Wednesday, 15 November 2017
Health Services: Statements
I am delighted to have the opportunity to address the House on health matters. The Minister for Health, Deputy Simon Harris, sends his apologies that he is unable to attend. I know that some Senators have raised particular matters which I will address later in my opening statement. I will start by giving an overview of some recent developments.
Any discussion will probably start with money and budget 2018. In October the Minister for Finance announced a total health budget for 2018 of €15.3 billion. An additional €646 million in current expenditure was allocated, with more than €200 million for new developments. Budget 2018 will mean additional front-line staff for the health service across the acute, mental health, disability, primary and community care sectors. This will provide for better access to health services, more help for families and additional supports for people with a disability and mental health issues, as well as for old and vulnerable persons. Funding is targeted at a number of key areas which include the following: a new access programme from 2017-18; helping families with the cost of medication and care; a shift to primary care services; expanding and developing mental health services; supporting disability services and supporting the most vulnerable.
The next step for the HSE after the budget is agreed to is to finalise its service plan for 2018 detailing the actual services to be provided with the moneys allocated. This process is ongoing between the Department and the HSE and should be concluded shortly.
Also in July the Minister announced the following immediate actions to start implementation of the report: an impact study of the removal of private practice in public hospitals to be chaired by Dr Dónal de Buitléir; a public consultation process on the future alignment of hospital groups and community health organisations; and plans to establish a governing board to oversee the HSE's performance. These represent the very first steps and a detailed implementation report is due to be submitted to the Government. In addition to the steps noted above, work on the health capacity review is progressing. This will be a comprehensive review concentrating not just on acute but also on primary and social care capacity. The emerging findings from the review will also inform the development of the new ten-year national capital plan. I understand the Minister, Deputy Harris, expects to receive the final report before the end of the year.
The development of primary care is central to the Government’s objective to deliver a high-quality, integrated and cost-effective health care system. The Sláintecare report also provided strong support for the need to strengthen our services as part of the overall reform of our health services. The provision of a €25 million primary care fund in budget 2018 demonstrates the Government's ongoing commitment to shifting the model of health care towards a more comprehensive and accessible primary care service in order to deliver better care close to home in communities across the country. This new funding will enable a range of initiatives to be progressed in 2018 which will focus on disease prevention and early intervention, particularly through the further development and expansion of GP services, community intervention teams and the recruitment of additional therapy posts. Throughout 2018 there will also be a continued focus on the development of primary care centres and primary care teams. In regard to GP care, the Minister is optimistic that agreement can be reached with GP representatives in the coming months on significant service developments that can also be introduced during 2018. As outlined by the Minister for Finance in his budget speech, this will be the start of a multi-annual change process that will enhance the role of primary care as the foundation of a more accessible and effective health service.
I would now like to talk about some developments in my own areas of responsibility. The provision of an additional €35 million in budget 2018 will help us to build on the work commenced in 2017 on the enhancement of community teams for child, adult, later life and mental health intellectual disability services. It will also help us to continue our move towards a full 24-7 service with an initial focus on increasing the provision of services on a seven-days-a-week basis. Further improvements are also planned to services for eating disorders and dual diagnosis. It is important, however, that we use this extra funding to ensure that not only are our services of a high quality but that we provide as seamless as possible a service for every service user. The HSE has been asked to prioritise this in 2018 and a further €55 million in additional funding will be provided in 2019. This will allow for a multi-annual approach to developing our mental health services, taking account of the review of A Vision for Change which is under way. It will see total additional funding provided for the implementation of A Vision for Change rise to €105 million over the period 2017-19.
Improving home care services so that people can live with confidence, dignity and security in their own homes for as long as possible is a key commitment of Government. Home supports are crucial to helping older people and, indeed, people of all ages with particular care needs to remain where they want to be, at home in the surroundings in which they are most familiar and comfortable. The current system relies heavily on family carers who play a crucial role in helping older people and others who need help to remain living in their own homes for longer. These carers not only make a profound difference to the health, well-being and quality of life of those they care for but also make an important, often unacknowledged, contribution to the economy. This is reflected in the 2016 census results published earlier this month which identified that some 195,000 carers are providing a minimum of 6.6 million hours of care per week.
In terms of resources, the HSE will spend approximately €370 million on home care in 2017 out of a total budget of €765 million for services for older people. This figure excludes funding for the nursing homes support scheme. The HSE’s national service plan provides for a target of just over 10.5 million home help hours, some 17,000 home care packages and 190 intensive home care packages, co-funded by Atlantic Philanthropies for clients with complex needs, particularly those living with dementia. In budget 2018 a further €37 million has been made available for older people’s services in order to further strengthen supports for older people, in particular to facilitate speedier discharge from acute hospitals over the winter period. A significant proportion of this additional funding will go towards home care services.
The resources available for home care services, while significant, are limited and, with the increase in our elderly population, demand is growing year on year. Accordingly the services and allocation of resources to individual clients require prudent management on an ongoing basis as demands for services increase. In this context, those clients who are assessed and approved for home care and who are not being provided immediately with a service are risk-assessed and placed on a waiting list for a resource as it becomes available. It is important to note that many people also purchase home care services directly from private providers. While the existing home care service is delivering crucial support to many people across the country, it is recognised that home care services need to be improved to better meet the changing needs of our citizens. The Department is of the view that a stand-alone funding scheme designed specifically for home care, together with an effective system of regulation, is needed.
In 2016 the Department’s intention to bring forward legislative proposals for the regulation of home care was indicated in the "Better Health, Improving Health Care" report. A Programme for a Partnership Government signalled the Government’s commitment to the introduction of a uniform home care service. My predecessor as Minister of State with responsibility for mental health and older people, Deputy Helen McEntee, played a key role in advancing this undertaking, tasking the Department with the development of a new statutory scheme and system of regulation for home care. The new scheme will improve access to home care in an affordable and sustainable way. It will provide transparency about individuals’ eligibility for services and about service allocation, and ensure that the system operates in a consistent and fair manner across the country. The scheme will also result in more effective integration with other health supports, including nursing, therapies and other primary care services.
A system of regulation will be designed to ensure public confidence in the standard of the services provided and to bring Ireland in line with best international practice. It will be important to get the balance right in this regard and to ensure that the system of regulation is effective and not overly bureaucratic. As an initial step in developing the new system, the Department commissioned the Health Research Board to undertake a review of the home care systems in place in four European countries. The review, which was published in April of this year, will help us to ensure that Ireland’s new home care scheme and system of regulation is informed by international experience.
The Department also launched a public consultation process on the financing and regulation of home care in July of this year. We received over 2,600 responses to this phase of the consultation process. The purpose of this public consultation was to enable us to find out about the views of service users, their families and health care workers on current and future home care provision. Preliminary analysis of the submissions has been undertaken and we would be happy to share details of some of the initial findings, if that would be of assistance to the House. A full report on the findings will be published early next year which will inform the Department’s development of the new funding scheme and regulatory arrangements.
The nursing homes support scheme provides financial support towards the cost of long-term residential care services in nursing homes and ensures that long-term nursing home care is accessible to everyone assessed as needing it. Participants contribute to the cost of their care according to their means, while the State pays the balance of the cost. The scheme aims to ensure that long-term nursing home care is accessible and affordable for everyone and that people are cared for in the most appropriate settings. The scheme, or fair deal, is now in existence for over eight years. This year, with a budget of €940 million, the scheme is providing financial support to over 23,000 people and, next year, the budget for the scheme will increase to almost €950 million. The waiting time on the placement list has been maintained at four weeks since 2015.
While the care delivered to residents in our community hospitals is generally of a very high standard, many of these services are delivered in buildings that are less than ideal in the modern context. It is important, therefore, that we upgrade our public bed stock and this is the aim of the five-year capital investment programme for community nursing units which was announced last year. This provides the framework to allow for an enhanced programme to replace, upgrade or refurbish these care facilities, as appropriate. Significant work was undertaken to determine the optimum scheduling of projects within the phased provision of funding to achieve compliance with national standards.
I will now look at some of the matters I understand were raised by individual Senators. With regard to emergency departments, there is no doubt that too many patients continue to wait on trolleys for admission to hospital on a daily basis within our health service. The Minister is cognisant of the distress that cramped and overcrowded conditions in some of our hospital emergency departments cause for patients and their families, and that these crowded conditions make emergency departments a very challenging environment to work in for doctors, nurses, hospital staff and hospital managers. Notwithstanding this, there is an often untold story of achievement within a system working hard to deal with growing demand for health care services. Last year there was a 2% increase in inpatient and day-case activity over 2015, as well as an approximately 5% increase in emergency department attendances - that is over 57,000 more patients, or the equivalent to the population of County Carlow. This year emergency department attendances are up over 1.8%, or over 16,000 patients, to the end of September, including a 5% increase in emergency department attendances by people over the age of 75.
Within this context, overall trolley numbers have remained static when compared to last year, despite these increased attendances. As of 6 November 2017, HSE data show there were 0.8%, or 625, fewer patients waiting on trolleys this year as compared to the same period last year. In addition, some hospital sites have made a considerable leap forward in terms of improving their trolley performance. For example, the HSE end of September TrolleyGAR data for St. Vincent’s Hospital in Mayo, Our Lady of Lourdes Hospital in Drogheda and Beaumont Hospital in Dublin, to name but a few, are showing a reduction in trolley numbers ranging from 30% to 50% as compared to the same period in 2016.This performance should be acknowledged.
Another issue raised was infection prevention and control of carbapenemase-producing enterobacteriaceae, CPE, and flu.Our system is working hard to grapple with the challenge of infection prevention and control, specifically the emergence of virulent antibiotic-resistant bacterial strains, or superbugs, as they are known. The Minister, Deputy Harris, recently activated the public health emergency plan to address CPE in our health system. This means the national public health emergency team will oversee an enhanced response to this on a weekly basis. These arrangements are in line with standing emergency plans which have been activated in the past in response to pandemic influenza and Ebola preparedness.
Each winter, the system must also deal with the increased demand for services due to the prevalence of the flu. Vaccination remains the most effective means of preventing infection by seasonal flu viruses and can reduce severe disease that can lead to hospitalisation and death. Since 2 October 2017, the flu vaccine has been available free of charge from GPs for all people in at-risk groups, and from pharmacists for everyone in at-risk groups aged 18 years and over. I would like to take this opportunity to urge those in at-risk groups, and those health professionals who have the highest degree of contact with vulnerable patients, to get the flu vaccine as early as possible this year.
Another issue raised is winter planning and funding. Tackling overcrowding in emergency departments, EDs, is a key commitment of this Government and I am delighted that €40 million in additional funding in 2017 has been made available as part of the 2018 budget to address winter pressures and waiting lists over the rest of this year. A further €40 million has been allocated for measures to improve access to unscheduled care and other acute hospital priorities in 2018. Some of this funding is already being utilised within the system with an additional 45 home care packages and 20 transitional care beds per week being provided for the duration of the winter period. This funding will allow for patients to return home, or to an appropriate community setting, when clinically appropriate, thus helping to alleviate some of the pressure our hospitals are currently experiencing. Funding will also be provided to increase bed capacity this winter and moving forward, as part of service planning for 2018.
University Hospital Limerick, UHL, emergency department was also raised. The ED in UHL is one of the busiest in the country, with 65,000 attendances annually. Last year the hospital experienced a 4.6% increase in new ED presentations, and demand for ED services at the hospital continues to rise. Since its opening on 29 May 2017, the new ED at UHL has seen a growth in activity. Initial data from the HSE for September indicates that ED attendances have increased by 4% and ED admissions have increased by 9.4%, as compared to the same period last year. The increased attendances may perhaps be directly linked to the opening of the new facility. The literature suggests a 10% growth in activity when new infrastructure is opened. However, this is expected to peak and return to more normal levels.
Nonetheless, the Government is aware of the overcrowding situation in the new ED of UHL. The Minister for Health has raised these concerns with UHL management, and has sought assurances that actions be taken to address the situation. As such, the University of Limerick Hospital Group has put in place an ED performance improvement plan which sets out in detail how performance will be improved. This is currently being implemented in Limerick.
I should perhaps mention that the new €24 million ED is three times the size of the previous ED, and provides modern, safe and fit-for-purpose facilities. It provides high-quality, comfortable accommodation that protects patients’ privacy and dignity. The new ED is designed around a pod-based system and this helps to improve efficiency. Once patients have been triaged, they are assigned to different areas of the ED, depending on the seriousness of their condition. Clinical teams are assigned to these units and are responsible for the treatment, discharge or admittance of patients within their particular unit. This serves to improve working conditions for UHL staff.
Another issue raised was waiting lists. Reducing waiting times for the longest-waiting patients is one of the Government’s key priorities. It is for this reason that €15 million was allocated to the National Treatment Purchase Fund, NTPF, in budget 2017 in order to reduce the numbers of long-waiting patients. This year the HSE and NTPF have worked effectively together to ensure the best use of public hospital capacity and the private hospital system to meet the needs of patients waiting for inpatient and day-case procedures. The inpatient-day-case and outpatient waiting list action plans this year focused on reducing the number of patients waiting 15 months or more for inpatient and day-case treatment or for an outpatient appointment by the end of October.
The targets set under the inpatient-day-case and outpatient waiting list action plans were achieved at the end of October with over 31,600 patients coming off the inpatient-day-case waiting list and nearly 100,000 patients coming off the outpatient waiting lists. In addition the NTPF has worked with both public and private hospitals to arrange insourcing and outsourcing initiatives. Through these initiatives over 18,200 patients have been offered treatment, and of these over 5,900 patients have accepted an offer of treatment and almost 2,600 patients have received their procedure. The impact of this focused effort on reducing long wait times for patients can be seen in the NTPF waiting list figures for the end of October. These data show that for the third month in a row the overall waiting list figures for the inpatient-day-case waiting list have fallen.
To ensure the continuation of this strong focus, the recent budget announced that additional funding in the region of €10 million has been allocated for the remainder of 2017 to the NTPF to fund patient treatment across a range of key specialties and procedures, such as hips, knees, cataracts, ear, nose and throat and others. In addition, further funding of €700,000 was allocated in October by the NTPF to roll out an endoscopy initiative for 2017. Approximately 700 of the longest-waiting patients will receive endoscopy procedures. The NTPF’s aim is that, under this initiative, there should be no patients waiting longer than 18 months for an endoscopy at year end. Indeed, the NTPF has advised that over 2,700 authorisations for endoscopies have been issued to hospitals so far. The recent budget announced a total allocation of €55 million to the NTPF for 2018 to address waiting lists and more than doubles their 2017 total allocation.
Next year will see a continued focus towards long-waiting patients, and overall waiting list numbers. It is estimated that this funding will provide treatment to patients waiting for inpatient-day-case treatments across a range of specialties and procedures, through working with both public and private hospitals.
The issue of scoliosis waiting lists was raised. This will be in addition to the HSE’s hospital activity funded under budget 2018. A further €10 million of funding will be made available to the HSE in 2018 to address other waiting lists, including children in need of paediatric orthopaedic and scoliosis procedures. For the first time in a number of years the waiting list for scoliosis-related surgery is decreasing. This is as a result of additional activity within our paediatric hospitals and the outsourcing initiatives. At beginning of February, 312 patients were awaiting spinal fusion and other spinal procedures. Currently, there are 175 patients on the scoliosis active waiting list.
The HSE is focused on maximising all available capacity, which has included the recruitment of theatre nurses in both Our Lady's Children's Hospital, Crumlin and Children's University Hospital, Temple Street, and an additional consultant orthopaedic surgeon in Crumlin who started in September. Patients have also transferred for treatment to the Mater Misericordiae University Hospital, Cappagh National Orthopaedic Hospital, the Royal National Orthopaedic Hospital and the Portland Hospital in the UK, and St. Franziskus hospital in Germany. Further investment in paediatric orthopaedic services for next year is being considered in the context of the service plan 2018 discussions.
Another issue raised was radiation therapy at St. James's Hospital. The national plan for radiation oncology provides the overall framework for the development of radiation oncology services in Ireland. In Dublin, radiation therapy is provided in three hospitals through the St. Luke’s radiation oncology network. These are St. Luke’s Hospital in Rathgar, Beaumont Hospital and St. James's Hospital. Radiation therapy is also available in Cork University Hospital, CUH, and University Hospital Galway. A new facility in CUH is under construction and will provide five linear accelerators once complete. Enabling works for a new facility at University Hospital Galway, UHG, are also under way.
Public services are contracted from private facilities in Limerick and Waterford. Patients from the north west can now be referred to the north-west cancer centre at Altnagelvin Area Hospital, Derry, for treatment, under a cross-Border service level agreement. The radiation therapy centre at St. James’s has four linear accelerators and provides a range of services for patients who require radiation therapy. Overall, comprehensive radiation therapy facilities are available to all patients who require them. These will continue to be developed to meet the projected increasing demand over the coming years.
Another issue raised by Senators was the paediatric transplant services. Currently, all Irish paediatric patients travel to the UK for heart, lung and liver transplants under the treatment abroad scheme, while kidney transplants are carried out in the Children’s University Hospital, Temple Street. Organ Donation and Transplant Ireland, ODTl, has advised that the current practice in regard to paediatric liver and lung transplants is working well. Between eight and 12 paediatric liver transplants are performed each year, with paediatric lung transplants occurring approximately once every two years. There are no plans to change this practice.
Paediatric heart transplants occur five to six times a year. There is a four-hour window of time, from when a donor heart becomes available, in which a patient needs to present for a heart transplant to take place. At present, the clinical recommendation is that paediatric cardiac transplant patients should relocate to the UK while awaiting heart transplant. I recognise that this is an exceptionally difficult and stressful time for families. I have requested that the HSE facilitate those families who opt to relocate by providing support and a financial contribution to their living costs in the UK. The possibility of undertaking paediatric heart transplants in Ireland was raised earlier this year. If any change to the current system was to be pursued, it would take a considerable time to implement. ODTI has advised that it is not feasible for Ireland to undertake paediatric heart transplants until the new children’s hospital is opened.
The Health Information and Quality Authority, HIQA, undertook a health technology assessment, HTA, to evaluate the treatment and transport options for priority 1 transfer patients. The majority of priority 1 transfer patients are paediatric patients transferring to the United Kingdom to undergo heart or liver transplant surgery. The HTA focuses on options for the transfer of these patients, but also explores commissioning paediatric heart and liver national transplantation centres in Ireland as a potential long-term alternative. The HTA advises, given the significant capital and staffing resources that are required, that it may be more realistic to consider the development of a transplant service in the context of the opening of the new children’s hospital rather than in Our Lady’s Children’s Hospital, Crumlin. The Department of Health will undertake a detailed analysis of the HTA in order to consider longer-term options in detail and is working with the HSE to consider the best option to address the service need in the medium term.
Organ Donation and Transplant Ireland, ODTI, has advised that it is not feasible for Ireland to undertake paediatric heart transplants until the new children’s hospital is opened.
The Health Information and Quality Authority undertook a health technology assessment to evaluate the treatment and transport options for priority 1 transfer patients. The majority of priority 1 transfer patients are paediatric patients transferring to the United Kingdom to undergo heart or liver transplant surgery. The health technology assessment focuses on options for the transfer of these patients but also explores commissioning paediatric heart and liver national transplantation centres in Ireland as a potential long-term alternative. HIQA advises that, "[g]iven the significant capital and staffing resources that are required, it may be more realistic to consider the development of a transplant service in the context of the opening of the new children’s hospital rather than in Our Lady’s Children’s Hospital, Crumlin". The Department of Health will undertake a detailed analysis of the health technology assessment in order to consider longer term options in detail and is working with the HSE to consider the best option to address the service need in the medium term.
The Minister gave his approval for the establishment and funding of an All-Island Congenital Heart Disease Network centred on Crumlin hospital and serving as an all-island centralised hub for paediatric cardiothoracic surgery and interventional cardiology. The All-Island Congenital Heart Disease Network is an example of what can be achieved in health terms by collaboration between North and South. It reflects the commitment of people, North and South, and the Government’s commitment, to the provision of an optimal congenital heart disease service, with the critical mass to provide safe, high-quality outcomes for congenital cardiac surgery and associated cardiology services for all children and young people in Ireland. This network will ensure that a very vulnerable group of sick children and young people get the best level of care, no matter where they come from on the island. It clearly demonstrates the potential of North-South collaboration on health care to bring tangible benefits and outcomes for patients across the island of Ireland.
That concludes my statement and I look forward to hearing the thoughts and views of Senators on the direction the health service should take and to our continued engagement on health matters. I am joined by officials who will be taking notes and helping with responses towards the end of the debate.