Seanad debates

Wednesday, 25 January 2017

10:30 am

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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I am delighted to be back in the Seanad to have an opportunity to have a discussion about the health service and to outline some of my priorities for the health service during 2017. When I spoke to the Seanad in July of last year we had what I considered to be a frank and positive exchange on a number of issues. I look forward to an equally interesting exchange of ideas today.

On that occasion in July I spoke of my hopes for building a health service that makes us all proud as citizens. I believe that we have a unique opportunity to put in place a long-term vision for our health services. Eight months on, I have not lost that sense of hope. We continue to face challenges and I get frustrated like everyone else on behalf of patients waiting on trolleys or for an appointment. It makes me and it must make all of us more determined than ever to tackle the problems that we face.

When I was appointed it became abundantly clear to me that this was going to be a process that was going to take a number of years, and that what we needed was to try and build a political consensus on a direction of travel, so that when the Minister changes, the plan does not change. When I have visited hospitals and other facilities within our health service, what I have detected from many people working within the health service is frustration that every time the Minister changes or the Government changes, the policy and plan changes. It is almost like going back to the beginning and starting all over again. We need to genuinely try to embed long-term planning and building blocks for where we want to get to. In my visits to hospitals and health facilities, it has been valuable and important for me to see for myself what professionals, patients and families experience, and there are positives and negatives too.

I have witnessed the exceptional levels of commitment of health care professionals and had so many patients tell me of the great care they have been given and how the treatment they have received has improved their lives but equally I am not blind to the fact that we still face significant challenges. We all know someone who is accessing services, a family member, a friend, or a colleague. We all share the same goal. Each of us wants to have a health service where people feel valued, respected and well-cared for and a service where the patients are at the centre.

We are now back in an era of reinvestment in health care. The budget for 2017 delivered the highest ever health budget in the history of the State at €14.6 billion. This unprecedented investment will serve to make a real difference in the services that we can deliver. It is not just about the size of the budget. It must also be about where that money is spent, where that focus is and indeed the output and the outcome from the patient's perspective.

Today I would like to set out some of my priorities. I wish to acknowledge the distress for patients and their families and the impact on staff caused by cramped and overcrowded conditions in many of our hospital emergency departments. Behind every trolley number, and there is a tendency to count trolley numbers, there is a patient in need of effective, timely and compassionate care from our health service. We must all try harder across the health service and do more to improve the experience of every single one of those patients. I am very conscious of the unacceptably high number of patients on trolleys at the beginning of the year, but I am glad to report that while numbers remain far too high, they have reduced more recently and now remain consistently lower than each of the corresponding days of last year. In fact, the number of people on trolleys in January this year, although far too high, is lower than the number of people that were on trolleys in January last year. It is important to acknowledge, not politically, the intensive efforts of staff and management across the health service who have contributed greatly to stabilising the situation after the high number reached immediately after Christmas.

The rate of increase of flu throughout the country increased substantially in the weeks directly after Christmas and the strain of flu circulating at present has been affecting elderly people in the main. I know people ask, is there not flu every year? Of course there is but there are different strains of flu and different times that flu strikes. This was a particular strain of flu that we had last seen a prevalence of in Ireland in 2009, and it was a particular strain of flu that impacted older citizens, and we saw that with the very significant increase in older patients requiring our health services. Although recent figures from the Health Protection Surveillance Centre suggest that this outbreak of flu may be reaching its peak, thankfully, I would continue to urge all “at risk” individuals who have not, as of yet, received the flu vaccination to contact their general practitioner or pharmacist as soon as possible. It is still not too late to be vaccinated.

Some €40 million of additional funding was provided to the winter initiative 2016 to 2017 to help alleviate overcrowding and I would like to report to the House on the implementation of this initiative. One of the key objectives of this year’s plan is to reduce the numbers of people waiting to be discharged from hospitals by providing the specific supports and pathways to allow patients to move home or to an alternative suitable community setting which meets their needs. Achieving this objective frees up beds in the acute hospital system, thereby reducing overcrowding in emergency departments. However, it does much more than that. It is about the dignity of the patient, the person who is ready to go home, who does not want to be stuck in an acute hospital and who wants to go home and be in a more appropriate setting. I want to commend those teams across acute hospitals and social care that work together on a daily basis, because they have exceeded the target set in the winter initiative and reduced the number of delayed discharges in our hospitals to an all-time low, with 458 people recorded last week, down from 638 at the start of the winter initiative.

A number of other practical measures have also been implemented. We have seen over 7,500 patients avail of community intervention teams, meaning that these patients were able to avoid hospital or be discharged earlier from hospital. Of this number over 1,000 patients received treatment directly from funding provided by the winter initiative. We have seen almost 3,500 patients avail of aids and appliances, enabling them to be discharged from hospital. We have seen 670 additional home care packages and 330 additional transitional care beds. We have seen an additional 35 acute beds open before Christmas in the Mercy University Hospital in Cork, in Beaumont Hospital and in the hospital in Mullingar. On 5 January, I sought and received additional, enhanced measures from the HSE, and these measures focus particularly on augmenting the supports for primary and community care, targeting acute capacity, opening additional transitional care beds, and opening more beds in our acute hospitals.

Reducing waiting lists is a key priority in 2017. It is not necessarily the headline number, how many people are on a waiting list, that is a cause of concern to patients. It is how long they must wait. I am encouraged that we were finally able to make some progress in 2016. We made investments in a targeted way and as a result of that we saw the number of patients waiting over 18 months for a procedure halved. We saw the first fall in the overall numbers on waiting lists in around two years. Now we have put aside €20 million for the National Treatment Purchase Fund, NTPF, in the budget for 2017, and committed a further €50 million in 2018. That is €70 million for dedicated waiting lists initiatives, to get down the length of time that people are waiting. We used to be quite good at this before the economic crash, and we really need to get back to that as quickly as possible. I acknowledge the considerable work that has been done across our hospitals and in conjunction with the NTPF to reduce those lists.

Senator Kelleher and Senator Colm Burke have raised a specific issue in regard to Cork University Maternity Hospital, and I am sure that they may touch on that later. I am very concerned about that level. I do not understand how we have arrived at a situation where the waiting lists in Cork are twice as long as the next highest. It is not acceptable. Every hospital has gone through the same sort of challenges in terms of finances, but we need to get in under the bonnet of what has happened in Cork. I had a very good meeting with the consultants there a couple weeks ago, and I will be following it up with them. I have asked them, the new maternity strategy team in the HSE and the soon to be new clinical director for maternity services to report back to me on a range of suggestions they want to see implemented. I am looking forward to having a further meeting and engaging further with Members of the Oireachtas from Cork in regard to that.

We need to have a very honest debate about how we are going to break what has now become a vicious cycle. Every year for the last two decades, if not longer, the Minister for Health of the day has stood here, or in a spot similar to here, and talked about hospital overcrowding, trolleys and apologised, and meant it. Ministers have then done their best to improve it but they have never managed to break it. The reason we have never managed to break it is that we have failed to take a number of the fundamental steps that we are now going to take, and on which I want to hear the views of Senators in terms of what we need to do. Some of those on which I would like to touch are bed capacity, recruitment and retention, and making the decisive shift to primary care a reality, rather than just a catch-phrase.

In regard to capacity, my Department will undertake a capacity review in line with the commitment in the programme for Government. Systematic analysis of the capacity requirements of the health service is an obvious requirement of proper planning and management. Such reviews should ideally be undertaken on a periodic basis and have a medium-term to long-term focus. The last report was in 2007. There is no doubt that a review at this stage is appropriate given that we are all aware of population and demographic changes in the interim. I cannot understand how the last new acute hospital we built was in 1998. If the Minister for Education and Skills was standing here and said that the last school we built was in 1998, we would all understand why there would be a problem accessing school places. We have not built a new hospital since 1998, and yet demographic pressures have increased. The troika was not in town for all those years. This is a collective challenge that we are going to have to rise to. We need a capital investment, and we need an investment that will result in an increase in bed capacity. We need to do this properly and on the basis of evidence.We need to see where the beds are needed and how much more we can do in primary care. If we really implement and embed primary care, how many beds should be in the community rather than acute hospitals? How will we manage chronic diseases? These are all issues that need to be considered with regard to acute and non-acute beds. For this reason, I am anxious the review will have a wider scope than previous reviews and will examine key elements of primary and community care infrastructure, in addition to hospital beds. Initial work on the capacity review has focused on expanding the concept of a preferred model of care and how it can inform the assessment of future capacity requirements. Given the current pressures being experienced within our hospital services, the process must also have a short-term focus and determine how capital investment over the coming years can be best targeted. We need to have a clear crystalised ask for the mid-term capital review with regard to capacity.

I will take this opportunity to address the recruitment and retention of nurses and midwives. I, the Department and the HSE recognise the importance of recruiting and retaining nurses and midwives in the public health service. As I have said on a number of occasions, recruitment is one of the key building blocks we need to put in place to break the cycle. It is also recognised that the fall in numbers employed between 2008 and 2013, from 39,000 to 34,000, had to be addressed when the moratorium ended. There is a global shortage of nurses and midwives and it is a challenging environment in which to grow nursing and midwifery numbers. However, the number of nurses and midwives employed in the public health service has increased from 34,178 at the end of 2013, to 35,835 at the end of December 2016, an increase of 1,657 nurses.

I accept there is much more we need to do and initiatives are under way to improve staffing levels throughout the country. The HSE is offering permanent posts to 2016 degree programme holders, and full-time permanent contracts to those in temporary posts. So many nurses I have spoken to who went abroad left because they did not have the option of a job in the health service, or certainly not a job on a contract of longer than a number of months. This is no longer the case. The HSE is also focused on converting agency staff to permanent staff, while also accepting there will always be a need to have some element of agency. The HSE's national recruitment service is actively operating rolling nursing recruitment campaigns. The campaigns encompass general, mental health, intellectual disability and registered children's nurses, and also midwives. In addition, a relocation package of up to €1,500 continues to be available to nurses who return from overseas.

The HSE ran a three-day open recruitment event over the Christmas holiday period in Dr. Steevens' Hospital for nurses and midwives from all disciplines who are interested in working in the Irish public health service and 220 candidates attended the event. I also had the opportunity to attend. A total of 115 nursing and midwifery candidates were deemed successful and placed on a panel following interview. The files for successful candidates have been passed to the contracting unit. This is the first of a number of career and recruitment events for nurses throughout 2017, with the next one scheduled for 31 March 2017.

In September 2016, the HSE set up a project group to review nursing workforce planning, recruitment and retention. The main objectives of this project group include identifying current recruitment black spots in a co-ordinated way and developing measures to incentivise and attract nurses to these essential posts. I accept nursing recruitment and retention is a challenging issue. We are in discussions with the INMO. It is important in the interests of the health service that we have these discussions and outcomes from them because the health service needs stability in the interests of all of our patients and does not need any disruptions. We are engaged in discussions with the INMO. The talks adjourned last night and management will revert to the INMO later this week with details and further nursing and midwifery recruitment measures to be undertaken in 2017. The challenge this year and the objective is to recruit 1,000 additional permanent nursing posts in 2017. These posts are provided for in the HSE's service plan and HSE management is committed to engaging constructively with the INMO to address its concerns and to agree a range of initiatives that will support future recruitment.

I am firmly committed to making the decisive shift of the heath service to primary care a reality in order to deliver better care close to home in communities across the country. The programme for Government emphasises the need and focus on enhancing primary health care services, including the building up of GP capacity, increasing the number of therapists and other health professionals in primary care and continuing to expand the development of primary care infrastructure.

The Government is also committed to ensuring that patients throughout the country continue to have access to GP services, especially in remote rural areas and also in disadvantaged urban areas, and that general practice is sustainable in such areas. There have been significant developments in general practice services recently, with more services being made available to our citizens and additional support provided by the HSE. I have emphasised repeatedly the need for a new GP services contract which will help modernise our health service and develop a strengthened primary care sector. Health service management has already progressed a number of significant measures through engagement with GP representatives, including the following: free GP care for all children under six years and those aged over 70; a specific diabetes cycle of care for adult patients with type 2 diabetes; a new rural practice support framework; and a revised list of special items of service that can be provided by GPs. The effect of these measures has been an increase in State funding to general practice of approximately €100 million as well as, importantly, improving services and accessibility for patients.

Preparations for the next phase of discussions on a new GP contract are under way. I am keen to ensure that future contractual terms for GPs would enjoy the support of the broad community of GPs, and in this regard officials from the Department of Health and the HSE will engage with the relevant GP representative bodies on a wide range of matters which will need to be encompassed by the contract development process. The aim is to develop a new modern GP service contract which will incorporate a range of standard and enhanced services to be delivered. If we can get this right I believe we can unlock new potential in primary care. Our GPs want to do more, they tell me they can do more, we know they can do more and they are qualified to do more, but they need to be resourced and supported to do more. We cannot expect them to do more or patients to benefit from more when people operate on a 44 year old contract. The new GP contract is a major priority for me in 2017 and a major priority for the Department of Health and the HSE.

Many Senators will be interested in the Government's commitment to providing medical cards to children in receipt of domiciliary care allowance. The Department recently received permission to draft a new Bill to deliver on the commitment that all children in respect of whom a domiciliary care allowance payment is made will automatically qualify for a medical card, therefore will no longer be subject to the medical card means test at any point in the future while in receipt of domiciliary care allowance. The legislation is being prepared and will be brought before the Oireachtas as quickly as possible. With the help and assistance of Senators I would like to get it passed and issue the medical cards as early as possible this year. In addition to the preparation of the legislation, I have asked the HSE to commence the process of planning for the requirements of the scheme, how the cards will issue and how people can apply for them so the proposal can be implemented in a smooth and efficient manner. This will benefit approximately 10,000 children with certain disabilities and special needs who do not receive a medical card. It will also benefit 30,000 children in receipt of domiciliary care allowance who have a medical card but are subject to reviews. The reviews will no longer be necessary.

I have been asked for an update on the relocation of the National Maternity Hospital to St. Vincent's University Hospital campus and I am pleased to provide one because it is such an exciting flagship project for our maternity services. In fact, the whole area of maternity care is an area where we are making significant progress. Following from what I have described as a landmark year for maternity services in 2016, the agreement reached on a governance structure for the new National Maternity Hospital at St. Vincent's University Hospital has enabled the project, which was stalled, to recommence. The existing National Maternity Hospital has been located at Holles Street since 1894, and much of the existing building dates from that era. Its redevelopment has been a Government priority for some time, in fact it has been a priority for many Governments, and I am very pleased we will get on with it and it will proceed. A planning application will be launched early this year. I have seen the exciting designs for the new hospital, which will cater for up to 10,000 births per annum. The design team has produced a very high-quality design, which integrates the new maternity hospital into the existing St. Vincent's University Hospital building. I have no doubt that such a state-of-the-art development will raise the international profile of the entire St. Vincent's University Hospital campus. In this regard, the potential for cross-campus research and development is immense. Work to finalise the strategic infrastructure development application is under way and I expect the application will be made to An Bord Pleanála early this year.

The new maternity hospital will give physical expression to the new model of care proposed by the national maternity strategy and will ensure that women will receive their care in an environment where their need for dignity and privacy is respected. The level of care in the hospital is superb and it has a long and proud tradition, but the building is simply not fit for purpose. It does not provide women with the dignity and privacy they deserve and should expect, and it certainly is not acceptable for staff to have to work in the building either. We need to get on with this as quickly as possible.

We are very committed to progressing the development of our maternity services in general, and 2016 saw the publication of Ireland's first ever national maternity strategy. In some sense it is unbelievable we did not have one before 2016. The HSE's national standards for bereavement care following pregnancy loss and perinatal death were also published in recent months, as were HIQA's national standards for safer better maternity services. These three publications represent key building blocks to provide a consistently safe and high quality maternity service. In addition, the new national women and infants health programme will lead the management, organisation and delivery of maternity, gynaecology and neonatal services, strengthening such services by bringing together work that is currently undertaken across primary, community and acute care.

I should also mention that additional funding provided last year, and continued this year, has enabled us to build capacity in the maternity workforce, including the approval of an additional 100 midwives, including for the development of specialist bereavement teams.It also provided for the implementation of the maternal and newborn clinical management system, the new electronic health record system which I saw in action when I visited Cork University Maternity Hospital. Yesterday, in just 24 hours, the eHealth team visited every other maternity hospital in the country in an initiative to quickly establish the next steps in rolling out the electronic health record system across our maternity network.

In a related development, I want to see construction start on the National Children’s Hospital in 2017. The Government decision that the new children’s hospital should be co-located with St. James's Hospital on its campus in Dublin 8 was made in the best interests of children with clinical considerations paramount in the decision. Co-location with St. James's Hospital and, ultimately, tri-location with maternity services on the St. James's campus, will deliver the excellence in clinical care that our children deserve. St. James's Hospital has the broadest range of national specialties of all acute hospitals as well as a strong and well-established research and education infrastructure, making it the acute hospital that best meets the criteria to be the adult co-location partner.

While we must invest in our children’s health, we must also consider the needs of our older people. We know we live in a country where people are growing older. This year, we will see an additional 20,000 people over the age of 65 and another 3,000 people over the age of 85 so Government policy must be about providing care in the community for older people so that they can continue to live in their own homes. A political consensus is emerging on this issue. We have a statutory care scheme for nursing homes. We say that, as a country, we want older people to be able to live and grow old in their own homes, yet the only statutory scheme states that a person must go into a nursing home. We need to underpin home care through a statutory scheme. I know there are a number of ideas across this and the other House about how to do that and we will have a debate in the other House on it. The Minister of State with responsibility for mental health and older people has taken a significant step in launching a consultation scheme and listening to the views of older people and policy makers so that we get this right. It is really important that we get this right and that there are no unintended consequences. Bearing in mind the fact that thousands of people benefit from home care packages today, we do not want to accidentally impact on that. We need to get this public consultation process under way, get it concluded within months, allow people to have their views and get on with legislating in respect of it. Meanwhile, a review by the Health Research Board of the way in which home care services are funded and regulated in four comparable European countries, which was commissioned by the Department of Health last year, is to be published shortly. I hope this will inform all our thinking about future decisions about the structure and governance of home care services.

The programme for a partnership Government is committed to reducing the cost of medicines, including prescription charges, for medical card holders. In budget 2017, the Government announced that the prescription charge for medical card holders aged 70 and over will be reduced this year. This measure will benefit over 300,000 people. Legislation is required to introduce this reduction and this is being drafted. I will continue to examine opportunities to address the cost of the charge to patients having regard to the funding available.

This brings me to the particular issue we, in common with many other countries, are facing concerning the cost of medicines. Advances in medicines have played a key role in improving the overall health of the population. However, this comes at an ever-increasing price. For example, the medicines bill in Ireland has increased from €400 million in 1998 to over €2 billion in 2016. Securing access to innovative medicines for citizens at an affordable price is, therefore, a major challenge but one that is not easily solved. A number of key initiatives have been introduced in recent times, including agreements with industry, the most recent being signed in June last year, as well as the introduction of generic substitution and reference pricing. These initiatives have generated significant savings and reduced prices in Ireland to a more sustainable level. This is to be welcomed. Nonetheless, the medicines bill is forecast to rise significantly in the years ahead driven primarily by the increase in cost and usage of recently introduced medicines and the very strong pipeline of new medicines. Therefore, our financing model for medicines needs to be both sustainable and affordable. However, the pricing model proposed by industry must also be sustainable and affordable.

It is important that we challenge the pricing structure and practices adopted by the pharmaceutical industry where they are wrong so that patients can access innovative products. That is why I have reached out to my colleagues in other countries seeking international collaboration in this area. I attended an OECD health ministerial meeting in Paris last week. Countries around the globe are facing the same challenge but if we do not work together as countries, and certainly as EU member states, in the same way the drug companies collaborate with each other, we will be unable to meet this challenge so we must work together. We have huge buying power when we work with other countries. I was impressed with what the Benelux countries have done in coming together to buy drugs and we can learn a lot from that so I am in talks with a number of other EU and OECD health Ministers to see how we can share information and help each other so that citizens in all our countries can access drugs.

Turning back to my priorities for 2017, we will also see a new national cancer strategy. I am very excited about the publication of this, which will happen in the coming weeks. It is a strategy for the development of cancer services in this country for the next ten years. Much of the heavy lifting was done by my predecessors in getting the model of care right. We must now look at things like survivorship. Thankfully, people are living beyond cancer but how do we look after them after cancer? How do we look after all of their needs such as their psychological needs, their well-being and the needs of their families and help them get back into employment? The new national cancer strategy will endeavour to set out a roadmap in that regard.

We will also publish an implementation plan for the neurorehabilitation strategy, which is so important. It concerns how we look after people who need neurorehabilitation such as those who have suffered a stroke and those with multiple sclerosis or a range of neurological conditions. I thank all the stakeholders and interest groups that have worked with us in this regard. We need an implementation plan and it will be published this year and provide the roadmap for the delivery of the service. It is specifically mentioned in the service plan and is a priority.

I will also take the opportunity to mention some priorities being progressed by my ministerial colleagues at the Department of Health. Empowering people with disabilities to live independent lives and to have greater choice and control over the services and supports they need to make that goal a reality is a key priority and the Minister of State with responsibility for disability issues is progressing that commitment through the task force on personalised budgets. This involves actually empowering people with disabilities and not thinking that the State's responsibility stops when it writes a cheque and sends it to a service provider. It involves asking the people with disabilities what they want done with those resources and what they want for their lives. The Minister of State is leading on that issue.

The Minister of State with responsibility for health promotion is driving the health and well-being agenda. Work is progressing on the public health (alcohol) Bill, which is really important legislation that needs to be passed and enacted, and on implementing A Healthy Weight for Ireland: Obesity Policy and Action Plan 2016-2025. We are on course to be the most obese nation in the EU if we do not get on with delivering on this plan.

The Minister of State with responsibility for communities and the national drugs strategy is actively progressing a new national drugs strategy which will set out Government policy from 2017 onwards in the areas of drug awareness and prevention, treatment of substance misuse and addiction, promoting rehabilitation, reducing the supply of illicit drugs and piloting supervised injecting facilities. I expect progress on the legislation relating to injecting facilities in the coming weeks.

The Minister of State with responsibility for mental health and older people chairs the national task force on youth mental health. This group is considering how best to introduce and teach resilience, coping mechanisms and greater awareness to children and young people and how to access support services voluntarily at a young age.

I thank the Seanad for inviting me here again today and I look forward to hearing Members' thoughts and views on the direction the health service should take. I have tried to touch on a number of issues, health being a broad topic. I would be delighted to interact on any other issues.

Photo of Keith SwanickKeith Swanick (Fianna Fail)
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I thank the Minister for coming to the House today to facilitate this debate. We all know the pressures the health service is under. The Minister is aware of my belief that the problems we see in secondary care will never be rectified until primary care is adequately resourced. To that end, we need to re-invest our efforts in training more young GPs, practice nurses and community health nurses. I know we spoke about the funding of the Institute of Community Health Nursing this morning during a Commencement debate, for which I thank the Minister.

I believe in a solution driven and pragmatic approach. To that end, I urge the Minister to sanction some extra funding for general practice out-of-hours services so that multiple GPs can work during particularly busy periods from mid-December to mid-January to help reduce referrals to accident and emergency departments. It is a simple, practical and solution-driven idea that would alleviate some of the pressures on the secondary care system.

I also ask the Minister to review our district hospital network, particularly district hospitals in rural areas like my own. Senator Conway-Walsh would also be very familiar with the hospital in Belmullet. These hospitals are a good distance from acute hospitals. For example, Belmullet is over 50 miles from one. The community hospital network should not be seen as a relic of a bygone era. I believe community hospitals have a pivotal role to play in a modern health service as they can fulfil multiple roles. For example, they can prevent admissions to acute hospitals because GPs can admit directly to them. They also facilitate discharges from acute hospitals. If somebody has a hip replacement, he or she can be transferred to a community hospital and receive rehabilitation with the help of a community physiotherapist in the community thus freeing up an acute hospital bed. More importantly, district hospitals can play a role that has been underutilised. They can work as an interface between the fair deal scheme and the acute hospital sector. If somebody is an acute hospital patient and applies for the fair deal scheme, they often wait a number of weeks in the acute hospital bed, possibly up to 12 weeks. There is no reason that the patient cannot be transferred to a community hospital for the intervening period before being transferred to the nursing home.That is another role that we should look at.

We also need, as the Minister said, to encourage community based investigations in general practice. My own surgery has an ultrasound scanner, a DEXA scanner for osteoporosis, spirometry for breathing testing and audiometry for hearing, to mention a few, but they are being under-utilised as there is no funding model available for medical card patients. This means that patients are disenfranchised as they have to travel to acute hospitals to have these investigations carried out, when they could be carried out in the community.

I take this opportunity to touch on two further topics. One is alpha-1 antitrypsin deficiency and the other one is narcolepsy. The Minister will be aware that 350 people are diagnosed with alpha-1 antitrypsin deficiency throughout the country. It is the most common genetic lung disorder in Ireland and can lead to severe lung, liver and skin problems. The majority of people with alpha-1 antitrypsin deficiency present with emphysema or chronic obstructive pulmonary disease, COPD. A new groundbreaking drug called Respreeza was shown to slow the progress of emphysema in a recent clinical trial. It was called the rapid study clinical trial, and 21 Irish alpha-1 patients took part. Since the trial ended these patients have been receiving the treatment from CSL Behring on a compassionate use basis. On 26 July last year patients were informed by the company that they would stop providing this treatment on 30 September. On 23 September this was extended until the 31 December 2016. Two further extensions were given, one until the end of January and the next until 28 February. These people are living in limbo, waiting month to month to find out whether they will receive the treatment which is changing the quality of their lives for the better. Unfortunately, on 9 December, the National Council for Pharmacoeconomics, the NCPE, published a decision to recommend against funding Respreeza. Alpha-1 patients are naturally devastated by this decision. They desperately need this issue to be resolved to prevent further distress and anxiety, and I would be grateful if the Minister could consider this.

The Minister will be familiar with the organisation SOUND, the support group for sufferers of unique narcolepsy disorder. It is seeking support to fund a national narcolepsy and related disorders service at St. James's Hospital. It is envisaged that this unit will complement the existing paediatric service for younger people with narcolepsy. It is something which is urgently needed. Its cost, €1.6 million, is a drop in the ocean in the grand scheme of things within the HSE. The reason that this is particularly time sensitive is that the 80 young people who suffer from narcolepsy as a result of the pandemrix vaccine will soon be adults and will no longer be provided treatment under paediatric services.

There are approximately 1,600 patients with narcolepsy in Ireland. SOUND represents the people who developed the disorder as a result of the swine flu pandemrix vaccine. There are currently 80 plus members, and the funding amount of €1.6 million will provide staff, including a neurologist, a neurophysicist, a respiratory consultant, clinical nurse manager, dietitian, laboratory nurse and four lab technicians. The recognition of the association between the pandemrix vaccine and narcolepsy disorder has exposed the lack of proper treatment pathways for patients. A 2012 Government report recognised the link between the vaccine and the disorder, and it was withdrawn from clinics. Sufferers have to live with a range of debilitating symptoms, including hallucinations, cataplexy, increased risk of accidents and obesity, to name just a few. It is an incurable, life-long illness which impacts on all areas of their daily life. This is a unique problem. As a result of a public health programme there are over 80 young people who will never know what a normal life is. There needs to be a commitment from the Government to ring-fence funding so that life-long supports will be put in place for sufferers. There must be a seamless transition from paediatric treatment to the treatment of adult sufferers, and there must be a commitment for a multi-disciplinary centre of excellence.

Photo of Colm BurkeColm Burke (Fine Gael)
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The health committee meeting is starting at 1.30 p.m. and as we are under pressure to attend that meeting it is unfortunate it is clashing with this debate. However, I appreciate the Minister coming in to the House to attend the debate.

It is interesting to look at the figures relating to accident and emergency medicine. As I understand it, last year there was approximately 1.3 million people who attended accident and emergency departments. My understanding is that figure is up around 6.5% or 7% across the country, which means that in real terms there are some 1.35 million to 1.4 million attendances, which is approximately 26,900 per week. That is a huge number of people attending accident and emergency departments. If there is a sudden increase of 20% in any one week, that is an increase of over 3,500 or 4,000 people into the system. It works out at around 3,800 per day. That is the challenge that the people who are working in the hospital system face. About 25% of that number are being admitted to hospital.

Demographic changes are an important factor and it presents us with a major challenge. I met with a hospital before Christmas. In 2015 it cancelled 40% of its elective surgery because of accident and emergency admissions. Its biggest challenge was a 12% increase in the number of people over 80 years of age who were admitted to accident and emergency. That is a huge problem because it is very difficult to say that a person in that age group can be referred home easily or sent back to a nursing home. There is a higher level of risk and therefore there must be a higher level of service provided to that age group. That is a major problem that we are going to have to address over the next few years.

Having studied the set-up of the health service over the last few months, I understand we are on about 2.8 beds per thousand. The OECD equivalent is 4.3 beds. I understand Germany has 8.3 beds per thousand. The Minister is right to say that there has been no major hospital centre built since 1998. Nothing was built between 1998 and 2008 at a time when we were flush with money. Even to start the process of building new hospitals takes time. We have been talking about the new children's hospital for almost 25 years. We now need to start planning for new building programmes. The Irish Association of Emergency Medicine, the IAEM, produced a report in 2012. We need to look at that now and take on board what it is saying as we have parked this issue for far too long. It sets out clearly what needs to be done regarding trauma networks, emergency networks, emergency care networks, clinical decision units, staffing levels and advanced nurse practice. Very little of it has been implemented. It is something that we need to urgently look at, including discussing with the IAEM to see how we can best deal with it.

We seem to have a big problem - my colleague Senator Kelleher is also involved in this in regard to the gynaecological services in Cork - where there appears to be one set of plans by the administration and another set by the medical workforce. As a result patients are suffering because there is no co-operation and co-ordination between the two, which is unfortunate. Some 4,000 people are now waiting for gynaecological services in Cork. I would agree with the Minister, and am surprised that this has been allowed to happen. It appears that we have a problem with the administration not reacting fast enough to such situations. Even in 2009 there was a substantial waiting list of over 2,900 people. That has grown since then because it was not dealt with. We have a problem with building a new maternity unit and providing two theatres for gynaecological services. Only one has been opened in the last ten years, and that is only open for 3.5 days per week. That does not make sense. Many hospitals are looking for theatres. This is a hospital that has theatres but the staff cannot be provided.

There have been a number of proposals to deal with these issues one of which, the National Treatment Purchase Fund, the Minister referred to. I am not satisfied that is the solution in Cork. One of the solutions put forward in regard to gynaecological services was about buying space in another facility.The available doctors would then be allowed to perform the procedures in another facility so that the care was continuous and patients were not passed from A to B and back to A again, which does not allow for the same continuity. This needs to be examined. My understanding is that space is available in other units to deal with these patients. We should not have to debate this matter today. It should have been highlighted and dealt with long before 4,000 people were on waiting lists.

Cork has identified that a six-bed day care unit for gynaecological services should be prioritised, as it would allow for fast-tracking. Approximately 42% of all patients waiting for gynaecological services are doing so at Cork University Hospital. This matter needs to be addressed.

The Minister referred to hospitals and the need for increases, but he should remember that, between 1986 and 2016, Ireland's population increased by 1.2 million. Cork alone increased from 410,000 people to 542,000, or more than 30%, but we did not receive one new hospital bed in those 30 years. That is why we need to prioritise a second major facility for Cork. We have good hospitals in the Mercy University Hospital and South Infirmary Victoria University Hospital, but they are no longer capable of dealing with their workloads. The 1960 Fitzgerald report set out clearly what needed to be done in Cork, including two major hospitals. We built one, but we do not even have a site for the second. This issue needs to be given priority and accelerated as soon as possible.

I thank the Minister for the work that he and his Department are doing, but we must prioritise a number of issues over the next 12 months.

Photo of Maire DevineMaire Devine (Sinn Fein)
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In case I do not go over time and have some left,-----

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I will be watching the Senator. Do not worry.

Photo of Maire DevineMaire Devine (Sinn Fein)
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-----could Senator Conway-Walsh take the remainder?

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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Do the Senators wish to share?

Photo of Maire DevineMaire Devine (Sinn Fein)
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No, because I am not sure how much I have. We will see, given the rush on time.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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The Senators are playing it by ear.

Photo of Maire DevineMaire Devine (Sinn Fein)
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I thank the Minister of State for attending. Is the Minister swapping out?

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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Not yet. I will stay for the Senator.

Photo of Maire DevineMaire Devine (Sinn Fein)
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It is time that we accepted that the health service is on dodgy life support in intensive care. Yesterday, 520 of our citizens were lying on trolleys throughout the State. This figure is growing towards the dangerously high levels seen over the Christmas period. The INMO's trolley figures date back almost a decade. They were unwanted at the time and it took a fight to get them accepted, but they eventually were. Traditionally, the last week of January and the first week of February see the peak, so I do not know whether we are out of the woods. I hope that we are.

It is not just the trolley crisis that has our health service on life support. Surgeries are being cancelled and wards are closed because of chronic understaffing. Current staff are stretched to the point of despair. The persistent problem with patients on trolleys is a direct consequence of decades of failed Fine Gael and Fianna Fáil policy. Coincidentally, they are now in government together. Deputy Micheál Martin's pledges are in the past, Brian Cowen called it "Angola", Senator Reilly said that never again would we see 559 patients on trolleys and the next prospective leader of the Senator's party was removed from his position.

In some cases, the treatment of patients in our hospitals is an attack on human rights. I do not say it lightly. That 612 patients are on trolleys cannot be attributed to the flu alone. The Minister was given plenty of warning in advance of this situation. The sick are facing these delays. The national service plan identified these risks. As to the extra €40 million for the winter initiative that was announced at the end of September or in October, front-line staff were sceptical that it would reach its target, to put it politely. Unfortunately, responsibility lies with this Government.

I was glad to hear in the Minister's response to the crisis during a radio interview his forced acknowledgement of a capacity issue, which had been denied for long. I was also glad to hear the CEO of the HSE outlining last week that at least €9 billion extra would be needed over the next decade to fix our health service.

The Minister rightly referred to how the last new hospital had been built in 1998. Primary care centres are being built, which is welcome, but if hundreds of patients are lying on trolleys annually, it is not rocket science to figure out that more beds are needed quickly. This will require significant capital investment from the proper collection of taxes. Proposing to abolish the USC while still treating our families, friends and neighbours in hospitals is fairytale economics. Allowing corporations, vulture funds and the like to use every loophole possible to avoid paying tax is a national scandal, given what is happening in our hospitals. People have died on trolleys. Irish people are fair and understand the need for taxes and the retention of the USC. They want the provision of services, not piecemeal tokens in their payslips that strip our front-line services even further.

The arrogant attitude of some among the HSE's management is unbelievable. Recently, they alluded to people keeping elderly family members in hospital beds in order to prevent them from entering the fair deal scheme, thereby protecting their inheritances. It was a sad departure for the HSE. I believe that the claim came from the same department that issued the memo, also rescinded, saying that nurses could use minimal force to remove patients from beds. I do not know what that department is doing, but its statements have been incredible.

To have this attitude towards frail and vulnerable people who have contributed for all of their lives to this country is an uncompassionate - that is not even the right word - trend that has developed in our hierarchical, non-practising management hospital structures. I have always advocated that compassion be returned to our health system.

I noted the HSE's recruitment initiative for nurses who were returning over the Christmas period. I will refer to the vox popconducted by the media with some of them. I mentored, trained and, at the airport, waved goodbye to a number of them. The majority maintained that they received better pay, conditions, training, respect and lifestyles abroad. They felt let down by the State, having been forced, as Mr. Tony O'Brien said, to leave. I do not blame them. I received a message from a young nurse at the weekend. She had returned from Australia. It was great to see. She told me that our system was doing her head in. She was trying to figure out payscales and hours. As an ex-union person, she asked whether I could figure it all out for her. To her, it was no wonder that no one was returning. We must examine how to make the transition into our system as smooth as possible. Will the Minister update the House on the many nurses he mentioned had been recruited under this initiative over Christmas?

I am concerned that talks between unions and management on the crisis in recruiting and retaining nurses adjourned last night. Are we looking at more industrial action? No one wants it, but it is often necessary to get things done. There is no time to waste. The union council meets next Monday and is likely to sanction strike action.

In early December, hundreds of seriously ill cystic fibrosis sufferers demonstrated outside the Leinster House gates regarding the availability of Orkambi. There has been a similar battle over Kalydeco for younger children suffering from the same illness. I understand that Vertex has made a revised reimbursement offer. Will the Minister update the House in that respect? He has updated us generally on the corporate greed of many drug companies. Will he also update us on the position on medicinal cannabis? I am thinking of a particular case of which he would also be aware. I chatted to the parents of a seven year old a couple of weeks ago.

I cannot conclude without referring to mental health. I stress the immediate need for the introduction of a 24-7 crisis intervention service to try to reduce the number of citizens who die by suicide. We all advocate for the implementation of A Vision for Change, but that will not happen anytime soon. I have held regional health conferences over the past month. The main issue raised time and again was that of access to 24-7 services. Our party laid a Private Members' Bill before the Oireachtas, but it was amended, diluted or voted down by the Government or Fianna Fáil. If we can do only one thing in this era of new politics, I plead for us to work together on a cross-party initiative to deliver in this regard. Starting at 7 a.m. today, I have had three conversations with two sets of parents and one young woman with a child about how to access services.One of the parents had a 13 year old who had sent a text showing a rope. This 13 year old was ready to commit suicide and had nowhere to go. Public representatives and councillors across the country deal with this on a daily basis, in the expectation of a bed or professional help being provided but we are lost. I look forward to receiving the work of the committee on the future of health care which will hopefully deliver a long-term vision. In the meantime, the Minister can look forward to my support and my criticism, and that of the Sinn Féin team.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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Senators Frances Black and Colette Kelleher are sharing time, six minutes and two minutes respectively.

Photo of Frances BlackFrances Black (Independent)
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I want to talk about the correlation between physical and mental health difficulties. If mental health was addressed it could reduce the pressure on hospital beds. It is imperative that mental health is recognised and afforded appropriate priority within the wider health agenda to reflect its contribution to the burden of disease in Ireland and its impact on other areas of life. The Healthy Ireland survey reports that almost 10% of the Irish population aged over 15 have a probable mental health problem at any one time. This equates to approximately 325,000, based on the census 2011 population data. Almost 20% of young people aged 19 and 24, and 15% of children aged between 11 and 13, have had a mental health disorder. According to the Suicide in Ireland survey, suicide is the leading cause of deaths in young males, exceeding road traffic accidents and cancer. There is a strong correlation between physical and mental health difficulties and a recently published report by the substance abuse and mental health services administration in the US found that adults aged 18 or over with any mental disorder or major depressive episode in the past year were more likely than adults without these conditions to have high blood pressure, asthma, diabetes, heart disease and stroke. In terms of health service utilisation, adults with any mental disorder used both emergency departments and hospitals more than those without a mental disorder, leading to higher health care costs.

The Healthy Ireland framework states that it is important to acknowledge the interplay between mental health problems and chronic disease. Depression is a very important public health problem and is often comorbid with chronic conditions. Mental health problems such as depression, when existing with any chronic condition, incrementally worsen health compared with having depression or chronic conditions alone. This reinforces the need to improve mental health well-being as a public health priority to reduce disease burden and disability and to improve the overall health of populations, tackling risk factors and promoting protective factors for lifelong health and well-being in the early years.

Building children's and adults' resilience to adversity is a central requirement of any population health framework. Healthy Ireland continues to report that mental health problems have huge personal impacts on those who experience them and result in significant costs relating to loss of productivity, premature death, disability and additional costs to the social, educational and justice systems. It is estimated that the economic cost of mental health problems in Ireland is €11 billion per year. Despite the high costs of mental health difficulties to Irish society, including the wider health sector, resources for mental health services continue to be disproportionately low compared to resources for physical health services.

In 2017 there will be a 3% increase in revenue funding for mental health. However, this is much less than the 7.4% increase in revenue funding for the overall health budget. In 2017, mental health funding represents just 6% of the overall health budget, which is significantly lower than other leading countries and lower than recommended in Irish mental health policy. A Vision for Change recommended that the proportion of the total health budget allocated to mental health should be progressively realised to 8.24%. In both Britain and Canada the proportion of funding is approximately 13% and in New Zealand it is 11%. The current funding allocation will do little to redress the historical underfunding and decades of neglect of Ireland's mental health system, let alone put in place the foundations for a modern mental health system as required by national and international standards. In addition, the impact of failing to adequately invest in the development of mental health services will continue to have an adverse effect on other areas of society, including the wider health environment. Could the Minister make a commitment that the proportion of the health budget allocated to mental health be increased to 8.24%, in line with the recommendations in A Vision for Change?

I also wish to highlight some issues around the lack of services and the denial of help for people with dual diagnosis. Dual diagnosis is the term used for people who are experiencing a mental health problem and a substance misuse issue. The presentation of dual diagnosis is now considered to be the norm rather than the exception. Dual diagnosis presents many challenges for health services. It is difficult to treat and has poorer outcomes such as increased risk of self harm and suicide. In the UK, 74% of users of drug services and 85% of users of alcohol services experienced mental health problems. Dual Diagnosis Ireland, a registered charity, states that 76% of services fail to offer a specific service for people with dual diagnosis. People must be dry to access most addiction rehab services, but they cannot get dry because of mental health issues such as social anxiety issues and they drink to reduce this anxiety. Another problem is that addiction treatment services usually do not assess for other mental health problems.

The main problem experienced by people who have dual diagnosis is that when they present themselves to a rehabilitation centre they are not treated for their underlying mental health issue and when they present themselves to the mental health services the substance misuse is not addressed. I recently heard a woman in Cork talk about her sister who had dual diagnosis but would not be accepted into a drug treatment centre as she was not clean and who was subsequently raped while living on the streets. The fact that something like this can happen in our society is an indictment of our health services. There is general agreement that integration between mental health and addiction services is sorely needed and long overdue.

I commend the Minister on his support for the Public Health Alcohol Bill and I feel that the passage of this legislation would not only address our unhealthy relationship with alcohol but would also help alleviate the 1,500 hospital beds taken up every day because of alcohol misuse. I have no doubt this legislation will save many lives and I hope the Minister's party support him on this Bill.

Photo of Colette KelleherColette Kelleher (Independent)
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I commend the Minister on the range of work outlined in his statement today. I listened keenly to what he said on older people and people with dementia and other disabilities. I commend him on the attention he has given to home care on foot of the documentary on RTE by Brendan Courtney. Deputy Mary Butler and I, co-convenors of the all-party group on dementia, are going to visit Scotland this evening to meet with NGOs, officials and the Scottish Minister for Health to learn more about their progressive policies on dementia care and care for older people, including home care. We have made the Minister of State at the Department of Health, Deputy Helen McEntee, aware of that and I will report back to her on it.

The matter I wish to raise will be no surprise to Members. The longest waiting lists in the country are the lists of 4,300 women on the CUMH gynaecology outpatient waiting list and the 512 on the surgery waiting list. I thank the Minister for making time to meet with the doctors involved on his recent visit to Cork. It had been hugely frustrating to them that their side of the story was not being told, as was also the case with the management side. Building on the goodwill emerging from that meeting, what concrete actions will the Minister take? What is the timeframe for these actions? I know from a recent parliamentary question that he will have a follow-up meeting in six weeks. What date has been set for this meeting? The Minister has requested a report from the HSE action plans for 2017 in respect of both the inpatient and outpatient waiting lists. Will this report address the particular issues in CUMH, which are outliers? What action will he take to provide a sustainable solution to build real capacity and not something which just relies on the National Treatment Purchase Fund? Will we have to wait for a "Prime Time Investigates" programme to get action on this in the same way we had to for home care?

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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Senator Nash has eight minutes.

Photo of Gerald NashGerald Nash (Labour)
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I am glad-----

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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My apologies to the Senator. I have jumped the order.

Photo of Gerald NashGerald Nash (Labour)
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I am happy to cede to Senator O'Donnell.

Photo of Kieran O'DonnellKieran O'Donnell (Fine Gael)
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I appreciate the benevolence of my colleague. I acknowledge the Minister's wide-ranging speech, one of the key features of which was the fact that, despite the increase in population, no new acute hospital has been built.One of the features of the Minister's speech was his point about the increase in population but that no new acute hospital has been built. I wish to make two brief points in that regard. First, the national maternity hospital in Dublin and the national children's hospital are both very welcome projects, but given that they are very large projects there is a danger that the rest of the country may lag. That is why it is so critical that when the capital plan is reviewed that factor is taken into account.

More specifically, I wish to deal with my area of Limerick. The Minister referred to progress on the planned maternity hospital. It is hugely important that we relocate to the site of the University Hospital Limerick. The Minister will examine that in the context of the capital plan. More specifically on acute services, as I am sure he is well aware, we should focus on acute services when there is not a crisis. I have heard people say the crisis is over. Now is the time to talk about it because it is cyclical and it will always come around again. We need to resolve the issue now. I accept we need to discuss the crisis when it happens but now is the more critical time. When the reconfiguration was taking place in University Hospital Limerick in 2009 part of it involved the building of 138 co-located beds on the hospital site. The accident and emergency units in Ennis, Nenagh and St. John’s hospitals were closed but the project never went ahead. In the HSE capital plan there is an application for 96 acute beds to be built on the University Hospital Limerick site. Following discussions with the Minister, Tony O'Brien, and more particularly Liam Woods, the national director of acute services in the HSE, I am pleased that we have got the go-ahead for the design element of the project to get under way. I welcome that. When the mid-term capital review takes place it is hugely important that this €25 million project is funded. We have a major capacity issue in Limerick University Hospital. We are short of beds. We closed three accident and emergency units with the loss of 18 bays. At the time 50 beds were closed in Ennis, Nenagh and St. John’s hospitals. A new state-of-the art accident and emergency unit is due to open this year. We hope it will be opened in May. I very much hope management will stick to the target and that the unit will open on time.

However, that is only one side of the equation. The other side of the equation - the missing piece of the jigsaw - is the 96 acute bed unit to be built alongside it over the dialysis unit with four floors of 26 beds each. I welcome that the design phase is now under way. However, when the HSE mid-term capital review takes place that project, worth €25 million for a 96 acute bed unit, must be funded. The Minister will have our full backing when the mid-term capital review takes place. Additional funding of capital projects must be available for the health sector. We have an increasing population. University Hospital Limerick has now the highest throughput of any accident and emergency unit nationally with more than 66,000 patients yet we have half the number of beds of University Hospital Cork.

In addition to more primary care and GP contracts we have a fundamental lack of beds at University Hospital Limerick for the mid-west region and Limerick. There is a provision in the HSE's capital plan for 96 acute beds. It is very welcome that the design phase is now under way but we want to see it go ahead. The Minister will have our full support for him to advocate for €25 million in funding to be provided in this year's mid-term review of the HSE’s capital plan in order that the people of Limerick and the mid-west can get the level of service to which they are entitled – an equal service to other areas in the country, which due to lack of beds is not the case at present.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I call Senator Nash. I apologise for my earlier intervention.

Photo of Gerald NashGerald Nash (Labour)
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Where was I before I was so rudely interrupted? I forgive you, a Leas-Chathaoirligh, for interrupting me. We will not fall out over it.

Photo of Kieran O'DonnellKieran O'Donnell (Fine Gael)
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We note Senator Nash's benevolence.

Photo of Gerald NashGerald Nash (Labour)
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I was happy to cede the floor to my colleague.

I am pleased that what we have heard to date has been a measured approach to the debate on health because that has not always been possible in this Chamber or in the other Chamber. I can understand why colleagues would want to take some time to focus their attention and that of the Minister on the emergency department crisis around the country. We all have our own experience of dealing with crises in emergency departments on a local basis and in some cases on a national basis. I have had much experience over the years of dealing with the perennial problem in my local hospital, Our Lady of Lourdes Hospital in Drogheda. Despite the best efforts of staff, HSE officials and successive Ministers it has always been very difficult to address the issues that both staff and patients face. It is very easy to kick the Minister of the day and accuse him or her, the HSE and hospital managers and staff of not doing enough and claiming they do not care about the state of the health service and the lack of adequate resources.

I am pleased that there is a degree of consensus in this Chamber on the issue as the approach I outlined is not one we want to take. We will not fix the problem facing constituents and the far too many people who are lying on hospital trolleys by taking that approach. After all, Ministers for Health are human beings too. They are compassionate, concerned individuals who do not want to have to preside over such a situation. I take the Minister's interventions on the issue at face value and I accept his bona fides that he is doing his utmost in difficult circumstances to resolve an issue that has confronted this State for far too long. Very tough decisions will have to be taken about how we resource and manage the health service. I hope it is not beyond our ability in this Chamber and across the political system to do that on a consensus basis to a large degree because the challenges are too great to become overtly politicised. There is a broad degree of consensus on what needs to be done in the health service while there are some differences about how the system can be resourced. The Minister is correct; issues such as bed capacity, retention and recruitment and how we properly resource and plan the primary care system are key to resolving the problem experienced in the expensive acute service area.

The challenges that face emergency departments across the country cannot be separated from the question of how we deal, for example, with our frail elderly population. That is an area in which I have become particularly interested in recent years. I am especially concerned about how we might better confront the challenges presented to citizens, families and the health service in general by the growing number of people with dementia and Alzheimer's in terms of taking a patient-centred approach to the delivery of appropriate care for them. Talking to those who work in emergency departments I am always struck by the number of possibly avoidable admissions of frail elderly people to hospital. I refer to people with dementia and Alzheimer's who might be better served in a different type of system. In fairness, thinking in the health service and the political arena has evolved considerably in terms of how we deal with those challenges.

The development of the national dementia strategy is very welcome. It has often been the case that many of us working in our constituencies over the years have found it difficult to access integrated services for people with dementia and Alzheimer's. Families become extremely frustrated at the difficulties they have in accessing the type of integrated services their older loved ones require. In the national dementia strategy reference is made to the consideration of appointing community dementia case managers. If we took such initiatives the health service and society would be much better off. Active consideration is being given to that approach in County Louth where there are approximately 1,200 to 1,400 people currently with dementia. County Louth is Ireland's first age-friendly county. The HSE, local authorities, DKIT, voluntary bodies and others have come together in recent years in a very co-ordinated fashion to look at how we can better deliver services for older people and how to meet some of the challenges that face society and the immediate community in the near future. The appointment of a community dementia case manager is being actively considered and would be a great boon for service users and their families.It would also allow health care professionals to take a closer look under the bonnet at what is needed for the frail elderly, particularly those with dementia. Families would also have the benefit of having a go-to person to allow them to access the broad type of services that people with dementia need. The ambition would be to develop that further over the next few years and, for example, resource community dementia case managers with the euros and expertise that they need to commission services that could be provided for people who need them in a very timely and efficacious way. There is a gap in the primary care system in terms of how we deal with cases like this, notwithstanding that significant improvements have been made in recent years and the new emphasis on primary care, which should be acknowledged.

I do not expect that the Minister will have an answer today to these types of very localised challenges, but it is something to consider. It is reflected in the national dementia strategy that we should be looking at different ways of dealing with the frail elderly with dementia to avoid repeated hospital admissions, which have a considerable knock-on effect in terms of bed capacity, staff and so on. There is a better way of dealing with people with dementia and the type of primary care services they require, such as speech and language therapy, physiotherapy, occupational therapy and so on. The outcomes would be much better. We need to put the patient, the client, the citizen, at the centre of the delivery of all our health services. A co-ordinated strategy would be better for our hospitals, patients and families and would allow the system to get improved data on how we can provide better services for the frail elderly, particularly those with dementia and Alzheimer's disease. As all of us in this Chamber know, this challenge is becoming deeper and we need to be better prepared. The national dementia strategy allows us to do that and there has been a new emphasis in this and previous budgets on how we can better address those issues.

Photo of Jennifer Murnane O'ConnorJennifer Murnane O'Connor (Fianna Fail)
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I do not want to repeat what has already been said, but I wanted to meet and speak to the Minister for Health, Deputy Harris, because he is my neighbour in Wicklow. I have been dealing with him in regard to a particular case, which I am sure the Minister of State has heard of, involving the respite centre, Tír na nÓg, which at this stage has been closed for more than a year. Even though we are getting information every few weeks from the HSE, and I am constantly ringing the HSE, I still have not been told when the respite service will open and where it will be. It is unacceptable.

To go back to what previous speakers said, the situation regarding accident and emergency departments, hospital trolleys and the people waiting on them is unacceptable. I know the Minister, Deputy Harris, and the Minister of State are doing their best, but every year for at least the past nine or ten years, the Minister for Health of the time has, particularly at Christmas which seems to be the peak, apologised for the system. That is unacceptable given that we are now in 2017. I can give the Minister of State the example of two cases that were raised with me in the past two days where families rang me, but I could give many more examples. In one case, a particular elderly man was brought to hospital in Kilkenny. He was put in the special unit and was there for a day or two. They took him out and put him on a trolley on the corridor, which is unacceptable. I have been ringing and he is still on the corridor.

I then had a lady, who is 82, who was admitted yesterday into the new accident and emergency department in Kilkenny - which I have to say is lovely - because she fell and broke her hip. They had to leave her in the accident and emergency department last night because they had no bed for her in a ward. I did not allow her to be put on the corridor. I told them she was not going on the corridor. I do not know if it worked but I insisted that an 82 year old lady was not to be put on a corridor because it is unacceptable.

I am here today, looking at us all and wondering who is to blame. I think we are to blame, and I think the people of Ireland, Deputies and ourselves need to look at this issue. We need to start getting out and picketing. We need to hold rallies and we need to make sure that in 2018 we do not see the same figures that we have seen this year of people waiting on trolleys. I received some figures that show up to 400 people are on trolleys every week in Irish hospitals. That is unacceptable. It is unacceptable because we pay our taxes. Many of these people seem to be elderly. They have their pride and their dignity and they do not want to be on a corridor on a trolley. I ask the Minister of State to raise this issue with the Minister, Deputy Harris. It is so important that, if nothing else this year, the trolley situation is sorted out and that we start either to build wards or reopen wards, because the problem is that we have wards that are not being opened. The reason we have that situation is because we do not have enough staff. We are also told that it is a health and safety issue. I am really annoyed because I find lately that I am getting more representations from families about this issue and I cannot help them. It is unacceptable. It is a very broken system.

I have mentioned respite and I would also like to mention Holy Angels, which is a school for children with special needs in Carlow. Five years ago it was promised a new school. I will compliment the Minister, Deputy Harris, because six months ago he came down and provided €150,000 for a leaking roof and some other works, but that is not good enough. We have been told that Holy Angels will get the money to build a new school this year. It is needed because Holy Angels cannot take in children because it has not got the proper facilities or space. A bigger school is needed because children on that waiting list are not being looked after.

Mental health is a massive issue all over Ireland. Statistics were given this week for areas that do not have aftercare like the mental health service in Carlow. There is a service there and everyone in it is working so hard. I compliment them, but there is no after-hours service. Again, we were on that list, because there is no service after 5 p.m. That is unacceptable.

I welcome the packages the Minister, Deputy Harris, mentioned. They are good because people are living longer and they want to stay in their homes. Putting a system and a fair deal in place for these people will help because many people do not want to go into homes or hospitals. They want to stay at home. We need to look at that in the long term, and I know the Minister of State will take this back to the Minister. I know he is doing his best but it is a very broken system. Unless somebody is accountable and responsible, we will be back here in 2018 and we will have the same system. It is not good enough.

Photo of Michelle MulherinMichelle Mulherin (Fine Gael)
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I welcome the debate and I also welcome the Minister of State, Deputy Corcoran-Kennedy, and the Minister, Deputy Harris, who has just left. I ask that the Minister of State raise with the Minister, Deputy Harris, the point that there needs to be an analysis of the health care groups which have been established and how they are actually operating, how effective they are and at what cost. We know the theory that streamlining health care services in hospitals along with academic input will improve the system, but I just question if that is really happening.

Since the advent of the health care groups, and to facilitate them, in the past year or more some 122 new general manager positions have created in Dr. Steevens' Hospital. These are new grade VIII positions at a cost of perhaps €100 million. Some 90% of managers are based in Dr. Steevens' Hospital and, as I understand it, 10% are in the rest of the country. At the same time as we see 122 new grade VIII general managers in Dr. Steevens' Hospital, there are 120 vacant consultant posts around the country that we cannot fill. We all know we cannot get front-line staff, including nurses, occupational therapists, physiotherapists and speech therapists. Why are we hiring more managers in what is supposed to be a streamlined and better service? What are these managers doing? Do they have budgets and what are their responsibilities? Why are they necessary? I am very impressed by many of the managers in our area. They are under a lot of pressure and they are making ends meet very well, but I was quite shocked to hear that these positions were created at this time. I acknowledge the additional funding in the last budget, but how can the Minister of State justify those positions? I would like some answers on that. I appreciate this may not be something the Minister of State can answer now, but I would like to know what is going on in Dr. Steevens' Hospital.

How are the health care groups operating on a regional basis? In my own area, there is the Saolta University Health Care Group, which incorporates Galway, Roscommon and Mayo. At present the budgets for home-care packages and primary care services right up to hospital services are going towards Galway because the main university hospital is there.The reality is that the budgets for home-care packages are not coming, as they ought to, to Mayo. There is proportionately more going to Galway to clear out trolley, etc., but we have a trolley problem in Mayo too. What is happening is that the big fish is getting more food and smaller hospitals such as those in Roscommon and Mayo, which are under pressure and, as far as I am concerned, give very good value for money, are losing out. We need more transparency. I have representations from people who need home-care packages. They need to be at home or to get out of a step-down facility or a nursing home, where the State has to pay for them because no bed was available in a step-down facility.

The next issue is that of primary care. In the Saolta west-north west region, we have seen a 16% increase in demand in primary care, but there has been a 25% cut in the budget in the past year. As a direct result, primary care services have been severely diminished, which is a reversal of what we ought to be doing given what we know about early intervention and about it being cheaper if we get to people earlier. However, resulting from this, in the past year alone 167 whole-time positions have been lost in our area. These include occupational therapists, physiotherapists and those working in the primary care sector. I am wondering what is going on. I know it is difficult and that there are so many aspects and layers to the health care and its budget, but these facts that I am bringing to the Minister of State do not impress me much.

I do not see any benefit arising in my county from the new health care groups for those who need health care and for the ageing population. They need these services. I would like to see some accountability on the part of the HSE for its 122 new grade VIII general managers. What is going on in St. Stephen's Hospital? I will conclude now. However, they should not be fattened up. Other areas need the resources. We cannot attract nurses. Who would want to work in an emergency department given the stress and pressure involved? A cousin of mine is a newly-qualified nurse. She has all the opportunities in the UK available to her. She would not dare come back to what she calls battle zones. This is complex. It is not just on the Minister. The HSE has service level agreements. What is going on? I would like some answers.

Photo of Rose Conway WalshRose Conway Walsh (Sinn Fein)
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I thank the Minister of State for being here and the Minister, Deputy Simon Harris, for attending earlier. I wish to address a couple of points. The first relates to the rural Ireland document. I presume the Minister and the Minister of State had an input into it. It is disappointing in its vagueness on what is being done to address health care from a rural perspective. I will refer to a couple of matters in it relating to mental health. There is no realisation in it of the situation. It states: "In line with the Connecting for Life Programme, provide support for local strategies across rural Ireland to address suicide and ... mental [health and] wellbeing." I know many people, and their families, who present at accident and emergency departments with mental health difficulties but are sent home. Young people, in particular, are presenting. These young people may have been protected under the child and adolescent mental health services, CAMHS, system and sometimes were residential patients under the CAMHS system. However, because the CAMHS criteria are so inflexible, once they reach the age of 18 they are kicked out and sent back into their communities. Time and time again, they present at accident and emergency departments and are sent home without any supports or services. I am extremely concerned for these young people and for those who are not being seen through the accident and emergency departments. I ask the Minister of State to address the matter in a real and proper way.

The document is too vague on health matters. While it needs more clarity and to be teased out, I welcome that there will be extra investment - €435 million for 90 projects - in public nursing home facilities and district and community hospitals. My fear, however, is that this provision is just to address the HIQA requirements and that we might end up with fewer beds than are there at present. Perhaps the Minister of State will clarify how many extra beds the investment will mean for rural Ireland. Does it address problems such as the closing down of bed spaces? Many of them, including some in my community, were closed down by the Fianna Fáil Government. For instance, in 2009 and 2010 half of the beds in Belmullet District Hospital were closed down. Is it the Minister's intention to reopen those beds with some of this capital investment? I think that is the way forward.

I do not like to use the word but there is almost a kind of a schizophrenic attitude towards primary care: we will invest in primary care; no, we will not; we will centralise and privatise it; and then back to primary care. It reminds me a bit of when the Department with responsibility for agriculture used to have us put as many sheep as possible on the hills and then have us bring them back down. The primary care model was first mooted in 2000-01 when the pilot projects were carried out. The Minister of State knows that they were never resourced - even in the boom time - in the way that was intended. There was never the investment in personnel or technology that is needed to run proper primary care centres. When the Government refers to 18 new primary care centres in the plan, it means nothing to the likes of me. That pilot primary care centres are not working because the investment has not been made is a huge failure.

There are many cancer patients who are not getting their treatment. They are ringing the hospital and being told to stay at home because the hospital does not have a bed for them. That these patients are not getting appropriate treatment is extremely serious.

I could raise many other issues, but I wish to raise one in particular. Has the Department examined the possibility of an all-island approach to health care? I see that as the way forward. Have any reports or scoping exercises been done? If not, will the Department oversee a consultation and scoping exercise on an all-island approach to health? We, including our Ministers in the North, will co-operate and work with the Minister and the Minister of State in whatever way we can to bring that about. Huge benefit could be gained through an amalgamation, if one likes, of resources under the NHS and the HSE. There are only 6.5 million people on this island. We should be able to provide a proper, robust and sustainable health service that is based on need and not on ability to pay.

Photo of Gabrielle McFaddenGabrielle McFadden (Fine Gael)
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I welcome the Minister of State to the House and thank the Minister, Deputy Simon Harris, for his attendance today as well. We all know that there is a huge issue with people on trolleys. It did not happen today or yesterday, although I understand January's numbers are down on those for last year, which is welcome. Listening to some, one would think the Government was happy with the situation and that the Government's aim was to have people on trolleys. It is obviously not the Government's aim. No one wants to see anyone on a trolley, particularly an elderly person. I also feel strongly that those involved in this issue should be offering suggestions on how we make this better rather than constantly criticising on the airwaves.

This is not just a case of throwing money and beds at the problem. This becomes clearer when we talk directly to those at the coal face. A multifaceted approach is required. One area I wish to highlight - I often speak on it - is the need to develop a sustainable and effective model of geriatric care in the community. Last year on a given day, three quarters of the patients in the accident and emergency department in a midlands hospital were elderly patients. They were presenting with various needs and some of them required intravenous medication, including antibiotics and basic hydration.If there was more joined-up thinking within the HSE in terms of the development of an effective community geriatric service model, many of these frail elderly people would not have to be treated in hospital and could be treated at home. These services should also be available on a 24/7 basis because patients, and elderly patients in particular, do not choose when to get sick. Connolly Hospital in Dublin is showing the way in this regard. I understand that the consultant geriatricians based at that hospital visit all nursing homes attached to it and hold regular team meetings with family members. They also liaise with palliative care teams and engage in decision making processes with multi-disciplinary care teams. This all adds up to preventing the needless transfer of patients to hospital by treating and caring for the elderly in the community, thus relieving pressure on the accident and emergency department and the hospital in general. In November 2013 Ms Mary Burke of Nursing Homes Ireland, in a statement to the Joint Oireachtas Committee on Health and Children, said she believed that the Connolly Hospital approach should be rolled out nationwide. She said that it would prevent readmission to acute hospitals. People might argue, rightly, that Connolly Hospital has patients on trolleys at the moment but it has definitely reduced the number of frail, elderly patients on trolleys.

A number of hospitals provide different models of geriatric care, including geriatric assessment units and outreach facilities. I would like to see community geriatricians teaming up with specialist nurses based in the community, visiting local nursing homes, community units and elderly patients in their own homes and treating them without the need to transfer them to hospital. As I have said already, this would not only help to reduce overcrowding but, more importantly, would preserve the dignity of older people and reduce the stress on families brought on by the ordeal of having an elderly person admitted to hospital. I have asked, on several occasions, for such a model to be rolled out across the country and I would appreciate a response from the Minister of State in that regard.

Photo of Tim LombardTim Lombard (Fine Gael)
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I welcome the Minister of State, Deputy Marcella Corcoran Kennedy, to the House and was pleased that the Minister for Health, Deputy Simon Harris, was present in the House earlier today. It is important to have senior departmental representatives here to discuss the health of the nation.

One of the key points made earlier in the debate was the fact that we have not built a new hospital in Ireland since 1998. In that year, the population was approximately 3.7 million. Today we have a population of 4.5 million and according to demographic profiling going forward, our population will increase by a further 1 million in the next 20 years. This means that planning our health service for the next 20 years and beyond will be very challenging. Major investment in hospitals and health infrastructure, including human resources, will be required. We must think outside the box and determine where such investment is needed. In my view, we will be looking at building new hospitals in places like Limerick, Cork and Galway. That will pose a very significant challenge for Government, whatever its make-up. We also need to put a funding strategy in place to fund this investment.

In my part of the country, the last new hospital to be built was Cork University Hospital, CUH, which opened in 1976, the year I was born. There has been no change in the intervening period. We must look at where we will put the new infrastructure. This involves working with the local authorities and local people to ensure that any new hospital will be capable of dealing with projected population growth and will be built in an appropriate location. We must develop a 20-year strategy for the development of our health infrastructure. One of the biggest challenges will be to find the best locations. If one looks at Cork, it has the potential to increase its population by 200,000 to 300,000 people over the next 20 years. A housing estate being developed in Carrigaline at the moment will have 1,800 houses it on completion. We need to have the infrastructure following such developments and that will be a core issue in terms of planning.

Cork has the largest waiting list for gynaecological services in the country. I attended a meeting with the Minister and every consultant in the maternity hospital three weeks ago and the statistics we were provided with were frightening. Action is required on this and many other issues. The Minister gave a commitment to revert to us on this and I hope he will give us a date for when he will provide the details of the review of what is happening in this area. At the moment, 50% of Ireland's gynaecological list is in one hospital in Cork. That is mismanagement and should never have happened. We must deliver on these major key issues.

Going forward, the biggest issue is that there will be an additional 1 million people in Ireland in the next 20 years. We must have a plan, going forward, so we can deliver core hospital infrastructure in every major urban centre in the country. That will be the real challenge for this Government and the next three or four governments that follow.

Photo of Marcella Corcoran KennedyMarcella Corcoran Kennedy (Offaly, Fine Gael)
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I thank the Cathaoirleach for giving the Minister for Health, Deputy Simon Harris and me the opportunity to speak about our health priorities. I thank Senators for their sincere and passionate contributions on a broad range of issues. These included mental health, local and national service issues, bed capacity, difficulties with emergency departments, our aging population, chronic disease and challenges in the areas of respite and home help care. Senators also referred to the analysis of the hospital groups on the type of services they are delivering, the increase in grade eight administrative positions in the HSE, difficulties with filling clinical vacancies, the all-Ireland approach to health care, home care packages and dementia care. The debate was broad and wide-ranging. Providing a response to many of the specific questions would be a matter for the HSE and I will ensure that Senators get answers to their questions.

I wish to take this opportunity to assure Senators of the Government's commitment to improving the experience of patients and their families using our health services. Improving the health service requires a concerted effort. It is important to highlight the fact that the delivery of health services in this country is the responsibility of the HSE. It implements Government policy, with the budget negotiated for the executive by the Minister for Health, Deputy Simon Harris. As the Minister pointed out earlier, health issues go beyond political affiliations. We all share the same goal and I am glad that there is a willingness to build a consensus in this House. We all want to develop a health service where people feel valued, respected and cared for. However, we cannot and should not underestimate the challenges that we face.

Overcrowding in emergency departments is unacceptable for patients, health care workers and policy makers. The Minister spoke of the various initiatives and efforts to tackle this problem and I echo his sentiments about recognising that when we talk about trolley numbers we are talking about people. The people must be at the core of everything we do. While there are many challenges, we cannot lose sight of the progress we are making. This year we have the highest health budget ever, at €14.6 billion. This represents an unprecedented investment which will make a real difference to the services we can deliver. Of course, delivery of health services by the HSE is not just about resources, but this year's budget allocation does demonstrate the Government's commitment to investing the gains from our recovering economy in improving our health service. We must maintain our focus on the way services are organised and delivered and on reducing costs. We must strive to work with the HSE to maximise the ability of our health service to respond to growing needs.

In respect of my own brief, we must focus on health promotion initiatives. We need to put more emphasis on prevention of health problems before they arise because the majority of chronic diseases are preventable. We also need to increase the uptake of various HSE screening programmes. The HSE website contains a wealth of information on screening programmes for cervical breast and bowel cancer, among others. The HSE also provides wonderful support to those who are trying to quit smoking on www.quit.ie, an excellent website which is well worth visiting.

The Healthy Ireland framework is a Government led initiative which aims to create a society where everyone can enjoy physical and mental health and where well-being is valued and supported at every level. The framework arose out of concerns that the current health status of people living in Ireland, including lifestyle trends and health inequalities, is leading to a future which is dangerously unhealthy and, very likely, unaffordable for us as a society. Healthy Ireland seeks to provide individuals and communities with accurate information on how to improve their health and well-being. It seeks to empower and motivate them by making the healthy choice the easy one.For example, last year the national physical activity plan was launched and the previous year we launched the national sexual health strategy. We are on course to significantly reduce the consumption of tobacco in society by 2025.

I was also delighted to launch A Healthy Weight for Ireland, the obesity action plan up to 2025. The action plan has 60 specific actions to improve this country's health and to reduce the burden of obesity across society. This policy and action plan aim to reverse obesity trends, to prevent health complications and reduce the overall burden for individuals, families, the health system and the wider society and economy.

We all have a role to play in the health and well-being agenda. No one action in isolation will reduce the increasing burden of chronic disease we face in the health service but if we reduce consumption of alcohol and tobacco as well as fat, sugar and salt in the food we eat, increase physical activity and get ourselves screened, we will improve the overall health and well-being of everybody in society. Often the small and sometimes not so small changes in lifestyle and behaviour will make a big difference. It can be challenging but that is the difference we should aim to achieve.

Sitting suspended at 2.35 p.m and resumed at 3 p.m.