Statements by Minister Harney and Minister of State Moloney at the Private Members Debate on Our Lady’s Children’s Hospital, Crumlin – 23rd/24th June 2009
Minister for Health and Children (Deputy Mary Harney):
Nothing concerns parents more than the health of their children. Nothing concerns people worthy of election to this House more than the health of our children. One of my main priorities as Minister for Health and Children is to try and put in place a new national paediatric hospital in which we could bring together the three children’s hospitals in Dublin on a single site in order to deliver better patient care for our children.
In this debate I wish to refute some of the suggestions made opposite. I have made many visits to Our Lady’s Hospital Crumlin. I hold the hospital in the highest esteem. Crumlin hospital is a centre of excellence, delivering outstanding care to the sick children of Ireland. It is the tertiary hospital for the vast majority of children with a serious illness. Its cancer services which were centralised there by Dr. Eoin Smith, are second to none. I have said in this House before and I repeat it now that the outcomes for children’s cancer in Ireland are top of the class, world-wide. We are at the top because we have centralised the service, even though, following initial diagnosis and surgery, some of the services are delivered in 16 hospitals around the country. This service was led by Dr. Eoin Smith of Crumlin hospital. What we have learned from the treatment of children’s cancer is what we are trying to achieve for adult cancers, with the concentration of the services into eight centres.
I refer to the international peer review of haemophilia services last October. The review group said that Crumlin hospital operated to best international practice. The group recommended the appointment of a new paediatrician-haematologist and Dr. Beatrice Nolan was appointed in March of this year. She came from the national tertiary centre at St. James’s Hospital which is an international service.
The standard of care provided in Crumlin, in Tallaght and in Temple Street hospitals is exemplary by any standards but we could do better. I have said and I repeat here that it has been suggested to me that we could save €20 million a year on the operation of those three hospitals by bringing them together on a single site. In reply to Deputy Catherine Byrne, the people who were the biggest persuaders in my decision to move to a single children’s hospital were some of the doctors in Crumlin. They were strongly enthusiastic for the establishment of a new children’s hospital bringing the three existing hospitals together to be co-located with an adult teaching hospital. Two sites were under consideration, at St. James’s Hospital and at the Mater Hospital and the Mater was chosen as the favoured site. It was only at that point that some of the paediatricians did not agree with the decision. However, there was unanimous agreement and the submission made by the hospital was for a single children’s hospital. The alternative is to build two new hospitals, one for Crumlin and one for Temple Street.
Crumlin hospital has 170 doctors and 708 nurses. It admits 30 patients a day and 45 day cases a day are carried out. A total of 102 out-patient appointments are seen every day. Temple Street hospital has 110 doctors and 365 nurses with 20 admissions a day, 14 day cases a day and 70 out-patients appointments a day. I do not have the information for Tallaght Hospital to hand. We want to bring these resources together in order to give better services to the patients.
Better services for patients will be achieved by having one payroll department, one human resources department, one waste management department, one department dealing with materials, a central sterile department instead of four, which was one each for the three children’s hospitals and one for the Mater. This is where the €20 million saving will be made. There will be one chief executive officer, one director of nursing and so on. In the short term we are seeking to integrate those services. It has now been agreed to have a single department of surgery. Deputy Reilly is correct in that we have five paediatric surgeons between those hospitals. One surgeon is due to retire and three new surgeons will be appointed this year. There will be seven surgeons and instead of them all being on call in three hospitals, a single service will be available across the three hospitals.
Dr. Des Bohan has come here from Canada. He is a very experienced paediatrician with specialist training in critical care and he will organise a joint department of critical care between Temple Street and Crumlin. Tallaght does not have a critical care department. He has made recommendations which we want to implement. In advance of building the new facility in 2014, we are moving to integrate the services. If Crumlin were to work more closely this year with St. James’s Hospital in the area of blood products and in the procurement of drugs with the other two hospitals, they could save €4 million.
Furthermore, I understand they are owed €3 million by private insurers. Temple Street Hospital seems to have a better record on making applications to private health insurers. That amounts to €7 million which we could get this year by closer integration on the procurement of products, particularly blood products for haemophiliacs in St. James’s Hospital, which is already approximately €900,000 over budget. I make these suggestions to be helpful. No matter who is in my seat, we will not have unlimited resources for health care. No country in the world has such unlimited resources. We must do our best.
There has been a 39% increase in funding for Our Lady’s Children’s Hospital in Crumlin since 2004. That is considerable. Approximately 74% of the increase goes on pay and 26% on non-pay. Listening to Opposition speakers, one would assume there was no additional staff in Crumlin. Since 2004, there has been an 18% increase in medical staff, a 29% increase in nursing staff, a 19.7% increase in health and social care staff, a 19% increase in management and administration staff and an 11% increase in general support staff. We have put substantial resources into Crumlin hospital, as we have in every other hospital.
Crumlin is being asked for a 3% cut, which is no more than every other hospital. Fine Gael published its pre-budget plan in October. On page 19 of that document, they said we must find 3% saving in every Government Department and every single activity. On page 21, they go on to say that existing levels of service should not be the basis for deciding budgets. This is the case in the health system because we want to try to maintain the previous year’s level of service. Fine Gael says we should have a 2% cut and that existing levels of service should not be the basis for deciding budgets. I do not make this point to be partisan. I am surprised to hear such proposals from a spokesman who aspires to be a member of a Government, particularly as Minister for Health and Children, in a time of unprecedented economic challenges. We will spend 40% of the money we will raise this year in income tax on the public health service. I do not know of any other country which spends 40% of all taxation on its public health system. We are spending a considerable amount of the money. In fact, we are borrowing more than €20 billion. Every single penny we are spending is actually borrowed money. We do not have the option of bringing a supplementary budget for hospitals before the House.
People are being asked to make an efficiency saving. All of us can do better, no matter how good we are. My Department is also making savings through voluntary early retirement and other schemes. We must all do better because there is less money. No matter who is Minister for Health and Children, that will be the reality for the next 24 or 36 months. In that context, it is not unreasonable to ask people to make efficiency savings. I find it strange that when we ask hospitals to make efficiency savings, some hospitals decide that the most sensitive area is the one that must be cut first.
Decisions on patient care and clinical care must be made by clinicians. They cannot be made by me or by the Health Service Executive. The HSE has given Crumlin hospital a budget of €139 million. I have already explained how there is €3 million outstanding from private health insurers and how €4 could be saved by greater co-operation with St. James’s and other hospitals. Funding must be allocated on the basis of decisions made by clinicians within the hospital.
The Fine Gael alternative suggestions are flawed for a number of reasons. Deputy Reilly referred again to the €16 million spent on advisers. When one is spending such large sums it is not unreasonable to get outside expertise. Even if we are spending too much on advisers, Deputy Reilly seems to use this €16 million for every problem that arises. Two weeks ago, it was to be spent on orthodontics, tonight it is to be spent on children’s services, next week it will be something else. One cannot spend the same €16 million on every problem one identifies. Taxi bills are for patients who travel for dialysis and other treatments. Staff taxis are used, in the main, by people who are called out at night and who may not have their own transport. They are used, in the main, by people who are providing front line services and not by administrative staff. If the HSE were to abandon its arrangements with private taxi companies, keep its own fleet providing 24/7 cover and pay for insurance, driver training and vehicle replacement it would be substantially more expensive. That is not to say we should not look at transport costs. Everything is being looked at.
I was criticised recently for centralising the issuing of medical cards in order to free up 300 people. The Opposition demand that we cut the number of administrators but oppose our efforts to provide services more efficiently. They cannot have it every way. Every cost is being examined. Since Professor Tom Keane became director of the national cancer strategy we have provided a volunteer transport service for cancer patients, run by the Irish Cancer Society. An allocation of €500,000 has been given to that service and it is working incredibly well. I would love to see it expanded because I am sure many people would be happy to give their time voluntarily to transport patients for essential care.
How do we organise services so that more money is spent on the care of the children? In the short term, this can be done by integration between the three hospitals. The HSE is headed by a paediatrician who is a former doctor in Crumlin, Professor Brendan Drumm. He has asked the former CEO of St. James’s Hospital to head a group to work with the three hospitals and, in particular, to work with Crumlin to come up with a plan for scoliosis patients for the rest of this year. If everyone applies his or her mind, ingenuity and sense of innovation, that issue can be addressed.
Yesterday, the board of Crumlin hospital decided not to close any further wards or theatres during the months of July or August. The board made the decision at a regular meeting. I had no part in the decision and I would be surprised if they were influenced by Deputy Reilly’s motion. I welcome that decision and the fact that the board was able to make it in the context of the current financial arrangements.
The way forward is the single children’s hospital but we will not have that until 2014. A huge amount of work has gone into that project. The chief executive of the development board has been appointed. He is the former deputy chief executive of St. James’s Hospital. The medical director is Dr. Emma Curtis from Tallaght. A huge amount of work is under way. Some people would prefer a different site for the new hospital. However, this is not about a piece of land or a building. It is about bringing expertise together in a single entity with all the benefits which flow from that.
The last thing we need is to politicise the plight of some of the sickest people in the country. I hope we can avoid that. Managers, Ministers, Opposition Deputies, doctors and nurses must look at how we can provide services in a more innovative fashion. I salute the fact that this year’s activity level for Crumlin is already ahead of last year’s. There are more day cases and we are moving to a situation where 85% of surgery is done on a day case basis. When I had my tonsils out as a child, I was in Jervis Street Hospital for a week. We have come a long way from that. Safe care can be provided on a day case basis, greatly reducing the need for 24-7 staffing. The more rapidly we can move in that direction, the more resources that can be provided to a larger number of people.
The budget for the National Treatment Purchase Fund is 0.5% of what we spend, and those who work on it do a fantastic job. They are maligned constantly. The fund has paid for the treatment of some scoliosis patients and two more will be treated next month in Cappagh National Orthopaedic Hospital. The fund does not pay three times more for the service there. Cappagh National Orthopaedic Hospital is a public hospital; it is as public as Crumlin hospital. The State does not own Crumlin hospital, it funds it. The State does not own Temple Street Childrens University Hospital or the National Children’s Hospital, Tallaght. There is a unique situation in the Dublin area whereby the State owns none of the hospitals but funds them. The new children’s hospital will be a State-owned hospital, and rightly so. There is huge support for that. Clearly, there are limitations with regard to hospitals the State does not own.
Professor Drumm has appointed one of his main finance personnel to go into Crumlin hospital to work with the staff there and to examine the activities with a view to supporting the hospital. If the hospital moves to an automated system for claiming from private health insurance, for example, it might help to secure that €3 million I mentioned. We must look at the many innovative ways to provide the money for the treatments and less money for administration and so forth. If all of us approach the issue of paediatric services on that basis, there is no doubt that no child would have to wait unduly for the treatment he or she needs and no child should ever be in pain while awaiting necessary treatment.
Minister of State at the Department of Health and Children (Deputy John Moloney)
Last week I responded to the Private Members’ motion and listened with great interest to Deputy Mary White and Deputy Simon Coveney. On that evening I refuted the allegation that critically ill children have had their service withdrawn. I reiterate that this evening. I support the Minister and her commitment to reforming the health services. We see that again in this particular area. I have in mind what has taken place previously, particularly the initiative she took to reform cancer services. The same arguments were made by Members on the other side of the House, yet we have seen the progress that has been made. I am more than pleased with it. Other developments were the consultants’ contract and progress with accident and emergency services. However, that is not the argument before the House.
I do not intend to be drawn into the remarks thrown across the floor that we are more interested in bankers because, clearly, people who are knowledgeable would not say that in the first place. I do not accept it. The strategic view the Minister has taken is the one on which we should focus. I also share her view about throwing out the same old remark about the money for every area coming from the same small pot of money. I cannot buy into that. It is nonsensical to include the issue of taxi fares when it is clear that most of the taxi expenditure goes to provide transport for essential services in the HSE. It is not worth responding to in the context of this debate. The real issue is the Minister’s strategic policy. While Crumlin hospital is central to the debate before the House, the most important issue is the sensible initiative taken to establish one hospital, instead of three, to serve paediatric needs across the city. With regard to the saving of €6.5 million, it must be put on record, because obviously it is a position that is not being taken up, that the issue is to protect front-line services, which is so important. It is also important to delve into the background to this debate and take the longer-term point of view. We are talking about initiatives for the appointment of new clinical directors. This is quite important and should make the public realise that the Minister has total command of the issue of providing essential services.
The issue we are debating is the €6.5 million. The HSE has advised that based on the financial performance for the first five months of 2009, the hospital should achieve a break even position at the end of the year. This assessment takes account of cost saving measures totalling €6.5 million, which have been agreed with the hospital and which are to be implemented over the remainder of the year. Much of the focus of the discussion between the hospital management and the HSE has been on ensuring that all areas of non-pay expenditure are critically examined and that costs are reduced where possible. The allocation for Crumlin hospital for 2009 is €139 million, an increase of more than 39% over the past five years. As with all expending facilities, the reduction that is expected is 3% over the 2008 figure. A particular challenge for the hospital is that it has been operating with 91 posts above its ceiling and employs 641 whole-time equivalents.
The point was made during the last Private Members’ debate that apparently the issue was purely to deal with life threatening illnesses. It should be pointed out that when the orthopaedic services in Cork were severely disrupted in 2007 by the early retirement of the consultant paediatric surgeon, efforts were made to recruit a replacement without success. At that time arrangements were put in place for Crumlin hospital consultants to provide the outpatient clinic service in Cork, with patients requiring surgery transferring to Crumlin. It should be noted that the HSE pays €0.5 million per annum for the service. It also pays the consultants separately. The HSE intends to advertise again for a paediatric consultant with a special interest in orthopaedics.
I heard the criticism last week of the National Treatment Purchase Fund. The fund has identified a number of cases from the waiting lists for treatment at Cappagh hospital. Two operations have been carried out for scoliosis patients as a result. Further cases are being reviewed. Discussions are ongoing with the three paediatric hospitals with regard to the provision of orthopaedic services generally and, in particular, the treatment of children suffering from scoliosis. The National Treatment Purchase Fund strongly rejects the recent media claim, which I was alarmed to hear on the radio one morning, that scoliosis procedures arranged by the fund cost two to three times more than similar procedures performed in the public hospital system. The claim is entirely incorrect. No evidence has been offered to support the claim which comes, of course, from unnamed sources. The prices the National Treatment Purchase Fund pays for operations are as competitive as the published prices for the public hospital system and no premium is paid for work through the fund. Achieving value for money for the taxpayer throughout the process of arranging faster treatment for the longest waiting public patients is a matter of the highest importance for the fund.
The commitment of the Minister is not just the short-term one of reducing and dealing with the overspend. Hospital care for children is provided across the three hospital sites in the city. Significant progress has been made over the years in developing paediatric services in Crumlin. There has been development of the national paediatric hospital, a priority project for the Government. It is of strategic importance in the development of paediatric services in Dublin and nationally. Work has been ongoing to move towards that model of care in terms of closer integration and co-operation of the existing three hospitals and the most effective use of resources.
It was claimed this evening that the cut was made without any concern. However, the Minister outlined the overall strategic position for providing paediatric services and made the point that the reduction is expected not just of Crumlin hospital but of all hospitals so they can remain within their service plans. I do not wish to make political points and I accept that dealing with health issues in children is important. However, when one considers that 40% of taxes go to the health service it does not make sense to suggest that we can just allow continuous overspends without a service plan being agreed as well. The HSE is fully aware of the financial challenges faced by the hospitals and is involved in ongoing discussions with hospital management regarding its 2009 financial allocation service plan. The priority is to ensure that services are maintained at an optimum level, in agreement with the Department and the HSE.
Our Lady’s Hospital Crumlin is no different from any of our hospitals. In common with all other hospitals, Crumlin is faced with the challenge of delivering a high-quality service to its patients while remaining within budget. A top priority will be to protect patient care. It has proved necessary for Our Lady’s Hospital to stay within budget. In that regard I agree with the Minister who made the point that Professor Drumm, who has known expertise in the area, clearly supports the notion that all hospitals should live within their service plan.
Having clinical directors is a tremendous initiative. Regarding the integration of the three hospitals, this key initiative is the same as the appointment of Professor Tom Keane in the cancer area and is the specific way forward. The appointment of a new clinical director to operate across the three hospitals is pivotal to the success of the integration of current paediatric services. The appointment of a director in the near future who will have responsibility for all three paediatric hospitals in Dublin in preparation for the advent of the new paediatric hospital shows the surety of the policy proposal. I re-emphasise that this post promises to contribute significantly to the achievement of more efficient and effective services, in Crumlin and the other two hospitals. It will draw the medical professionals together with greater co-operation and integration in respect of the critical service they provide.
The new consultant contract also allows the model of clinical director to operate in a way that is internationally recognised as effective. This was not possible in the old manner, before the new contract was negotiated and went into operation. The new model allows equitable access to care based on medical need, more efficient use of public resources and a requirement to support patient safety initiatives in high-quality acute sector services.
I shall deal with some of the issues regarding the service provided at Crumlin. So far this year, the hospital has delivered more treatments to patients than in the same period last year. In the first four months of 2009, there were 3,704 treatments for children as in-patients, running approximately 6% ahead of the service plan target. There were 5,095 day places. Staffing levels at the hospital have increased by 24% since 2004. This percentage reflects the increase to the approved ceiling of 1,550 but the actual increase is higher, at 31%. Day care activity has increased by 26% since 2005, outpatient attendance by 16% and elective admissions by 12%. The issue of cancellation of operations has cropped up, creating the notion the hospital is not keeping to its service plan. It is important to establish some of the reasons.
I shall finish on this point. To bring clarity to the issue of cancellation of operations, which I heard discussed on a radio programme last week, I point out that operations are cancelled for a variety of reasons. The patient may be deemed unfit to proceed, the procedure may be cancelled by the patient or the guardian, or there may be normal rescheduling due to appointment times not being suitable.
I support the long-term strategy of providing a world-class paediatric service. Arising from her commitments in the past, the Minister will deliver this level of health reform and I support her fully.