Mary Harney (Dublin Mid West, Independent)

It is a great pleasure to be here to discuss the health services. I propose to make some opening comments to set the context of what we are doing with our health services and then, by way of reply, to deal with the issues raised by Senators. One measurement used in any country to establish the quality of health services is life expectancy. When we joined the EU, life expectancy in Ireland was two years below the EU average. Today, it is one year higher. We have added four years to life expectancy during the past 12 years. A child born in Ireland today will live longer than a child born in the UK, Denmark, Germany and many other countries, something of which we must be proud.

Patient safety and quality guides me in the reform of the health services. We live in an era in which standards, monitoring and enforcement are at the heart of everything we do in health care. This dictates how and where things happen. If we are to be concerned with good outcomes for patients, we must be up to the consequences of patient safety and evidence based medicine.

At the heart of the cancer control plan was the fact that all the evidence from Ireland and outside suggested that when breast cancer patients were treated in a centre dealing with 150 new cases per year, their outcomes improved by between 20% and 25%. What does this mean? It means one in four or five women who would have died will survive breast cancer. I am pleased to say we have transitioned our breast cancer services from 32 hospitals some three years ago to eight centres now along with the satellite centre in Donegal. I am pleased to acknowledge the recent data published by the cancer registry showing that between 1996 and 2006 the survival rates for breast cancer in Ireland went from 70% to in excess of 80%. What does this mean? It means ten women who would have died in the mid 1990s are now surviving breast cancer. The improvement is even greater for prostate cancer. It has increased by 23 percentage points. Some 23 men who would have died in the mid 1990s are now surviving prostate cancer.

What else are we doing in cancer care? We are establishing rapid access clinics for lung and prostate cancer at the eight centres. Most of these are open and the remainder will open later this year. This will ensure that men with symptoms that could cause prostate cancer can rapidly be accessed and this is equally the case for lung cancer. We are also rolling out our screening programmes. Last year, 122,000 women were screened as part of BreastCheck. This has now been rolled out to every county in the country. Last year, 280,000 women between 25 and 60 years were screened for cervical cancer.

Recently, we began the introduction of the vaccine. Some 80% of women who go for screening will be prevented from having cervical cancer. The belt and braces approach will add a further 20% to the numbers receiving the vaccine and, hopefully, 25 years from now, will prevent young girls from getting cervical cancer. The first screening programme to involve men will begin on 1 January 2012 when we introduce the colorectal screening programme. Unlike other screening programmes, it will involve a good deal of self screening and the kit will be sent to people in their homes. A person will carry out his or her own test and send it back. Approximately 6% of those tested will require follow up measures such as a colonoscopy and approximately 12 hospitals in the country will provide colonoscopy suites. Between now and then we need a significant public awareness campaign but it must be informed by research and that research is underway. The reason for the research is because it is the first time people will have been involved in self screening and it will be the first time we have a screening programme involving men. Although the participation rate for BreastCheck is more than 70%, one of the highest in the world, we anticipate the rate for the new programme will be 50% which, by world standards, would be good. However, we need public awareness campaigns to be informed by good research and this is underway. Also, we need to train nurses to carry out colonoscopies and to ensure the infrastructure is in place throughout the country for the follow through. This is the reason it takes a period of between 18 to 24 months from the time one agrees to carry out a screening programme to its introduction.

I refer to infection control. I am pleased to say that in the past two years the rate of MRSA has declined by 39%. We have set remarkably ambitious targets for the reduction of health acquired infections, including MRSA. Targets include a reduction of 30% for MRSA and a reduction of 20% overall for health acquired infections as well as a 27% reduction in antibiotic consumption. Why has this taken place? The reduction has taken place because a focus has been applied to it and because we are measuring. It is not possible to manage anything or reach targets unless one measures what one has. In recent years for the first time we have been carrying out infection and hygiene audits within our public hospitals. They are proving to be remarkably successful because there is now a focus within the acute hospital environment on the need for infection control. Hand washing is the most basic and effective tool for minimising the spread of infection in an acute hospital. There has been a very significant increase in the number of health care professionals and visitors who participate in hand washing.

Earlier, I remarked that the focus is all on patient safety, patient outcomes and evidence based medicine. We have 57 hospitals in the country and 37 accident and emergency units. For a population for 4.3 million this means that the various services provided will change. There is no question of downgrading hospitals. At issue is upgrading patient care. This means we must enter a period of constant change. Ireland is no different to any other country in this regard. For example, our cancer control plan is being emulated in other countries. Several people have come to Ireland and met me and I have met people at international conferences interested in the manner in which we have introduced a very successful evidence based cancer control plan. Equally, we must learn from other countries the most effective and safest way to provide services for patients especially when it comes to acute hospital services. For more serious and acute illnesses, that service must be provided in larger hospitals where there are a larger number of expert staff working together in multidisciplinary teams with the patient at the centre of their care. It does not mean there is no role for smaller hospitals. Smaller hospitals can do more in respect of diagnostics, elective work and community based facilities. The future for health care is not a hospital future. Throughout the world, health care systems are minimising services provided in a hospital environment. The hospitalisation model is neither desirable nor affordable. More than 90% of our health needs can be provided in primary, community and continuing care, the reason there is such a focus on these areas.

I refer to care of the elderly. The Fair Deal is providing equity of access and treatment as far as funding is concerned for every older person and their families. No longer are siblings or children responsible for paying the long-term care needs of their family members. No longer will people have to mortgage their house to pay for their parents' long-term care. Everyone is treated on the same basis whether they are in a public or private nursing home. Of the 27,000 people in long-term care in Ireland, approximately 10,000 are in public nursing homes and 17,000 in private nursing homes. Heretofore, some 90% of the care cost in public nursing homes was paid for by the State. In respect of private nursing homes, approximately 40% of the care costs was paid on average and some 60% had to be paid by the individuals and their families. This placed an undue financial burden and a burden of trauma and concern on individuals and their families. Many of us are aware of a litany of family experiences whereby loans had to be taken out to fund the care. That was not desirable, fair or equitable and I am pleased it has been brought to an end. This year, more than €1 billion will be spent on long-term care of older people. As far as older people are concerned, the policy is for care in the community. Some 95% of older people can be cared for in their own homes and communities. From a starting point of zero some five years ago, there is now 11,000 people per year with home care packages and 53,000 people with home help. In fairness, home help has been in place for a considerable length of time. However, home care packages are a new part of the support mechanism at community level to support older people at home. Community services that traditionally would have been provided in acute hospitals are now being provided at home and older people in particular are the beneficiaries.

In addition to patient safety and evidence based medicine guiding what we do and where we do it, we have seen the emergence of great clinical leadership here. Dr. Barry White heads up the HSE quality control and clinical affairs division, a new division in our public health system. He has appointed a number of key leading clinicians to head up different care programmes. They are leaders in their fields who have considerable peer support and credibility among colleagues. Their remit is within the resources they have because we do not have additional money. The public health services were reduced by €1 billion this year. I refer to the resources being spent on these care areas.

They must come up with new and innovative ways to ensure their parents are cared for. I have seen fantastic clinical leadership such as that shown by Professor Keane.

Last week I published the new cardiovascular strategy which for the first time includes stroke patients. Each year in Ireland 2,500 people die from a stroke, 10,000 people have a stroke, there are 10,000 cardiovascular deaths, while 30,000 people live with the residual disability. For certain stroke patients, the effects of a stroke can be reversed if they are thrombolysed within four and half hours. A lead clinician has been appointed to roll out thrombolysis services throughout the country. Instead of thrombolysis services being provided in just a small number hospitals, they will be provided in every network.

Equally, in the case of acute coronary syndrome, if somebody is subject to stenting, or PCI, within 120 minutes, one can reverse the effects of a heart attack. Currently, stenting is done in four or five hospitals, but we will be moving to a situation where it will be done in ten hospitals. The lead clinician is Professor Kieran Daly from the coronary care unit in University College Hospital, Galway. He is a leader in his field both in Ireland and overseas. The leader in the case of stroke patients is Professor Peter Kelly from the Mater Hospital in Dublin, while the leader in the case of patients suffering from heart failure is Professor Ken O'Donnell. I mention them because, like many other senior clinicians, they are prepared to put their heads above the parapet and show genuine leadership in rolling out programmes within the budgetary constraints within which we are operating to provide care for patients. They are optimistic they can do this and very often it is about working in a different way. For example, if stroke patients are cared for appropriately as soon as possible, it reduces the length of time they will have to stay in hospital and greatly improves the outcome in terms of disability. Two years ago we had one stroke unit but now we have 12. However, we need a number of others. This greatly enhances the outcome for patients and reduces the burden and the cost on the hospital and the public health system.

The accident and emergency unit is seen as the shop front in terms of hospital activity. Four years ago few patients were seen within six hours, the target we had set. Today I happy to say 87% of patients are seen and sent home or otherwise within six hours. The vast majority of the remaining 13% are seen within 12 hours, but the target is six hours. We are determined to reach that target. There are six hospitals, in particular, which have not been in a position to reach it. They include among them the large acute hospitals in Dublin which require medical assessment units which are being put in place. I expect the improvements we have seen in Waterford, Letterkenny, Sligo, Portiuncula, the Midlands, Mullingar and many other hospitals to been seen in Beaumont, the Mater and Tallaght hospitals.

The new chief executive officer in Tallaght hospital, Professor Conlon, is making great improvements in the operation of the hospital and I expect to see similar improvements elsewhere. A new chief executive officer, Dr. David O'Keeffe, has been appointed in University College Hospital, Galway and I expect his clinical leadership, experience and managerial skills to bring great improvements. Even though we have made huge improvements, we still have some of the journey to travel. In our criticism of the deficiencies, we must be fair about the positive outcomes achieved.

Mental health services were referred to this morning on the Order of Business, to some of which I listened. For many years these services were the Cinderella of the health service. However, in 2007 we published A Vision for Change which is the future of mental health services and into which everybody has bought. It is about providing for community based services. I come from the Ballinasloe area of County Galway, as does Senator Mullen. When I was a very young girl, I remember visiting Ballinasloe and hearing about St. Brigid's. If memory serves me right, there were close to 3,000 patients there when I was a child. The story was that if one went into it, one had little chance of ever coming out. That is the dark past as far as dealing with mental illness is concerned.

I am happy to say the vast majority of mental health patients are now in a community setting being cared for at home or in day services, but we still have facilities which are not fit for purpose such as those mentioned by the Mental Health Commission in its 2009 report — St. Brendan's, St. Senan's and St. Ita's hospitals. I was asked earlier by the media what one had to say to the patients still in these facilities. The first thing is that it is not acceptable and that it will end. The new unit in Blanchardstown has been completed. Some 100 additional psychiatric nurses are being appointed and 30 of them will be appointed to that unit, to which the patients from St. Brendan's Hospital will move shortly. A new acute unit is being built in Beamont Hospital for patients from St. Ita's Hospital, while new facilities are being put in place in Wexford for the patients of St. Senan's Hospital.

I say to the patients and their families that in the past this would not have been commented upon. Today we have an independent commission, a statutory body, the sole focus of which is on the interests of patients. It is the voice of patients and carries out inspections without fear or favour. Whether they are for mental health patients or elderly patients — there has been controversy about some of the inspections which have taken place of places in which elderly patients are cared for — if buildings or services are not fit for purpose, it must be brought to an end as soon as possible.

The Minister of State, Deputy Moloney, has put in a huge effort. However, there are still industrial relations issues which must be addressed. We require psychiatric nurses to move from the hospital setting into the community but this still has not been agreed. The Croke Park agreement has huge potential as far as public health services are concerned and I hope we will achieve redeployment. Nobody will lose his or her job. We are asking people to work in a different place in a different way. If we all put patients first, we can meet the challenges in the mental health services.

As Senator Prendergast is in the House, people in Clonmel, in particular, were not happy about moving into community facilities. However, I understand much good work has been done since our meeting with Oireachtas representatives in order that we can proceed with the €10 million project to improve community services in Clonmel and remove patients from the awful acute facilities that have been the hallmark of mental health services in the area.

I recently announced new proposals on behalf of the Government in regard to private health insurance. Half of the population have private health insurance policies. Notwithstanding the recession, the rate of decline has been less than 2% — I believe the actual figure is 1.6%. This indicates that there is strong support for the private health insurance market in Ireland. One can argue about why that is the case, but in a society in which people like me and most people in this room can afford to make a contribution towards their health costs, they should do so. The reality is that we have one company which has a disproportionate share of those over 65 years. VHI has 90% of the over 80s, 80% of the over 70s and 70% plus of the over 65s. Last year it lost €170 million on the over 65s. I am equally aware that it has a 60% share of the health insurance market and that many of its competitors believe that is disproportionate. Asking its competitors to transfer money through the tax relief at source system from its younger members to it is a huge bone of contention. It is the Government's strong view, based on the advice available to it, that as long as we remain the owner of a company and the regulator of the market, that is unacceptable.

There are no good health reasons the Government needs to own VHI which must be authorised on the same basis as the other companies which must put aside 40% of their premium income for their reserves to meet the solvency requirements of the regulator, but VHI does not have to do this. That is grossly unfair from the point of view of promoting competition in the market. VHI needs capital if it is to be authorised. The Government is willing to bring forward that capital on the good investor principle on the basis that when we sell VHI, the money will be returned. It would not make sense to sell VHI before it was capitalised because its value would decrease hugely. Most important, without a sustainable business model, VHI would not be attractive from a State or private interest perspective. To make it attractive, we must ensure older people are supported by younger people. That solidarity is the hallmark of our private health insurance market — that we pay more than health insurance should cost when we are young in order that older people do not have their premiums hiked up by virtue of their age or medical condition. This is known as risk equalisation. If we want community rating of policies, whereby we all pay the same for the same policy and do not discriminate or show bias based on age or medical condition, that requires younger people, under a risk equalisation model, to support older people. Our model of risk equalisation introduced in 1996 was struck down by the Supreme Court in July 2008. We must reflect on this. It is an extremely complex issue, but in the meantime we are using the taxation system to transfer money from younger to older people.

By 1 January 2013, the intention is to have a new risk equalisation model based not only on age and gender but also on health status. In the meantime, we must use the scheme we have as a transitional measure to make sure we continue to support older people, who are an increasing cost for health insurers.

In addition, insurers are required to comply with minimum benefits legislation. In other words, there are minimum benefits that they must cover but they are outdated now in light of our current experience and policy. For example, the legislation does not require insurers to cover primary care or preventive care. I will amend minimum benefits insurance later this year to require a heavy emphasis on primary care and preventive care. It should not be that one's insurance only covers episodes in hospital or diagnostics provided in a hospital environment. That is not desirable from a cost point of view or from a patient experience and outcome point of view. That will also be addressed. This will fit in with the new eligibility legislation we are preparing regarding what we are entitled to in the public service.

Evidence-based patient safety is at the heart of everything we do. Clearly, we must continue to encourage the clinical leadership that has emerged. We must also get more from less, as we will have less money next year than we have this year. We have taken €1 billion out of our public health service this year. It is a challenge but when we are challenged in Ireland and when we are ambitious, it is amazing what we can do.