extension of free GP care to persons with prescribed illnesses will be published in the next couple of weeks. Progress also continues to be made in building primary care capacity and in chronic disease management, particularly for the management of diabetes which will commence in the coming months.

Some Members asked what I was doing to address the costs of health insurance. I can assure the House that the Government is committed to keeping down the cost of health insurance so that it is affordable for as many people as possible. We remain committed to protecting community rating, whereby everyone pays the same price for the same health insurance product, irrespective of age or health status.

The programme for Government contains a commitment to put a permanent scheme of risk equalisation in place, which is a key requirement for the existing private health insurance market and is designed to keep health insurance affordable for older persons and to maintain the stability of the market. The Health Insurance (Amendment) Act 2012 gave effect to a new risk equalisation scheme with effect from 1 January 2013. This will contribute to the protection of affordability for those who need it most. It is important to note that the measures contained in the new risk equalisation scheme are designed to result in no overall increase of premiums paid in the market. Rather it is intended to spread the risk more evenly between the healthy and the less healthy, as well as the old and the young.

I have repeatedly raised the issue of costs with health insurers as a whole and I am determined to address costs in the sector in the interests of consumers. Last year, I established the health insurance consultative forum which comprises representatives from the country's main health insurance companies, the Health Insurance Authority and the Department of Health. The forum was established to generate ideas which would help address health insurance costs, while always respecting the requirements of competition law. Given the VHI's significant share of overall costs in the market at 80%, I will continue to focus strongly on the need for the VHI to address its costs and to address aggressively the base cost of procedures, including professional fees. I will also continue to focus on the need for more robust auditing and the need for clinical auditing to be introduced, which would be for the first time. In other words, the treatments that some clinicians are delivering would be challenged as to their necessity.

The issue of delays in replies to parliamentary questions was commented on by many Members and I am happy to provide some detailed information. My Department received over 7,500 parliamentary questions in 2012. Some 4,045 of these concerned operational issues and were referred to the HSE for direct reply to the Members. In its service plan, the executive has a commitment to answer within 15 working days 75% of parliamentary questions referred to it. Of the 4,045 referred to it for direct reply, 74% were answered within 15 working days and 83% within 20 working days. This represented a significant improvement on 2011 when the percentage answered within 15 days was 56%. Of the total amount of parliamentary questions referred to it in 2012, only 64 remained open at the year end. We want to improve further on this by examining IT solutions that would help Deputies and Senators to track the progress of parliamentary questions.

Procurement issues were also raised in the debate. The HSE is fully committed to the Government's procurement objectives and initiatives and will continue to support the Government programme to reform public sector procurement. Adherence to the Government's public service reform objectives regarding the use of shared services will be a requirement for the newly created structures, in procurement and other matters. The director general designate of the HSE has acknowledged that the new governance and management arrangements for the future health service will require us to change radically the way we approach the provision of shared or common services to meet the needs of all parts of the health system. In addition, the financial challenges we face mean we must take advantage of any opportunity for increased value in the way we provide such services.

As this day marks two years in Government, I have mentioned some of the progress that has been made but I might just mention some other areas. On outpatients, there are clear and comprehensive data now being reported for the first time which will allow the special delivery unity and the National Treatment Purchase Fund to target resources at the longest waiting lists. There are new cystic fibrosis services in the Nutley wing of St Vincent's Hospital which opened in the summer of 2012 at a cost of almost €30 million. There is the decision to co-locate the new national children's hospital at St James's, made in November 2012. Thirty-five locations for primary care centres have been identified, of which 20 will be commissioned subject to the agreement between the local GPs and the HSE on active local GP involvement and subject to site suitability and availability.

In October 2012, a new drug pricing agreement was reached with the Irish Pharmaceutical Healthcare Association, IPHA, which will deliver savings in excess of €400 million over a three year period. Approximately half its value - €210 million - will be used to cover the cost of new drugs from 2013 to 2015. The balance will go towards reducing expenditure on drugs supplied through the General Medical Services scheme and community drugs schemes. The Department and the HSE have also reached an agreement with the Association of Pharmaceutical Manufacturers in Ireland, APMI, which will deliver further savings in the cost of generic drugs. Total gross savings, between the IPHA and APMI agreements, for 2013 will be in the region of €120 million. There is also a drug reference pricing Bill, which is going to committee this week or early next week, that will allow us, after consultation, to set the price for generic drugs. We have a new medicine management initiative, as outlined by Deputy Barry.

The HSE's health care capital allocation for the period 2012 to 2016 is €1.87 billion, of which €1.67 billion is allocated for construction of health care facilities and the remaining €200 million is allocated to ICT infrastructure. In addition, the Government announced in November 2011, that up to €200 million from the proceeds of the sale of the national lottery would be allocated for the construction of the new national children's hospital. We have also appointed the chair to the new national children's hospital group.

We will be opening new facilities. There will be a new wing at Ennis hospital. The new emergency department at Letterkenny is finished and will be opened officially later this year. The outpatient and emergency department at the Mater hospital are completed and we are making progress with the new central mental hospital.

Value for Money and Policy Review of Disability Services in Ireland was published on 20 July 2012, the National Housing Strategy for People with Disability 2011-2016 was approved by Government in October 2011, and the implementation framework was jointly published with the Department of the Environment, Community and Local Affairs in July 2012.

The children, adolescents and young people with complex disabilities unit, led by a principal officer, has been established in the Department of Health. On 1 January of this year a permanent scheme of risk equalisation put in place in the private health insurance market.

In December the Government approved the implementation of the judgment of the European Court of Human Rights in the A, B and C v. Ireland case by way of legislation with regulations, within the parameters of Article 43.3.3° of the Constitution as interpreted by the Supreme Court in the X case and progress has been made towards producing the heads of a Bill.

There many other areas relating to older people, health and well-being, and health protection. Deputies asked about the €35 million earmarked for mental health and the increase in the number of beds for child and adolescent psychiatry. There were also issues around the drugs task forces, HR and health reform as I have outlined. So there has been considerable improvement.

I also wish to mention the long-running problem with Tallaght Hospital board has been resolved. Hospital groups have been set up in Galway and Limerick, with a phenomenal effect in Galway in particular. Clinical programmes are moving ahead - we have developed them in emergency medicine, acute medicine, fragile older patients, stroke care and heart failure. For the first time anywhere in the world that we are aware of, we have introduced a new early-warning scorecard so that doctors and nurses in Tralee will react in the same way as they would in Letterkenny, the Mater Hospital or St. James's Hospital in the face of a patient who may be deteriorating. The screening for bowel cancer has commenced.

The reforms will continue unabated. I will not be deflected from the course we have set. I remain determined, as does the Government, to see this through. I am as committed to it as ever. I am more certain and convinced than ever that we will succeed because of the new leadership emerging in the HSE, the Department of Health and indeed the VHI, but most importantly among the clinicians, medical nursing and allied professionals - the men and women on the front line who have already delivered so much for us in terms of the improvements I set out earlier.

Molaim an Bille don Teach.

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