Seanad debates

Wednesday, 28 May 2008

6:00 pm

Photo of Mary HarneyMary Harney (Dublin Mid West, Progressive Democrats)

Irish doctors are the best paid in the world by a long margin, as are all health care professionals. As I stated previously, pharmacists are paid, on average, €100,000 more here than in Northern Ireland, yet we cannot get support for the reforms we are introducing. Under the new regime, we will ensure that as a result of the high public salaries, there is greater concentration on access based on medical need rather than private insurance or financial means.

In the public hospitals, nearly half of the patients of some clinicians, some of whom are not great fans of mine, are private fee-paying patients. I used to be a great fan of universal insurance but the reality of universal insurance in Ireland would be that we would simply be paying consultants a couple of hundred more million euro to see the patients they are supposed to see to justify their public salaries.

I have just come from a meeting of the Cabinet sub-committee on health involving the HSE, the Minister for Finance and the Taoiseach on aspects of the transformation agenda. Among the changes are the measurement of performance, including the number of patients being seen at outpatients departments. There are many measurement requirements in the public health system. One thing is certain, if one does not measure, one cannot succeed in managing. The reality is that there is a great disparity between the number of patients seen in each outpatients unit of the same specialty.

In the other House recently I referred to Dr. Tubridy, a neurologist in St. Vincent's Hospital in Dublin. As a result of changing the way the neurology department operates, he was able to double, in the course of 18 months, the number of patients being seen in a calendar year. The doctors were able to devote twice the time to each patient on foot of the appointment of administrative support staff. No further resources were required.

In the physiotherapy department in St. James's Hospital, 18% of patients did not turn up for outpatient appointments. This clearly implies the slots are not available to other patients. However, as a result of patients being able to make their own appointments in St. James's Hospital at times that suit them, and as a result of texting and other simple measures, the hospital has enjoyed a 50% reduction in the number of patients not showing up for appointments. The hospital intends to decrease the figure to a negligible level of 1% or 2%. I salute these kinds of initiatives.

The change under way involves measuring performance. As I stated, 18% of patients do not show up for outpatient appointments. We know that for every one new patient seen, there are almost three repeats. There should not be repeats in that with a few exceptions, they should be seen at general practitioner level. Very often the patients do not see the consultant but might see the consultant's registrar.

Measuring what is happening is essential to changing performance. I accept that some do not like this. Some doctors have said to me they are independent, which is true for clinical matters, but this does not mean that we cannot measure what is happening in the public health system with a view to improving performance. This is happening across the system and will happen also at the community and continuing care levels.

Central to the reforms is ensuring that those who are accountable for spending the money and delivering the service are accountable to the Oireachtas. We should not confuse accountability for the Vote or the finance with the responsibility of the Minister. Nobody would suggest that the Minister for Justice, Equality and Law Reform is not responsible for law and order and matters concerning crime and justice, yet it must be borne in mind that the Garda Commissioner is the Accounting Officer. Similarly, Professor Drumm is the Accounting Officer in the health system. He gets the money voted for the public health service by the Oireachtas and attends meetings of the Committee of Public Accounts, as he will do tomorrow, to account for how it is spent. That, in my view and that of anyone who has considered management systems and the need to ensure responsibility for service delivery, is very important. It was not good enough under the old regime when the Secretary General of the Department of Health in Hawkins House was the Accounting Officer for every single health board in respect of how they spent their money. Clearly, this does not make sense.

The Secretary General is not involved with every HSE area or hospital. He is not involved operationally in the delivery of services on a day-to-day basis. To expect him to be accounting for the spending of every single penny does not represent good management, nor does it lead to a very close link between the money and the performance in respect of its allocation.

Since the HSE was established, it received an increase of €5 billion, which is more than the amount spent running the entire health service in 1996. That puts what I am saying in context. Health care is expensive. Those who work in the health service are generally well paid, as they should be, and are highly skilled professionals. Given that we pay them good salaries, we are entitled to ensure the best possible outcome. It is a question of outcomes and nothing else. It is not a matter of driving budgets, although everybody must live within his budget, as used to be the case under the health boards. It is a question of ensuring the allocated budget is spent as wisely as possible in delivering enhanced quality-assured care to patients and service users.

I do not believe that making hospitals responsible at a local level to local communities will work. However, I am a major fan of patient advocacy and every group appointed by me has included people solely with a patient advocacy role. For example, last week I was pleased to meet the new Medical Council, which now has a lay majority. While it will not take effect until next month, its members held a three-day induction course in a County Wicklow hotel from Thursday to Saturday of last week and I was pleased to meet them. Ms Margaret Murphy was one of those whom I appointed. I met her through a patient safety conference in the United Kingdom organised by its chief medical officer. She had come to his attention because she had been obliged to litigate to establish the reason her son had died in a hospital in Ireland as a result of an adverse incident and no one would give her an answer. That era is over and patients are not obliged to litigate to find out what happened. Inquiries will take place, lessons will be learned from them and there will be a change in respect of how patients are handled.

Only three weeks ago, Professor Drumm and I launched a new patient involvement strategy, which must be devolved to the lowest possible level at hospital, community and nursing home level. For example, many nursing homes now have user councils whereby those who live in such nursing homes can put forward their views on how they operate. It could pertain to simple matters such as the presence of a coffee bar. I learned of a case recently in which the residents observed they had nowhere to meet someone to have a cup of coffee. While these are simple matters, they make a great impact on the quality of service that can be supplied.

I wish to deal with the rate and pace of the establishment of the HSE, which has been mentioned. Prior to the passage of the legislation in 2004, an interim board was established in 2003. However, the interim board had no statutory backing and it was impossible for it to do certain things. It was necessary to create a body that had legislative backing to take forward the agenda. At that time, it was not possible to decide what staffing levels should be. It was much more effective to launch the organisation, put in place a new chief executive office and management structure and then allow the new management structure to decide what staff ratios were required. Recently, a consultancy called Empower has carried out a review of clerical and administrative staff within the HSE. Believe it or not, the HSE is on a par with the Scots, the Welsh, the British, the French and so on in respect of the numbers of administrative and clerical staff in the organisation. However, huge discrepancies exist between one region and another arising from the old health boards.

It is important to perform such exercises and to have the experience of trying to manage before deciding on redeployment and voluntary redundancies. The State has operated very few voluntary redundancy programmes. However, many people observed, of the last such programme, that the wrong people left, some of whom then returned as consultants to the system. I do not want that to happen. If a voluntary redundancy programme is to be carried out in which it is known exactly who is needed and where, it must be based on ensuring the required skill sets are retained in the organisation and that those who have a skill set that may not be required in a particular area are encouraged to move on by way of voluntary redundancy. While I believe this to be possible, it must be done carefully and properly.

Moreover, McKinsey & Company has performed a review with Professor Drumm and the board of the HSE's management structure regarding positions and accountability and whether to keep two pillars, that is, a primary care or continuing care pillar and, for example, a hospitals pillar. The failure to integrate is an issue at local level in particular and these issues must be examined in the context of an organisation that at least knows what it is about. One cannot do such things with an interim board with no statutory backing. This is a mission that has never been embarked on in Ireland previously, in either the public or private sectors. This is something that has been attempted only in very few public systems around the world. No one has ever sought to perform this kind of change on the scale being attempted in Ireland through the HSE with more than 100,000 people, many of whom work in voluntary organisations that are funded, but not owned, by the HSE. Virtually no acute hospital in this city is owned by the HSE, contrary to the popular view. Such hospitals are funded by the HSE but are in the voluntary sector and are owned by others. Ireland has a strange structure and we must ensure, as we move forward in respect of the organisation of our public health system, that we do so in a way that makes sense.

Senator Fitzgerald mentioned the issue regarding Clostridium difficile. Until May of this year, it was not measured and was not notifiable. Consequently, making it notifiable naturally gives rise to headlines outlining the number of outbreaks that have occurred. There were no outbreaks previously because no one was responsible for notifying them to anyone else. Sometimes, positive developments, such as requiring a hospital to notify, are seen in a negative context. Hospitals now are required, because of enterprise liability, to inform the State Claims Agency of all adverse events that take place. This has been perceived by some media commentators as a highly negative development, with reports of so many adverse incidents in this hospital or the other. Worldwide, 10% of hospital experiences are adverse but thankfully, only 1% are fatal while the other 9% are non-fatal. This statistic obtains in Canada, New Zealand, the United States and in many European countries. Unless such events are reported, we certainly will not learn from the experience and will not improve matters from a patient safety perspective.

As for our population and home-care packages, I accept we have a long way to go to put in place the requisite home supports for older people. However, we started from a base of virtually zero a couple of years ago and now have 11,000 older people being clinically supported at home with the various therapies that facilitate them remaining at home rather than going into residential care. Moreover, Ireland has an extremely young population. It has the second youngest population of the approximately 40 countries in the OECD. Ireland has the youngest population of the 27 member states in the EU with 11.1% being over the age of 65. The equivalent percentage in Italy and Germany, for example, is 20% and I understand it is approximately 16% in France and the United Kingdom. Ireland has an extremely young population but often does not get the benefits of that young population. Our health spending at 9% of national income is the average across the OECD.

My point is that health reform is in its infancy. I personally believe strongly that a corner has been turned. I see this every day. The health awards took place a few weeks ago and I could not believe the kind of examples of innovation that were happening, in many cases without any new resources, simply by people thinking outside the box and being encouraged to view matters differently. In particular, measurement drives performance. Senator Quinn, who is present, is a businessman and I am certain he used to measure how his staff performed. I always saw him on the shop floor any time I went into the Superquinn in Lucan or into any other Superquinn branch. It seemed to be that he was present in all the Superquinn branches at once.

Managers who measure can manage and those who do not, cannot. Members are aware that some people who give the impression of working hard sometimes do not produce many results. A new era of measuring has arrived. It will involve, as noted previously, measuring outpatients and what happens in the community sector. As for contracts of employment, negotiations have yet to take place with the general practitioners and others. The remuneration of those who give a better service, work longer hours and so on, as many do in rural areas, should support and incentivise this. Sometimes in the past those who shouted loudest and complained most got the resources.

Individual cases, which always are very sad, in which services do not match expectations always will arise. There always will be the potential to improve and the health service is no different in that regard. Perhaps it never will be different as no health system is. There will be constant issues because democracy means that citizens are concerned about their health and naturally they will make their public representatives aware of when things do not happen. Equally, there are huge numbers of positive developments. Senator Prendergast mentioned moving the breast services from Clonmel to Waterford. That has happened and, as she is aware, I visited South Tipperary General Hospital only two weeks ago, where I visited the oncology ward and spoke to a number of women who had undergone breast surgery in Waterford. They were extremely satisfied with the service they received and were particularly pleased to be able to have their oncology treatment in South Tipperary General Hospital. This also will be the case in counties Sligo and Mayo and everywhere else.

Ireland is one of the best performers in the world in respect of the treatment of children's cancer. The service is centralised in Crumlin and chemotherapy is delivered in 16 hospitals through a protocol throughout the country. It is known that Ireland performs extremely well with children's cancer. It does not do well with other cancers because of the fragmentation of the service. We must learn from this and must be sufficiently courageous to inform ourselves, examine the best international practice, consider all the evidence available to us and then implement it because sometimes we have fallen down on implementation. When doing so, we do a great disservice to patients and to ourselves and that era is over. Members of the public are up for the kind of change that is under way and are patient enough to wait for it, notwithstanding the fact that it causes heartbreak and difficulties when services cannot be provided as quickly as we would wish. Improvements in accident and emergency services are a fine example of this as they are 70% better than in 2003. Comparing this month to the same month in 2003 shows a huge improvement in waiting times and we must do better. At present an average waiting time of 12 hours is the target and we aim to half that later this year. The target time, from when one presents to when one is admitted or discharged, will, hopefully, be no more than six hours. If we can adapt these targets on an incremental basis we will have a public health service of which people can genuinely be proud. Hopefully countries will look to our public health services in the way they have looked to our economic performance in recent years.

I am pleased to be in the House to deal with this motion. I compliment the Labour Party on putting forward proposals and some of them are already happening. There must be clear lines of accountability and responsibility. It would be nice to press a green button in order that they could happen instantly but that is not possible. However, they are going on as we speak and the internal restructuring of the organisation is happening at great pace. A new human resources director in the HSE starts on 9 June and we have seen the huge effect of the estates manager, Mr. Brian Gilroy, on leveraging the values of properties to invest in the capital programme. I believe that as the summer passes and the organisational structure is put right due to the HSE's internal analysis, some of the issues referred to in the Labour Party's motion will be addressed.

Comments

No comments

Log in or join to post a public comment.