James Reilly (Dublin North, Fine Gael)

I thank all the Senators for their contributions, including the questions they have asked. Many of these questions are of considerable interest to people. Even though I know it has not been raised directly, I would like to address the issue of thalidomide survivors. I know the question will be coming from Senator White in any event. I also know that some of them are here today in the Visitors Gallery, as we have already acknowledged. I welcome them to the House. I met the Irish Thalidomide Association and, separately, the Irish Thalidomide Survivors Society in July. I informed both organisations that my main concern was to address the health and personal social care needs of survivors living in Ireland. I have now written to both representative organisations to inform them that the parameters of a HSE health care package are being drawn up by officials in my Department and in the HSE. My Department will be in touch with the organisations when we are in a position to discuss the details involved.

As I have previously outlined in the Oireachtas, Irish survivors of thalidomide receive a monthly payment from my Department. Because the thalidomide drug was manufactured by a German company, they also receive a monthly payment from a German foundation. All these payments are tax free and, on average, they receive a tax free payment of €26,000 each year or €2,166 per month. The commitment in the programme for Government is to reopen discussions with survivors and that is what I am committed to. At my meeting with the Irish Thalidomide Association I said that I would have to be guided by legal advice regarding the State's liability. The Attorney General has confirmed that the State has no legal liability in this matter. Notwithstanding this position, however, I want to enter into meaningful discussions around the financial gesture of good will towards Irish survivors of thalidomide. This would be in addition to the health care package already mentioned.

However, none of us can ignore the severe financial challenges that the health service is facing. The likelihood is that these challenges will increase next year and continue, unfortunately, for the foreseeable future.

May I be forgiven if some of my replies do not reflect the chronological order of the questions asked? If I were to answer them chronologically, I would have to cross-reference them with my notes.

Senator MacSharry raised a number of issues. I thank him for support. He mentioned taking the Vote back. I am certainly considering the restructuring of the HSE and its abolition. In the course of doing so and in creating a new structure, the Vote may well return to the Department, to be disbursed thereafter to organisations responsible for smaller budgets.

Professor Hannah Magee's report, Changing Cardiovascular Health: Cardiovascular Health Policy 2010-2019, was produced in June 2010. This policy established a framework for the prevention, detection and treatment of cardiovascular diseases so as to ensure an integrated and quality-assured approach in their management, and to reduce the burden of these conditions. The policy proposed that cardiac and stroke services be reconfigured on a network basis at hospital and emergency care levels. It also involved an improved ambulance service so 80% of patients would be brought directly to the appropriate centre for initial treatment within the accepted critical timeframe.

Central to the network concept was the principle that every hospital should deliver a range of cardiovascular services either on site or in formal partnership with others. Acute and national specialty services would be provided in a smaller number of comprehensive centres to ensure the high-volume 24-7 throughput that is required to support rapid, responsive and accessible quality care.

The report recommended that emergency percutaneous coronary intervention, PCI, be delivered within 120 minutes of first contact with the patient and that this service be available on a 24-7 basis in a small number of centres, sited to maximise patient access and workforce expertise and coverage. Where it is not possible to meet this deadline, patients should be assessed for thrombolysis as soon as possible. The report recommends that designation of cardiac networks providing diagnostic and interventional services include non-invasive diagnostic imaging facilities, in addition to echocardiography, catheterisation and angiography.

The report referred to the role of comprehensive cardiac care services providing interventional investigation — intervention refers to cardiac catheterisation and stenting — and treatment over the working day, and stated some will provide 24-7 catheterisation, including stenting and PCI for acute myocardial infarction. The facilities needed in addition to those for general cardiac centres include two cardiac catheter laboratories as a minimum, with 24-7 availability.

The national clinical programme in the HSE has considered the requirements for patients in the north west. The population in the north west needs a permanent catheterisation laboratory to allow for local diagnostic angiography and initial assessment of non-ST segment elevation myocardial infarction acute coronary syndrome, non-STEMI ACS, patients. Based on 2008 HIPE data, there are 225 patients from Letterkenny and 162 from Sligo per annum. The laboratory should be located in the north-western region.

The number of patients with STEMI — major heart attack — is small, amounting to 47 patients from Letterkenny and 46 from Sligo per annum based on the 2008 HIPE data.

The national clinical programme for ACS is developing a clinical protocol with the ambulance service for the country to allow the appropriate treatment and transfer of patients. The protocol will set out the clinical circumstances where patients are safely treated locally — I refer to thrombolysis if the history is short — and the clinical need for transportation to a primary PCI centre. The primary PCI centres available for patients from the north west will be located in Galway and Dublin.

The available data for the affected population militate against a justification for a 24-7 primary PCI centre in the north west. It should be noted that such a centre would require two catheterisation laboratories, along with at least five cardiologists, on-call nursing and technical staff. In view of this, the HSE is considering cross-Border co-operation, in respect of which discussions are ongoing with Altnagelvin Area Hospital. This is one of many areas of cross-Border co-operation I have discussed with the Minister of Health, Social Services and Public Safety, Mr. Edwin Poots.

On mammography services, we are committed to ensuring that quality and optimal care are paramount in decisions on the provision of services throughout the health system. I announced in June that a follow-up mammography service would resume in Sligo for women who had previously had a diagnosis of breast cancer. In the region of 20 to 25 women in the Sligo catchment area require this service each month. The service will be provided on an outreach basis from University Hospital Galway to Sligo. It is intended that one radiographer will attend Sligo General Hospital on one day a month to undertake follow-up mammograms for women in this area who currently travel to Galway. To do so, it is necessary to increase the complement of radiographers in the Galway service.

While a recruitment pause is currently in place within the HSE, it has introduced an exemption process to enable priority posts to be advanced. The HSE has advised that two radiographer posts for Galway have been exempted from the recruitment pause. I am advised that interviews for these positions are scheduled for 21 November. The date for the resumption of follow-up mammography will clearly be determined by the date on which the additional radiographers are appointed and able to take up their positions.

A number of Senators asked about Galway and Limerick university hospitals. The HSE has identified a need to have available from time to time senior executives, either team-based or individuals, on a short-term basis to strengthen executive teams, lead a project or programme, provide an injection of skills that are required, or assist in the transformation agenda set by Government.

In June 2011, the HSE invited tenders from potential service providers to compete for appointment to a four-year framework agreement for personnel placement and supply services. Under the framework agreement, service providers can be asked to source and supply either senior interim managers or more long-term senior management candidates. At present, the HSE is focusing on putting senior interim managers in place. The tender process was completed and approved in late August 2011 and the framework agreement was established on 8 September 2011. Five companies have been appointed under the agreement. On 10 October 2011, the five companies were invited to participate in a mini-competition to source and propose candidates for an interim management support structure for HSE west. These are being evaluated. The competition closed last week and we hope to make decisions very shortly. This is a HSE process rather than a departmental one and is about strengthening the performance of acute hospitals, which play crucial roles within our health service.

I do not want this to be misinterpreted by anybody. I am fully supportive of this initiative. I said the SDU would support clinicians where they are having difficulties meeting targets and where their lists are growing longer. The SDU should be in a position to provide recommendations on helping management. It does not involve a witch hunt but a method of supporting management and filling gaps where they exist, as they do in Galway where there is no CEO. We need to bring our management up to speed.

Senator Crown spoke about management versus leadership. The real problem is that of management versus administrators and of administrators being promoted to management without having been given the necessary skill set to do the job. It is not their fault but we need management. We will support management by bringing in outside management to help. The SDU has at its disposal the National Treatment Purchase Fund. The moneys therein will be used in very different ways than they were used heretofore. Some may still be used in the normal way, that is, to buy services for patients, but other moneys will be used to fund initiatives to address underlying problems, in emergency departments, hospital management, etc., to make the recommendations that work. It is a matter of thinking differently, thinking outside the box and examining circumstances before acting. That has been the real boon of the SDU.

I take on board what Senator Gilroy said and thank him for his support. I agree that I do not deserve that support if I do not deliver. The SDU is key to delivering what I have promised.

I have full confidence in those involved. They have made great strides to date. I will attempt to explain much of what we are doing now from a gardening or farming point of view. One does not realise that one did not do things correctly in the autumn until the spring when the crop does not grow. We must do things now to reap the rewards in January and February next year and further down the line. I am pleased that this arrangement is now in place and I hope people will learn from the process and will be empowered by it rather than intimidated or undermined.

I have dealt with questions Nos. 29, 27 and 26 but if I have left out any answers I will come back to them. I was asked specifically about the future of Bantry General Hospital. It is in a particular, isolated geographical area and it requires a different approach to that of other hospitals. It is part of the smaller hospital framework document, which has not been finalised. However, I gave an undertaking that there would be proper communication. By this I do not mean sending out leaflets informing people what is happening, I mean consultation with the doctors in the hospital and the community and with politicians. We will lay out clearly for people what exactly is happening so that they can be satisfied that their concerns have been taken on board and that there is an organised plan with timelines that can be adjudicated on. This is not 100% complete and I am not in a position to go into the detail because that would undermine the process I have just outlined.

Senator Burke asked a question about non-consultant hospital doctors, NCHDs, and how to reduce the numbers leaving. I have a particular interest in this area and I have a formal answer to the question as part of question No. 35. I am concerned that we have many young doctors in the country who believe this is not the place for them to pursue their career. There are myriad reasons for this. Part of the cause is down to their senior colleagues and the way they are treated. Part of it is down to management and they way they are treated. Part of it is down to the lack of a clear career path.

In this country people must wait for someone to die or retire before a consultant post becomes available whereas in other countries they go through a training procedure and then they are qualified to practise as a specialist consultant. I want that to happen here and I want to create a new specialist grade in order that when one finishes one's specialist registrar training, one is eligible to apply to become a consultant. If no consultant posts are available the people concerned are forced to leave these shores. They leave at a time when their families are growing and then when it is time to come back their children have reached the critical age of 12 years. I gather from talking to most people who have gone abroad, that once their children become teenagers most of them have no wish to come back to Ireland because they believe they belong somewhere else and this makes life difficult.

Apart from that, there is the idea that we should consider some form of retention of our medical students when they qualify in order that we get two or three years during which they would repay the taxpayer's investment in them. It costs approximately €150,000 to train them. Let us consider how much money we invest by the time they become specialist registrars. It is closer to €1 million but we are not holding on to them; we are pushing them away. I wish to cease this and bring in a specialist grade whereby they can become autonomous clinical specialists answerable to the clinical director but independent of other consultants. Such people could have a clear career path whereby in four or five years they would become consultants. That would be subject to peer review and publications in journals and so on. In other words, I wish to make clear to people here and to any doctors who might be listening to the debate that this would not be like the English grade which is a no man's land where one never gets out. This is something entirely different, another step along the path to becoming a consultant and one that would be beneficial to our doctors and service. We will have the expertise of these highly trained individuals here. I need not say a gret deal more about it.

The issue of medical students and the number of medical schools in Ireland was raised. Senators will forgive me from crossing over ahead. The allocation of college places to prospective students is not within the remit of the Minister for Health. Under legislation, the universities are autonomous and academically independent institutions and they reserve the right to determine their own selection and admission criteria.

In 2006 the Government agreed to a programme of reform of medical education and training which included a phased increase in the EU intake in Irish medical schools at undergraduate level from 305 to approximately 725 students. The current EU intake in Irish medical schools is 705.

Under the Medical Practitioners Act, the HSE has responsibility, in co-operation with the medical training bodies and after consultation with the Higher Education Authority, to undertake appropriate medical practitioner workforce planning for the purpose of meeting specialist medical staffing and training needs of the health service on an ongoing basis. This includes assessing on an annual basis the number of intern training posts, the number and type of specialist medical training posts and the need for and appropriateness of non-consultant service posts required by the health service.

The career path of a non-consultant hospital doctor, NCHD, following graduation normally involves one year for an intern, two to three years for a senior house officer, SHO, one or two years for a registrar and up to seven years for a senior or specialist registrar. Typically, doctors who graduate from Irish medical colleges undertake a one year internship in the public hospital system. Following their internship they can apply for senior house officer posts. Alternatively, they can choose to leave the system at that point or at a later stage. The HSE has advised that there is currently no shortage of interns in the public hospital system. However, as Senator Colm Burke adverted to, we have had to recruit doctors from overseas because of the shortage of SHOs and registrars. Some 450 posts were due to be filled in July this year. Most of these posts were in service rather than training posts and it appears that the posts are not attractive to Irish doctors. I am afraid this may be the understatement of the year. They are not attractive to many doctors at all. This is what the new Medical Practitioners Act sets about addressing. We have training posts that everyone is happy to apply for except in the case of one hospital, which I will not name and shame, because no one wants to work there although it is a training hospital. The word has gone out among NCHDs that it is not a nice place to work.

The special delivery unit has been tasked by me to bring in a protocol on behaviour for senior clinicians with regard to how they deal with their peers, juniors, other staff and patients. This is the least we should expect. When I was in Holland I was most impressed by a 500 bed hospital I visited. There was no one waiting in the accident and emergency department, there were no hand washing facilities because they were not necessary since everyone was admitted to a room. We do not have that luxury here but we will work towards it. The hospital has four full-time staff working in customer relations. Every year it runs a day course for everyone in the hospital from the neurosurgeon down to the porter and from the matron to the cleaning staff. They are informed that they represent a business card for the hospital and they had better not let down the hospital.

We need some of this outlook and this is what the special delivery unit will focus on as part of its work. There should be standards of appropriate behaviour. I put it to the staff in my surgery that no matter how bad a day they might be having they should remember that the person on the other side of the desk is there because he or she is sick and he or she is having a worse day. This is the way it must be and we need more of it. Many of the problems arise with those who are unhappy with the service they receive because of the attitude demonstrated, despite the fact that many doctors and nurses work under considerable pressure. It takes only one or two people to give many others a bad reputation. The vast bulk of our people do an amazing job in horrendous conditions and it is my job to ensure these conditions change as part of the reforms.

Senator Burke asked about the group which is to deal with NCHDs and the new specialist grade. The group will meet and I will appoint a chair and it will get on with its work expeditiously. I have referred to the training posts and the clear targets for consultants. This is another issue related to the work and the clinical programmes are assessing it. The acute medical programme has assessed the number of new posts needed. Approximately 25 posts in specific areas will be needed to get the maximum benefit and this work is ongoing.

I am keen to explore the scope of the work nurses do with my Department and the nursing profession. I believe those in the profession are up for change as well. I am pleased that they are beginning to deliver rosters. I am aware that certain people suggest this is a distraction but it is core to the way we do our business. It is not possible to run a health service when someone works their entire working week in three days; that cannot be done. That is from a different time and place. I look forward to co-operation in that regard.

Consultants must change the way they work as well. We have to have an arrangement where consultants are available on Saturday and Sunday to do ward rounds and read X-rays and diagnostic results to ensure patients can be discharged 24 hours a day, seven days a week, not 24 hours a day, five days a week. I am sure there is a great deal of good will and it is forthcoming. I encourage people to co-operate in that regard.

To deal with Senator Mary Ann O'Brien's questions, under the medical card scheme, medical cards are made available to persons and their dependants who would otherwise experience undue hardship in meeting the cost of general practitioner services. Eligibility is based primarily on means and the overall financial circumstances of the adult or civil partner, as well as any dependants.

The review process is an important quality assurance aspect of the general medical services, GMS, scheme which distributes in the region of €2 billion of public funds each year. Two years is the average period nationally for which an individual or a family holds a medical card before a formal review under the GMS scheme. The medical card review process for the over 70s is based on separate legislation and the process has been simplified to facilitate older persons who have not had a change in their circumstances. Where changes in circumstances have occurred, the case is reviewed in the normal way.

I have also taken the initiative to inquire about what happened to the discretionary medical cards issued in the past. Under the previous health board system, the chief executive officer had discretion to issue a medical card where undue hardship was being experienced, typically where somebody had a serious illness, either terminal or otherwise. This extended to children. That facility is gone. Therefore, we set up a new group within the Health Service Executive in the PCRS consisting of four doctors, including general practitioners and community health doctors, to review applications and issue discretionary medical cards. That avenue is now open.

On the broader question of including specific groups which comes up not just in the case of children but in the case of other groups such as the terminally ill, we are trying to move to a position where everybody will have a medical card. We will endeavour to examine and expedite the cases of those who are considered priorities such as the individuals the Senator identified, but I have come to this House having spent an hour with the Minister for Public Expenditure and Reform. We are between a rock and a hard place. Some €1 billion has been taken out of the health budget for this year and we have been tasked with taking more out next year. I am doing my best to minimise this and as such, will not get engage in megaphone diplomacy here. We all have our role to play in that regard, but I am trying to explain that we are not in a position financially to do what we would like to do and that we are not in a position to do what we will do as quickly as we would wish. The situation is unacceptable for many. Many have made legitimate arguments, but, unfortunately, the money is not available to address all the issues identified.