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

There are quite a lot in mental health and that is where there is a particular issue because of the possibility of retiring at the age of 55. The latest HSE recruitment campaign for nurses received 3,700 applicants and that is the number currently being processed, and future recruitment drives are being planned to encourage nurses to return to Ireland. The number of nurses employed fell by 5,000 between 2007 and 2013. In 2014, for the first time in seven years, the number of nurses employed in our health service increased by 500 and the number of nurses notifying the Nursing and Midwifery Board of Ireland of their plans to leave the country fell last year, whereas approximately 2,000 informed the nursing and midwifery board in this respect, as they need to get a certificate to travel abroad and have their qualifications recognised abroad. The number was 2,000 in 2011, it fell to 1,600 in 2012 and in 2013, it fell again to 1,200 in 2014 and I hope it will fall again this year. While there is not yet evidence of nurses returning home in large numbers, there is very clear evidence that they are not leaving in as great a numbers as they did in previous years.

On the issue of the non-consultant hospital doctors, NCHDs, rotating, the point about the six months contracts is a very good one. Under MacCraith report, doctors in training are supposed to know where they are going for the next two years and I expect that to be implemented. It may be necessary to have a different contract because when it comes to voluntary hospitals like St. Vincent's or the Mater, they are the employers, but it is different for the HSE, but so long as people knew where they were going, at least they could make plans. It is very hard to be suddenly told to go off and move somewhere else. It did not happen on the GP scheme that I was on but I know it has happened to other doctors. As Senators may know, this week the Irish Medical Organisation is balloting on revised payscales for new consultants.

I do not want to comment on that because the ballot is now under way, but if it is passed it will allow us to regularise some of the locums and people in temporary posts and to re-advertise unfilled posts.

It is intended that consultants would be appointed to the hospital groups in future, but we will have a difficulty recruiting consultants for a number of reasons. Our system is not an easy one in which to work. It is difficult to get protected time to do research and academic work, which is very important for consultants. It can be difficult to get simple things such as a secretary. People always say there are too many administrators in the health service, until they want one, and it can often be difficult to get administrative support when one needs it. A lot of work needs to be done in that space.

We will have an ongoing problem which will not change, namely, that it is increasingly difficult to get doctors to agree to work in smaller and peripheral hospitals. They are not willing to be the "I can do everything" doctor that we used to respect in the past but what we now know may not be the safest doctor. That will not change. It is not solely about money; there are many other factors.

On agency staff, the HSE is very keen to convert many agency staff to proper contract staff. Contracts are being offered to nurses and doctors to move from agency to contracted work. Some are taking them up, but others are not. Agency staff are paid more, do not have the same level of responsibility and have more flexibility. It is not the case that everyone who works as agency staff wants a permanent contract, and that is something we will have to work through.

On the reforms to the funding model of the health service, at the end of this quarter or the early part of the second quarter, the ESRI and the Health Insurance Authority will have completed their work on the costing of universal health insurance, which is a key piece of work. There will be a cost to it. The kind of social insurance that is paid in other European countries is different. Low to middle-income earners across Europe pay more social insurance than we do for their health care and their employers also pay quite a lot. We probably have among the lowest rate of employers' PRSI in Europe. In Belgium, France and other countries, a large part of the health service is funded through employers' contributions, which can often be as much as 20% or 30%, rather than the 10% rate in Ireland.

When we have the costings we will need to have a debate. In this country in the past year we saw major unwillingness by a certain proportion of the population to pay water charges, even though people all over the western world pay water charges. We also saw people refusing to do it. We need to bear in the mind the possibility that if we introduce compulsory health insurance, some people will not be able to afford it and others will refuse to pay it.

When we have done that work, I intend to go to the Government with the revised roadmap on how we can achieve universal health insurance. There are already some building blocks such as the fact that, all things going to plan, we will have approximately 50% of the population covered by a GP this year for the first time ever. We then intend to go on to the new GP contract for the whole population. We have a package in place which is designed to make health insurance more affordable again. We are already seeing, for the first time since the economic crash, a rise in the number of people who have health insurance, and I expect to see that continue throughout 2015. It would be nice to increase the percentage to 50%.

The hospital groups will be further developed in the year ahead and we will have more developments on activity-based funding, but we are way behind where we need to be in realising real reform in our health service. The HSE does not have a single financial system ten years after it was established. We do not have diagnostic related groups, DRGs, a basic thing that is in other countries to assess how much a patient costs. We do not have individual health identifiers, the health PRSI number to which I referred. One cannot track patients through the health service, let alone charge them or attach some sort of charge to a health insurer, unless one can put a number against them. An enormous amount of work needs to be done to bring about a universal health service in Ireland, but I do not want people to think for a second that the vision has been abandoned. It has not. We need to move away from the vision, speeches and promises to an implementation plan with a realistic timeframe and a proper public debate as to what people are willing to pay for universal health care.

I do not think that even if we introduce a different funding system that we will not have debates in our Parliament about individual cases or problems. That is the case in all health services, regardless of how they are funded. Other countries are less politicised; that is true. When something goes wrong in a hospital in France, the focus is on the hospital and its board of management. When something goes wrong in Germany, such as somebody not being eligible for something, the focus is on the insurer. In Ireland it always comes back to the Government, the politicians and the Minister. I do not know if that is because of our funding model. It may be more to do with our political culture. I could be wrong about that, but let us see if that changes in the next decade.

Senator Crown is very accurate on the OECD numbers. We perform poorly on access, but about average on outcomes. Our health service is ranked 13th out of 31 by the European Health Consumer Index, and when it comes to things like mortality, survival rates and hospitalisation rates, we are in the middle tier. There are single payer, insurance-based and all sorts of other systems which are well behind us on outcome data. I do not think there is a perfect system.

Senator Gilroy asked about the enhanced role for non-medical professionals in emergency departments. He is correct. We need to have more advanced nurse practitioners, who can see minor injuries very quickly, in our emergency departments. We need a better minor injuries service in general. In some hospitals one goes into triage, is assessed as having a minor injury, is put into a different stream and is seen within two hours. If that can be done in many hospitals, why can it not be done in them all? That is the kind of thing we are discussing with the emergency department task force.

The same applies to the use of GPs in emergency departments. There are GPs in my local emergency department, and there were GPs in St. James's Hospital in the past. If somebody presents with a sore throat, he or she can be referred quickly to a GP on the campus, rather than being put into a prioritised system with people who are extremely ill. People wait forever because an emergency department is for emergencies.

We now have a lot of minor injuries units which, unfortunately, are under-used. They are not open 24-7, but they are open most of the time. There is a very good one in Smithfield which is open to medical card and private patients. It is not a good thing to have people with minor injuries waiting for ages in the Mater and St. James's Hospital when they are only 15 minutes away from a minor injuries unit. The minor injuries unit in Roscommon is under-used. There is a good one in Cork in, I understand, one of the old orthopaedic hospitals. They are all very much under-used and the HSE is planning a publicity campaign to inform people that the minor injuries units exist. There is one in Loughlinstown and one in Dundalk, and they are not used to the extent that they should be. I have no doubt that the HSE will be pilloried for spending money on public relations, but it is important that the public are better informed about what services are available and where they can access them.

I am at a bit of a disadvantage in answering Senator Gilroy's questions on mental health. The Minister of State, Deputy Kathleen Lynch, does such a sterling job in that area that I am not as up to date as I should be. The Senator is correct in saying that many of the posts are replacement and promotion posts, rather than additional posts.

On the Nursing and Midwifery Board of Ireland, I have made my views and concerns known to the chairman. My officials have made our concerns known to the Government appointees on the board. They make up a minority of the board, but it is independent of the Government. I do not have a role in setting fees. It is an acceptable principle that people, not the taxpayer, cover the cost of their regulation. I met a group of pharmacy assistants recently. They work in pharmacies and assist pharmacists. Their annual fee is €190. Interns, that is, junior doctors in hospitals, who are not exceptionally well paid, have to pay a fee of €310. For therapists the fee is €100. A fee of €150 is in the mix of fees that people pay.

It is important that the Nursing and Midwifery Board of Ireland ensures value for money. The money belongs to nurses and midwives, not to it, and it needs to make sure that the money it has is spent appropriately. It also needs to ensure that it better explains to nurses what they are actually paying for and what services are offered to them.

It is a sad reality that the number of complaints against nurses and midwives has increased significantly. Members will be familiar with the referrals to the Nursing and Midwifery Board of Ireland after the Savita Halappanavar case. The House knows that there are referrals to the board on foot of what we saw in Áras Attracta. Those fitness to practise hearings are expensive and often go to the courts. That is the reality of these things, but that is the bigger picture. However, I hope the board will engage with the unions and the staff associations and try to come up with some sort of compromise on the fee.

It was either Senator Healy Eames or Senator Moloney who asked me about the discussion with the GPs on children aged under six. These discussions are going quite well. I am much more confident now than I was before that we can get this over the line in the first half of this year, but there is many a slip between the cup and the lip so I do not want to promise something that is not within my power to deliver. However, I am more confident about this than I was before.

There is one point I wish to make, and I would appreciate if Senators would also make this point if they are on local radio or otherwise in the media. There is a perception that what we are doing is extending the doctor visit card to middle class and better-off children under six years of age. That is not it at all. It is a new primary care service for all children under six years of age, including those with medical cards already. It will be a different and better service from what they have to date, but I do not want to go into too much detail on this. It will be a different quality and standard of service and it will be universal. It is not just a case of extending the doctor visit without fees scheme to middle class and better-off children or, as I should say, children of middle class and better-off parents.

All of the figures that Senator Healy Eames requested on health and well-being, IT and primary care are in the service plan which was laid before the Oireachtas some months ago. Off the top of my head, the budget for health and well-being is about €200 million; for IT, it is €55 million, up from €40 million last year. I cannot remember the figure for primary care - perhaps €2 billion - but there is a very detailed breakdown of all those figures in the service plan which was laid before the House in November.

No one will lose their registration, by the way, as a result of their working conditions.

Senator Cullinane mentioned waiting lists. It is important to point out that there is no single waiting list. One often hears of 350,000 people on waiting lists. This figure, it should be noted, includes people waiting three or four days. What people really want to know is how long they have to wait and not what number they are on a waiting list. There are different waiting lists for different hospitals and different consultants. Outpatients is different from surgery, while surgery is different from tests such as scopes and scans. Some waiting times are improving. The waiting times to see an occupational therapist, OT, or a physiotherapist in the community are going down. For palliative care, the waiting time has gone down to almost nothing. Unfortunately, however, most are going up and I am not going to pretend otherwise.

This is not down to cuts. Activity is increasing. More surgery is being done and more outpatients are being seen than before, but demand is rising quicker than supply. As a result of this, waiting list targets are being breached and will continue to be breached for the next six months at least. We are doing a mixture of things on this, including providing transparency on waiting lists and greater efficiency. There are also some particular initiatives around endoscopy, orthopaedics, ophthalmology, scoliosis and the reopening of some of the closed theatres in Cappagh. However, we are not where we need to be. We should be able to eliminate some of the very long waiters - people waiting over a year - but based on the current HSE service plan, which is based on existing level of service, it will not be possible, based on the current budget, to meet the targets of eight months and 20 weeks.

On BreastCheck, the extension of this service to women in the 65-69 year age group is on schedule and it is happening as quickly as possible. It has to be phased in. That was always the case. Staff have to be recruited and trained. Radiographers have to be employed. Equipment has to be tendered for and procured. This is something that is going to be rolled out over a number of years. It was never going to happen in the first quarter of 2015. We are talking about in the region of 150,000 or 200,000 people. It was never going to be possible to screen all of them in one year.

In terms of the exact number of people who will be scanned, I do not have those figures to hand but I will have them tomorrow. A parliamentary question on this will be answered tomorrow. The amount of funding is what it is in the HSE service plan. It is between €100,000 and €250,000. However, it is not that anyone is trying to drag his or her feet here. It takes time to provide a new service to hundreds of thousands of people.

Screening is one of the areas in which this Government has done very well. Other than breast, we have introduced colorectal screening, for example, for bowel cancers. Screening for diabetic retinopathy for people who have eye disease because of diabetes was introduced for the first time as was screening for neo-natal deafness to pick up deafness while in the maternity hospital or in the few weeks after birth because early intervention is so important when it comes to sensory loss. We have a good story to tell here.

Senator Barrett mentioned some statistics. The more I look at health, the more I am wary of statistics and of how much we spend as a percentage of GDP and GNP and all of that. We do not always compare like with like. For example, social care, which costs us a lot of money, elderly care and disability costs fall under the local authority budget in Great Britain and not under the NHS. Therefore, comparative figures with the NHS are inaccurate because they do not include the €1 billion we spend on the fair deal scheme or the money we spend on disability and so on. Also, money for the health service comes from different places; it is not just what comes from tax. It is necessary to take into account insurance contributions and out-of-pocket expenses which are pretty high in Ireland compared to other countries. Therefore, it is often very hard to get proper numbers on this. I cannot tell the House for sure whether we are a high, middle or low spender on health. However, the ESRI will be doing that as part of its work, and I should have a proper answer on that quite soon.

Senator Barrett mentioned that sometimes people in the health service bad-mouth their own service. I would not use that term myself. However, sometimes people in the health service try to advocate for their patients and, in good faith, in attempting to advocate for their patients, without realising it, damage the reputation of their own hospital and their own service and, in fact, therefore, do not do their patients any favours. There is a fine line between advocacy and inflicting reputational damage on one's own hospital and one's own health service. Sometimes, unfortunately, people cross that line.

The Senator makes a very good point on the amount of beds we have in the health service. The issue is less about beds than how they are used. One of the best things that has happened in recent years is that the average length of stay has gone down considerably. The average patient used to spend nine or ten days in hospital. That is now down to six or seven days. Therefore, each bed gets used twice as much as it used to. This is a much better thing to do than doubling the number of hospitals.

We need to do a lot more on hospital avoidance. I still cannot believe that in my own local hospital - Connolly Hospital - which I visited last week, patients are still being sent in from nursing homes in ambulances to have catheters changed. I really thought that stuff had stopped. In large parts of the country, there are patients who would never have to go into hospital if the nurses were in the community to give them their drips and their intravenous lines, IVs, at home or in the nursing home. That is why we are expanding the community intervention teams to do that, but we have so far to go on that.

Then there is the unspeakable - or rather the speakable - that we all know about. These are, of course, the delayed discharges. Even today, there are over 700 people in our hospitals who do not need to be there and would not have to be there if the appropriate nursing home places and social care was available to them. There will always be a certain number of delayed discharges but it should be something around 300 and not 700.

I think I have covered everything. However, on the Limerick emergency department, the new annex has been opened providing an additional 22 beds on a temporary basis. The new emergency department is ready for opening in 2016, and I know it is desperately needed. When it comes to the new emergency department in Galway, which is also needed, funding is not provided for this in the current capital envelope, but funding is being sought in the next capital envelope to do that.