Minister Varadkar’s Speech – Seanad – HSE National Service Plan 2015

Acting Chairman (Senator Diarmuid Wilson):  Item No. 1 is statements on the HSE National Service Plan 2015.  I welcome the Minister, Deputy Varadkar, to the House and ask him to make his contribution.

Minister for Health (Deputy Leo Varadkar):  I am pleased to address Members of the Seanad on the HSE’s National Service Plan 2015.  I know that Members may also wish to discuss emergency department overcrowding and influenza.  I am happy to update Members on both of these matters also.  As the HSE service plan is now in operation, it is time that I update the House on the contents of the plan and my priorities for the health service this year.  As this House is aware, the health service faces important challenges in 2015.  We are dealing with immediate difficulties due to overcrowding in some emergency departments and more longer-term challenges, for example, our ageing population and an increasing incidence of chronic disease.  I wish to outline how I intend to address both of these immediate and longer-term challenges.

All Members will recognise that the health service has been through seven very difficult years of retrenchment as a direct consequence of the financial crisis that the State had to address.  In the period 2008-11, €1.5 billion was taken out of the health budget.  This occurred under the last Government led by Fianna Fáil.  Under the current Government, health spending has remained flat with a modest increase provided for in 2015.  Nonetheless we are still trying to run a quality, modern health service with fewer staff, less money and more demands than we had seven years ago.  Budget 2015 represented the first welcome step in reversing this prolonged spending freeze by increasing the funding available to the HSE – the first increase in seven years.  As a result, the HSE has €635 million more to spend this year than it had budgeted for in 2014.  This €635 million is made up of Exchequer funding of €305 million and projected one-off revenues of €330 million.

This funding increase is part of a two-year process to stabilise and improve health funding.  The spending ceiling for health in 2016 has already been increased upwards by a further €174 million.  Health funding for the first time since 2008 is going in the right direction.  A minimum savings target of €130 million has been set in areas such as procurement, drug costs and agency costs in 2015.  In a welcome development, any further savings that can be delivered over and above this target will go back into the delivery of the health and social care services and will not be used to reduce the deficit or the debt and that is important.  The more realistic budget parameters of 2015 allow the HSE service plan to include a number of targeted enhancements to health and social care services by providing generally for existing levels of services.  The service plan also progresses key elements of the health service reform programme.

Before I talk about the specifics of the 2015 service plan, I would like to update the House on the current position in overcrowding in our emergency departments and the number of patients who are waiting on trolleys.

I would again like to stress that my Department, the Health Service Executive and I regard the current situation as unacceptable.  I am very much aware of the distress and hardship it causes for patients and their families.  Many different factors contribute to overcrowding and trolley waits.  Factors vary from hospital to hospital and this needs to be reflected in the measures taken by hospitals in response to the current difficulties they face.  In all cases, however, effective local leadership, management and communication are of key importance in addressing overcrowding in emergency departments.  Staff unions and management all have a role to play, as does the Government.  I firmly believe that all of us involved in health service provision need to co-operate and work together to find solutions to this long-standing problem.

In response the immediate situation, hospitals are taking exceptional measures to reduce overcrowding and have invoked hospital escalation plans.  These include the opening of additional overflow areas, curtailing non-emergency surgery, providing additional diagnostics, that is, easier access to scans and other tests, strengthening discharge planning and twice daily ward rounds.  There has also been increased collaboration between hospitals and hospital groups to enable access to additional capacity, for example, opening a ward in Navan to relieve Drogheda.

These and other measures have resulted in improvements to the number of patients waiting on trolleys.  I do not think I have today’s figures in front of me.  I think I printed off the wrong attachment.  At 2 p.m. today, the number was 237 on trolleys, 143 of whom were there for more than nine hours.  We expect the number to fall below 200 later on in the day but, inevitably, that will go up overnight.  It will then go down during the day tomorrow.  Those are not the figures I was looking for but I suppose they give Senators an idea of where we are.  They are similar to this time last year and previous years so I suppose where we are is regarded as normal by Irish standards but should not be regarded as normal in my view.  What we need to achieve this year is a new normal which is a much lower level of patients on trolleys than we have had in recent years.

Also impacting on emergency department overcrowding is the issue of delayed discharges of patients who no longer require acute care in hospitals.  In late 2014, I provided additional funding to begin to address this issue.  This has continued into 2015 with a further €25 million provided in the budget to fund additional fair deal, short stay and community nursing beds and home care packages.  These measures are beginning to have an effect with the number of delayed discharges now at around 750 whereas it had been approximately 850 in September.  I intend to keep this matter under careful and continual review in the weeks and months ahead.

Looking to the future, it is clear we need to come up with long-term sustainable solutions to emergency department overcrowding.  The emergency department task force I convened before Christmas met again last week and had a very productive meeting, co-chaired by Tony O’Connell, the outgoing national hospitals director, and Liam Doran, who is general secretary of the Irish Nurses and Midwives Organisation.  The essential elements of an action plan were discussed in detail.  As intended, the action plan will be finalised by the end of January.  It will set out immediate, medium and long-term solutions across the continuum of care to address emergency department issues, with a view to achieving a significant reduction in trolley waits over the course of 2015.  The task force is scheduled to meet again in early February.

While on the matter, I do not want to lose sight of the contribution over time that better public health and well-being can make by helping to reduce demand for acute health services.  The same applies to better primary care and social care – primary care so that people do not have to go into hospital as often and social care so that they can get out quicker.  This year’s service plan provides for the improvement of the health and well-being of the population as a whole through the continued implementation of the Healthy Ireland programme.

Many of the immediate problems with which the health services are currently grappling are caused by underlying structural issues which I am determined to tackle.  While there is undoubtedly a strong case for increased funding in health in the years ahead, it is also important to acknowledge that as a demand-led sector, health will quickly absorb any funding provided.  If we have learned anything from the Celtic tiger years, it is that providing more resources without reform simply does not work.

The continuation of the programme of health service reform is of critical importance.  With this in mind, the HSE’s 2015 service plan gives priority to progressing the Government’s reform agenda.  The 2015 service plan provides for the establishment of community healthcare organisations which will improve the way in which primary care is delivered in the community.  This will enable better and easier access to services for patients, closer to home and in which patients can have confidence.  Likewise, the reorganisation of public hospitals into hospital groups is designed to deliver improved outcomes for patients.  Each group of hospitals will work together to provide acute care for patients in their area integrating with community and primary care.  The objective is to maximise the amount of care delivered locally while ensuring that specialist and complex care is safely provided in specialist centres and larger hospitals.  The priority in 2015 will be to get the seven hospital groups up and running and to agree a strategic plan for each one.

The HSE will further implement activity based funding on a phased basis this year.  Under this funding model, hospitals are paid for the quantum and quality of services they deliver.  This, I believe, will drive efficiency and, hopefully, increase transparency.

I also want to highlight the work of the national clinical programmes as an example of clinical leadership.  They have already greatly improved services in many specialised areas, such as stroke and cardiac services.  The service plan foresees the development of the national clinical programmes into five integrated care programmes, dealing with patient flow, older persons, chronic disease, children’s health and maternal health, and will improve the integration of services, access and outcomes for patients generally.

As I mentioned earlier, the 2015 service plan, provides for the delivery of an existing level of services, with targeted enhancements in some areas.  One of the service enhancements is the commencement of the extension of the BreastCheck screening programme to women aged 65 to 69 years of age.  Screening of these women will commence towards the end of 2015 and will be expanded on a phased basis.  The additional eligible population is approximately 100,000 and when fully implemented 540,000 women will be included.

The 2015 service plan also provides for the implementation of the first two phases of a universal GP service, making available a GP service without fees to all children under six years and everyone over 70 years.  The aim is to have universal GP care without fees for children under six years implemented in the first few months of this year, subject to the conclusion of discussions with the Irish Medical Organisation and the successful completion of a fee-setting process.  Signing up, of course, will be optional for GPs.  The over 70s will be facilitated under the existing contract once the relevant legislation has been passed by the Oireachtas.  With the co-operation of the House we hope to have that done in the first quarter of this year.  By the end of 2015, almost half of the population will have access to their general practitioner, without charges, for the first time.  That is a major and concrete step on the road to universal healthcare.

The service plan also provides an additional €30 million to fund new hepatitis C drugs in 2015.  This has the potential to bring major benefits for patients with serious illness as a result of hepatitis C.  We are ahead of many other countries in making these medicines available.  As with other countries, Ireland must ensure that access to high-cost treatments such as these is managed.  We must prioritise access for patients who can benefit most, while also ensuring that the financing model is sustainable and affordable.  Our aim is to provide access for as many patients as possible given the resources provided by taxpayers.  An early access programme for over 100 patients with the greatest need for these new drugs is already in place.

Budget 2015 provides an additional €35 million in ring-fenced funding for mental health, bringing to €125 million the total investment by the Government in mental health services since 2012.  The additional funding will enable the HSE to continue to develop and modernise our mental health services in line with A Vision for Change.  This includes the ongoing development and reconfiguration of general adult teams, including psychiatry of later life, and also child and adolescent community mental health teams, along with other specialist mental health services.  This will be delivered through further recruitment and investment in agencies and services in order to achieve consistent provision of quality services across all areas.  The funding will also permit urgent specialist needs to be addressed, including services for those with mental illness and an intellectual disability, suicide prevention services, psychiatric liaison services, and addressing the gap for low secure acute care and rehabilitation services to service users with complex needs.

A number of measures will be taken in 2015 to further develop primary care services and allow more people to receive a wide range of quality services in their own community.  An additional €14 million is being provided in 2015 for primary care developments, including the extension of the pilot ultrasound GP access so that GPs can get ultrasounds for patients, particularly in the southern part of the country, without having to refer them to hospital and also the provision of a minor surgery services pilot in about 30 GPs practices and primary care centres, thus enabling 30 GPs around the country to perform minor operations which are normally done in hospitals.  There will also be extension of GP out-of-hours services, within existing resources, to areas currently not covered, particularly urban areas, and more spending on community orthodontic and ophthalmic services.  Some €1 million in additional funding is being provided for each of those in an effort to significantly reduce or eliminate the children’s ophthalmic services waiting list in Dublin and also reduce waiting times for orthodontic treatment around the country.  Additional funding of €2 million is also being provided to improve maternity services, although how that is to be deployed has to be determined.

Patient safety will, of course, remain an overriding priority across the health service in 2015 and this is reflected in the plan.  The HSE has redesigned its national quality and patient safety function and has established a quality and patient safety enablement programme.  The overall goal of this programme is to improve the quality of services with measurable benefits for patients and service users.  Priority areas that were identified in last year’s service plan will continue to be the focus of attention and include medication safety, healthcare associated infections and the implementation of the national early warning score.  In addition, the process for identifying, reporting on and following up on serious reportable events, SREs, has been strengthened.

The Health Identifiers Act 2014 provides the legislative framework for a national system of unique identifiers for patients and health service providers for use across the health service, both public and private.  Individual health identifiers are primarily a patient safety tool and are designed to ensure that the right information is associated with the right patient at the right point of care.  It is rather like a PPS number for health.  In addition, identifiers will help make our health service more efficient and will support health reform initiatives, including the activity based funding model I spoke of earlier.  Health identifiers are a fundamental building block in support of the e-Health agenda.  The HSE will develop and implement the individual health identifier on a phased basis starting in 2015.

Every employer’s greatest resource is its workforce and, with this in mind, a priority highlighted in the service plan is the development by the HSE of a workforce plan to ensure that staff are motivated and retain good levels of job satisfaction while delivering effective and compassionate care.  The HSE will have more autonomy and discretion to manage staffing levels within its overall pay framework in 2015. This should greatly assist in reducing reliance on agency staff which is very costly and is one of the key priorities for the HSE in 2015.

With greater autonomy and greater capacity to utilise any further savings achieved within the health service comes an even greater responsibility for cost containment and cost avoidance.  The HSE has, therefore, put in place a considerably enhanced governance and accountability framework for 2015.  This is set out in detail in the service plan.  The framework provides the means by which the HSE, hospital groups and community health organisations and other units, will be held to account throughout the year for their efficiency and control across the balanced scorecard of access to services, patient safety, finance and human resources.

There are enormous demands and cost pressures on our health service.  Healthcare demand continues to rise due to our growing and ageing population, the increasing incidence of chronic conditions and advances in medical technologies and treatments.  Health systems all around the world are struggling with this issue of rising costs.  Against this backdrop, I am aware of the limitations as to what can be achieved with the funding available for this year.  Clearly, we do not have sufficient funds to address all areas of concern or all the priorities we would like to address across the health sector immediately.

However, what we have been able to do in this year’s HSE service plan is to make a start, an important start, towards the restoration of stability to the health service and its budget.  The modest increase in resources being provided in 2015 and reflected in the service plan is the first step in a two-year process to stabilise the health budget.  My focus is now on assisting and supporting the HSE management and staff in achieving the service delivery and patient safety and quality targets set out in its service plan.

Minister for Health (Deputy Leo Varadkar):  I thank Senators for a very interesting and informed debate over the past few hours.  Before I go into my substantive response, one or two individual cases were raised.  Senators will appreciate that I do not have any patients’ charts on my desk and it would not be right for me to comment on individual cases but perhaps those cases were raised more to illustrate a point than to seek a specific response.  A few questions were raised about particular local issues or local hospitals and I am not going to answer them here today.  We have 40 hospitals in the country and that is only the hospitals, never mind another few hundred social care institutions and other primary care institutions.  I do not have a day to day working knowledge on which wards are being opened and closed in particular hospitals or matters like that.  No Minister ever has, ever will and or ever should have that, but my officials will take note of those questions and get replies from the hospital, local management or the group, or the HSE, as appropriate.

The vast majority of the questions and issues raised by Senators were national matters and I will respond to them as best I can.  A few Senators raised the issue of ambulances.  I want to point that our ambulance services in Ireland are improving.  It is not that long ago when all an ambulance and a driver did was to take one to hospital.  Now ambulances are largely staffed by paramedics and advanced paramedics who can offer one care on the scene.  We record the response times for Echo and Delta calls and turnaround times and they are published every month in the HSE’s performance assurance report, PAR, and they are improving.  Senator Ó Murchú made a good point, namely, that when it comes to health care we tend to only hear about the bad things, it will never be a front page story that our ambulance turnaround times and response times are improving.

The budget for ambulance services in 2015 has been increased by €5.4 million.  We now have intermediate care vehicles, which means we are not using ambulances for simple transport.  It was inappropriate to use an emergency vehicle for simple transport between hospitals.  We have 100 community first-responder teams, now responding on the scene, particularly – but not only – in rural areas.  I will be with them tomorrow launching the national network of community first-responders.  We want many more of them because what we need in a remote area is somebody living locally who can respond very quickly.  It is not practical to have an ambulance in every parish answering one call a week.  That is not realistic.

We also now have rapid response vehicles.  These are paramedics who travel by car who can get to patients and begin treating them before the ambulance arrives.  I have been out with that crew in recent months, as some of the Senators will know. Under this Government we now have an air ambulance for the first time and that is particularly important in the midlands, the Border areas and west in getting people to specialist centres such as the neurosurgery centre in Beaumont or cardiothoracic surgery in the Mater, which is where they need to go and not to the local hospital.  That goes for Connolly hospital as well, which would not be able to deal with level one trauma such as a major head injury.

We are integrating all the call centres.  Within the next few months all of the calls will run through a single centre in Tallaght instead of there being seven or eight around the country, which was the case previously.

There has been much talk about the eight minute and 20 minute targets.  They are UK targets which are not met in Scotland, they do not apply to a large parts of Wales and are often not met in large parts of England.  HIQA now acknowledges that we need to have a different set of targets for Ireland.  I live in Castleknock.  My nearest hospital is Connolly hospital.  If the bus lane is blocked it would be quite difficult for an ambulance driver to get me to Connolly hospital in eight minutes, and that is in an urban area.  My grandmother and cousins live in Dungarvan in west Waterford and there is no way one could get from Dungarvan to the hospital in Cork or Waterford in eight minutes.  That is impossible, even by helicopter, never mind by ambulance.  There are targets in that if one applies the eight minute target and if the ambulance gets to the patient in seven minutes and the patient dies, that is counted as a success.  If the ambulance gets to the patient in nine and a half minutes and he or she is defibrillated at the scene and treated in the ambulance and survives, that is counted as a failure.  It is a funny way of doing a target in my view.

Senator Fidelma Healy Eames:  The Minister should change it.

Deputy Leo Varadkar:  What we need are targets that are based on patient outcomes.  We need to do proper a clinical audit as to what happens to the patient, not when the vehicle arrives, and that is now being done.  Dublin fire brigade already does a clinical audit and for the first time the national ambulance service will start doing a clinical audit this year and that will give us patient relevant information, rather than just times.  There are three reports, one is published and two are pending, and when we have those we will put an action plan in place.

I think it was Senator MacSharry who pointed out that there are 90,000 fewer medical cards in 2014 and there will be fewer again this year, about 60,000 fewer.  That is true.  The economy is improving.  More people are getting back to work and at least for some people incomes are rising and therefore fewer people are entitled to medical cards on a means test.  However, the number of discretionary medical cards – those who get them on, for want of a better word, medical or compassionate grounds – is increasing.  It has increased from 50,000 at the start of 2014 to 75,000 now and that reflects some of the changes that were announced by the Minister of State, Deputy Lynch and I a few months ago.  It is still a work in progress and it is by no means perfect, but the fact that there are 25,000 more discretionary medical cards tells a story.  The more I look at this issue when it comes to medical cards, the more I am convinced that universal health care is the only solution.  Once we have a means test there will always be somebody who earns a few euro more than the qualifying threshold and somebody who does not fit the clinical criteria.  That is where we need to go and that is still very much the vision.

Regarding nurses, there has been some concern today about coverage in the news about there being 1,000 nurses who may retire.  It has been difficult for a number of years to retain nurses and fill nursing posts.  Some 36,000 nurses work for the HSE and the voluntary hospitals funded by the HSE, so 1,000 represents 3% of the nursing work force.  A 3% turnover in a workforce in any given year is not enormous.

Senator John Gilroy:  They are concentrated in specific areas.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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