Seanad debates

Tuesday, 4 November 2014

6:25 pm

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael) | Oireachtas source

I will respond to two Adjournment debate matters following the conclusion of this business. I will try to cover as much as I can. A number of questions were asked about national policy issues and many others about individual persons or facilities, which could perhaps be better dealt with by correspondence or by means of an Adjournment debate than a debate on health policy and budgets. I am pleased to hear the Minister of State, Deputy Kathleen Lynch, is due to speak in more detail in the coming weeks in the Seanad on mental health.

One of the first issues raised related to ambulance cover and ambulance services. In recent decades ambulance services have improved immensely. Previously, all an ambulance did was drive one to a local hospital but now we have many paramedics in the system who can assist a person from the moment he or she is picked up by an ambulance until such time as the person is brought to hospital. One of the big improvements introduced by the Government is that we now have an air ambulance. It has been particularly valuable in the midlands and the west in getting people not to the nearest hospital but to the most appropriate hospital, for example, to provide cardiac catheterisation in the event of a heart attack or various other interventions in the case of major trauma. In many cases, the nearest hospital is not the best place to go and a specialist centre is required where one can be provided with the necessary care. An air ambulance is particularly important for non-urban areas.

That said, ambulance services in this country fall short of what is expected from a modern ambulance service. By and large, what still happens in this country, as Senators outlined, is that an ambulance is called out and the person in need of treatment is picked up and taken to the nearest emergency department. That is not what happens in other countries, where a person is triaged over the telephone and sometimes it is decided that an ambulance is not required at all. Protocols are in place to allow an ambulance service to appropriately decide not to send an ambulance. What happens in other countries is that while people are waiting for an ambulance they are given good advice over the phone as to what they should do while waiting for an ambulance to arrive. In some countries up to 40% of people are treated by paramedics who can be trained and many are already trained to deal with minor injuries or complaints and to discharge a person from an ambulance. Up to 40% of cases are dealt with in that way in other countries, and when people are taken in an ambulance they are brought to the right place, which might well be the local minor injury unit. A collapse can be caused by many different reasons but a minor injury, laceration or broken bone can and should be dealt with in a minor injury unit. However, that is not what happens in this country where one gets inappropriately taken to an emergency department and sometimes we take people to the wrong emergency department. If people have had major trauma, been in a major accident or perhaps has major head trauma, they should be looked after in an ambulance and taken to the right hospital not to the nearest emergency department where they are theoretically stabilised and then transferred with great difficulty, often many days later, following lots of phone calls between the two hospitals.

We have a significant distance to go in terms of improving the ambulance service in the coming years. What bothers me is that to a certain extent the debate in this Chamber is all about capacity; that we must have more capacity in the existing system and that we must have more ambulances and more resources. The fundamental problem with our ambulances is that they are not designed properly so just adding capacity to a system that is not set up in the right way would be wasteful and would not get us the results we need. That is true of many aspects of the health service where, time and time again, putting in more resources and capacity does not result in better outcomes because the system is not designed correctly in the first place. Modernising the system and bringing it up to the required standard will not happen quickly. When it comes to reconfiguring hospitals and moving centres from one hospital to the next we will have to make sure that ambulances are well organised and can get people to where they need to be.

Senator Moloney inquired about terminally-ill patients with medical cards. The system has changed somewhat. Initially, when emergency medical cards for terminally-ill patients in palliative care were introduced about two years ago, a six-month expiry date was put on the card. The definition at the time was that a terminally-ill person was not expected to live after six months, which obviously caused all sorts of difficulties when the person had the good fortune to live longer than his or her doctors thought he or she would. The system was changed some time ago to a review of 12 months and we are now going beyond that to a position where there will be no formal review any more if someone has a medical card on the basis of a terminal illness. There will not be a periodic review but there will be check-backs because there have to be. A serious issue would result if the system did not have to provide for audit or check-backs but there will no longer be a formal review or expiration of the card in the sense that there was in the past.

I strongly agree with Senator Moloney’s view on the fact that medical cards are connected to all sorts of other benefits which creates all sorts of anomalies and problems. In other health services the health service is blind to people’s income and everyone pays co-payments, for example, in some of the Nordic countries, and the equivalent of the Department of Social Protection covers the difference. We have a different system where we almost mix our health service with the welfare system. Once one tags people in a certain way based on eligibility they automatically get treated differently even if that should not be the case.

Senator Moloney made the valid point that if one has a medical card all sorts of other benefits are included such as school transport, an exemption from exam fees and, believe it or not, a lower rate of fee for freedom of information applications, and of course a lower universal service charge rate and therefore lower taxes. If we start giving out medical cards to more people based on medical need as opposed to income, a serious question of equity would arise. I can understand the reason a person should get a medical card in order to access certain medical services but one could ask whether he or she should pay lower taxes than someone who earns the same income. I do not think so. There is much work to be done to ensure medical cards are about medical services and do not have ten or 15 ancillary benefits attached, which is the case at present. The situation developed over time, as it was a very easy way of means testing; if one passed the means test for a medical card then one would pass the means test for anything else such as school transport or other benefit. However, if we decide to have more discretionary medical cards, and more medical cards based on medical hardship, we will create a whole new set of anomalies that must be addressed.

A very valid point which was well made during debate is that often those who apply for a medical card are actually seeking access to appliances or particular forms of therapy. We are hoping, in the course of the review, to be able to allow the HSE to provide these to people. In other words, the HSE, having determined that an individual is not entitled to a GP-visit card or a medical card could provide a particular therapy or appliance to that individual who either cannot afford or cannot access it.

I am aware of the case of a young child who had a GP-visit card and a long-term illness card. In order to help out, the HSE provided the rest of the family with a GP-visit card, even though they did not need it. What they did need was the one thing they could not get, namely, access to physiotherapy. There is a big gap there that we must address and I think we can do so. Problems arise when we run into a requirement for primary legislation which means that things cannot be done as quickly as we would like. We may need to take two or three steps in doing what I think we are all trying to do.

The issue of recruiting and retaining doctors was also referred to during the debate. Agency and locum work can be very attractive for doctors and other health service staff because the rates of pay are better, one can work whenever one wants to and one can take long periods of time off. However, it is not good for patients because they do not get continuity of care and not good for the taxpayer because it costs more. I was disappointed last week when the Irish Medical Organisation voted against the new payscale which would have provided a starting salary of €127,000, rising to €175,000 with incremental progression. That defeat was heavy which makes it very difficult to come up with a new solution. That said, I would point out that over 200 doctors have accepted contracts on the low salary and another 100 have provisionally accepted. It is not the case, therefore, that all vacancies are not being filled. An interesting pattern is emerging whereby posts can be filled in certain specialties but not in others. That is often linked to expectations about what one would be paid in the private sector or in other countries for the same work. Sometimes it is not just about money either. Applications for posts are also made on the basis of quality of services provided, the clinical environment and so forth.

I was a little confused to hear Senator Cullinane's remarks about bold and radical decisions and making the right decisions because as I understand it, it remains the policy of Sinn Féin that there should be a public sector pay cap of €100,000 or at least that there should be a very heavy burden of taxation on those earning in excess of €100,000.

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