Opening Statement by the Minister for Health, Dr. James Reilly TD, at the Joint Oireachtas Committee on Health and Children

Opening Comments

Thanks to the Chairman and members of the Committee for your invitation to discuss health service issues. I am accompanied by Ministers of State Kathleen Lynch and Alex White and together with my senior Departmental officials we will provide the Committee with as much information and clarification as possible. I apologise that my opening statement is significantly longer than the norm, however, as requested by the Committee, I have addressed a number of substantive issues in some detail.

1. Budget 2014 – Implications for the Health Services

To the forefront of all our thoughts are the announcements made earlier this week in relation to Budget 2014 and in particular its implications for the health services. I am pleased that the Government has provided funding for free GP care to children of 5 years of age and under, as the first step towards providing Universal GP Care in line with commitments set out in the Programme for Government.

I am also pleased that a further €20m has been provided to continue the investment in mental health services, primarily in the area of community mental health teams.

The Budget provision for the Health Sector is some €360m less than was provided in 2013, which represents a 3% reduction in funding over last year. As a result, 2014 will be another extremely challenging year for the health services. The Government has had to make some very difficult decisions in relation to the Health Estimates as part of the budgetary arithmetic. The prescription charge will increase from 1st December to €2.50 per item with a €25 monthly cap on expenditure per household. In addition, the income thresholds for medical cards for persons over the age of 70 will be reduced to €500 per week for an individual and €900 for a couple. Legislation to give effect to this change will be enacted before the end of the year.

Extremely ambitious savings targets have been set in relation to medical card probity and for pay savings to be achieved under the Haddington Road Agreement. However, these challenging savings targets will be the subject of a verification exercise as to their achievability, a process which will conclude before the finalisation of the Revised Estimates Volume. The verification exercise will be overseen by the Secretary General of my Department, along with the Secretary General of the Department of Public Expenditure and Reform and the Secretary General to the Government.

The implications of the Budget for the provision of health services will be set out in the HSE’s National Service Plan which will be formally submitted to me within the next three weeks, in line with the provisions of the Health Act, 2004. The 2013 Service Plan required the HSE to continue to focus its delivery of series on the dual challenge of protecting patient outcomes while, at the same time, reducing costs. 2014 will be no different in this regard and measures impacting on the health system as a result of Budget 2014 will again be assessed against these key criteria – with the outcomes of this consideration set out in the Service Plan.

There is no doubt that the level of funding available for the health services in 2014 creates a significant challenge to the HSE. In setting out the operating framework for the delivery of HSE services throughout 2014, the Service Plan will look to deliver the maximum level of safe quality services possible within the funding available, with prioritisation, where necessary, of certain services to meet the most urgent needs.

The Plan will also set out targets in respect of each programme area to ensure that performance can be evaluated throughout the year in order to identify any emerging areas of concern, and should any concerns arise, allow for the implementation of necessary remedial measures without delay.

2. Employment Conditions of Non Consultant Hospital Doctors

The Joint Committee has asked that particular attention be given to the employment conditions of NCHDs at today’s meeting, and this I am more than happy to do. I have said before that I want to create a health system that protects, nurtures and develops the people who work within it. That is why I am determined to change the role of NCHDs within our health system.

It is essential that doctors enjoy reasonable working conditions. I want to reassure hospital doctors that the Government is committed to achieving compliance with the European Working Time Directive in respect of NCHDs by the end of 2014.

This is a complex task and a key challenge is to ensure that we achieve compliance while maintaining essential hospital services. I want also to emphasise that this is not primarily a matter of resource availability. Among the range of measures to be addressed are changes to NCHD rosters and work patterns, greater use of consultant teams, introduction of electronic time and attendance systems, reallocation of tasks between health professionals and reorganisation of services.

At my request, in 2013 the HSE has brought a renewed and urgent focus to compliance with the EWTD. In particular, a senior national group has been working closely with individual hospitals, with an emphasis on eliminating shifts of more than 24 hours and instances of doctors working more than 68 hours per week.

Achievement of compliance with EWTD cannot be a top-down process. In my view the best approach is that there be a strong joint process involving the HSE and the NCHDs themselves in working through the practical steps necessary

Ireland must have sustainable arrangements to train and develop the medical workforce we need in order to provide safe and effective services to our population. I am therefore committed to retaining doctors who are educated and trained in Ireland within our health service.

In July this year, I set up a working group chaired by Professor Brian MacCraith, President of DCU, to carry out a strategic review of medical training and career structures, with a view to improving retention of graduates in the public health system. This group is currently working to produce an interim report by end-November 2013 and a final report by end-June 2014.

There has been an intensive engagement at the Labour Relations Commission in recent weeks, in an effort to secure agreement between the IMO and health service management on the early elimination of shifts of longer than 24 hours and achievement of EWTD compliance in our hospitals by December 2014. I would like to acknowledge the work of the Commission and the parties to this dispute in arriving at the proposals which have been finalised in recent days.

The issues involved are complex and a range of solutions will be required. I think it important to emphasise, though, that achieving EWTD compliance is not primarily a matter of financial resources. Amongst the steps will be changes to NCHD rosters and work patterns, greater use of consultant teams, service reorganisation and task reallocation between health professionals.

The foundation of the package of measures which will now be put to IMO members is a joint IMO and management approach to identifying the steps needed in each hospital and agreeing the timescale within which these are to be put into effect. Beginning in late September, an intensive series of meetings has been taking place, involving every hospital in the country. The IMO and NCHDs are actively participating in this process, with senior health service managers. The focus is on eliminating the vast majority of shifts of over 24 hours by the end of November, and the remainder by January next.

There will also be national-level oversight, again involving joint working by health service management and the IMO. I am pleased to see that real sanctions will be available to be applied to hospitals which do not implement agreed steps on time. I hope, however, that it will not be necessary to invoke these on a widespread basis and that there will be major advances in the coming months towards ending shifts in excess of 24 hours, and moving towards the national goal of EWTD compliance by the end of next year. We have a shared objective of affording hospital doctors acceptable working conditions and offering them a career path so that they can plan and enjoy a fulfilling career within the Irish health service.

Discretionary Medical Cards

I would now like to refer to the issue of medical cards awarded on a discretionary basis. This issue has received a significant level of publicity since our last meeting and, as recently as last week, was the subject matter of Private Members Business in the Dáil.

I was glad that, with my colleagues in the Department, I had the opportunity to, again, set the record straight and to reject, out of hand, the contention that there is a deliberate targeting of holders of discretionary medical cards. There has been no change to the policy on discretionary medical cards in the past year and the scheme continues to operate in such a way that those who suffer financial hardship as a result of a medical condition receive the benefit of a medical card.

The HSE has provided me with an analysis of the individuals who held a medical card on 1 March 2011 and their current eligibility status. This note concludes the analysis accounting for each and every case.

On 1 March 2011 – 97,121 individuals had Medical Cards / GP Visit cards that were awarded where the HSE exercised discretion.

On 1 October 2013 – 38,283 of these individuals still had Medical Cards / GP Visit cards that were awarded on a discretionary basis.

A further 41,779 of these individuals had a Medical Card / GP Visit card which was awarded on the basis of means.

17,059 of the individuals no longer have either a Medical Card or a GP Visit Card. Records show that these individuals no longer have eligibility because;

2,361 are deceased.

6,265 did not respond to a variety of HSE correspondence associated with the review procedure and the medical card was suspended.

2,109 initially engaged with review procedures but these did not conclude with an assessment with the National Guidelines, e.g. essential items to allow the assessment to be completed were not provided and the applicant was informed of this outcome.

6,324 were reviewed and were not eligible when assessed with the National Guidelines for Medical Card and GP Visit card eligibility.

The processing of medical cards at a national level, rather than at a local level before mid-2011, ensures that all people are assessed in a similar and fair manner when applying for a medical card.

At my request, the HSE put in place a process where a medical doctor would consider the assessment for discretionary medical cards.

In previous years, there was a decentralised process which meant there could be inequities throughout the country. Now, the process is standardised and there is fair and equitable treatment for all.

Reduction in GP fees under FEMPI

The Committee requested that I address the reduction in GP fees under the Financial Emergency Measures in the Public Interest (FEMPI) Act 2009.

Under the General Medical Scheme (GMS) contract, GPs receive a range of fees and allowances, including an annual capitation payment in respect of each medical card and GP visit card patient on their GMS list.

As a result of the economic downturn, significant restrictions on Health spending have had to be implemented since mid-2008 as part of the Government’s efforts to address the major deficit in the public finances.

A review was carried out earlier this year under the Financial Emergency Measures in the Public Interest (FEMPI) Act 2009 in relation to the operation, effectiveness and impact of the amounts and rates payable to general practitioners under the relevant Regulations.

Having carefully considered the submissions made during the consultation process, I decided to reduce certain fees and allowances payable to general practitioners. I am satisfied that the proposed reductions are fair and reasonable. Overall the reductions in GP fees will save in the region of €38 million in a full year.

Payments to GPs have been reduced by 7.5%. However, rather than introducing an across the board cut of 7.5%, a more strategic approach has been taken:

(a) The weighting for patients over 70 years has been reduced

In 2001, when the then Government introduced medical cards to all over 70s, it was agreed that each patient aged 70 years or over would be given a certain weighting when allowance are calculated. Reducing the weighting for these patients from 3.1 to 2.1 will save an estimated € 5 million in a full year.

(b) Removal of special fees negotiated in 2001

The elimination of special payments related to the number of discretionary medical cards will result in savings of €10 million in a full year.

(c) Seasonal flu vaccination fees reduced

The fee payable to GPs was €28.50 whereas the fee payable to pharmacists is €15. There is no justification for paying GPs a higher fee for the same work. Reducing the GP fee to €15 will yield €5m in a full year.

(d) Other fee reductions

A range of other reductions have been made in capitation and other fees and allowances which will bring the overall reduction to 7.5 %.

During the consultation process, the Irish Medical Organisation and others expressed the opinion that any fee cuts could result in patients no longer being able to avail of a “same day” GP service and could also cause GPs to reduce staff hours. These issues were considered along with the other points raised during the consultation process.

The following Regulations have been prepared to give effect to my decisions and these came into effect on 24th July 2013:

  • S.I. 277/2013 – Health Professionals (Reduction of Payments to General Practitioners) Regulations 2013
  • S.I. 278/2013 – Health Professionals (Reduction of Payments to General Practitioners) (National Immunisation Programmes) Regulations 2013

Pharmacists, Consultant Psychiatrists and Consultant Ophthalmologists have also been subjected to fee reductions under FEMPI and public sector workers have taken significant further pay reductions under the “Haddington Road” Agreement.

It is appropriate that GPs should share the burden on the country’s road to economic recovery. I am satisfied that the fee reductions are fair and reasonable and will not have an adverse effect on patient care.

Under the FEMPI legislation, the Minister for Health is required to carry out a review of the operation, effectiveness and impact of the amounts and rates fixed under the regulations each year. This will involve a full consultation with stakeholders in 2014. A decision will be taken at that time regarding maintaining, restoring or further reducing fees.

EPSCO Council meeting

I will attend the Employment, Social Policy, Health and Consumer Affairs (EPSCO) Council on 10 December 2013. The agenda is set by the hosting Presidency, Lithuania. Ministers will discuss progress on a number of legislative files which are important both from a public health and economic point of view. The Tobacco Products Directive remains a priority for the Irish Government. In recent weeks I have assisted the Lithuanian Presidency by arranging for 16 EU Health Ministers to issue a statement supporting the Directive and by sending a joint letter with An Taoiseach to MEPs urging them to support larger warnings on cigarette packs. I hope that agreement on this Directive can achieved by the end of the year.

In addition to Tobacco Products, other key pieces of legislation under negotiation are the new Clinical Trials Regulation and two Medical Devices regulations. These regulations will enhance patient safety but we must also ensure the regulatory framework for the pharmaceuticals and medical devices sectors continues to support innovation and maintains Europe’s competitive advantage. It is possible that agreement on Clinical Trials can be reached by the end of this year. It will probably be the latter part of 2014 before negotiations on medical devices are concluded.

Recent Health Service Developments

I would like to update the Committee on some significant developments in the health sector since I last spoke with you in July.

3. Protection of Life During Pregnancy Act, 2013

The Protection of Life During Pregnancy Bill was signed into law by the President on 30 July, 2013. And it will be commenced as soon as is practicable. There are operational issues which need to be addressed before it can be commenced and the Department is liaising with the HSE in this regard. These include the establishment of a panel of medical practitioners for the purpose of the formal medical review provisions and administrative facilities to enable the review committee, drawn from the review panel, to perform its functions. A committee has also been established to develop implementation guidelines for the Act.

4. Establishment of the HSE Directorate

The HSE Directorate was established in July, following the enactment of the HSE (Governance) Act. The new Directorate is accountable to me, as Minister for Health, for the performance of the HSE. The Directorates is a step in a much wider process of reform which envisages, as set out in the Programme for Government, the eventual dissolution of the HSE. The HSE Governance Act builds on existing accountability arrangements under the Health Act (2004) such as annual service plans and reports, codes of governance and the provision of information to the Minister for Health. The Act allows the Minister for Health to issue directions to the HSE on the implementation of Ministerial and government policies and objectives and to determine priorities to which the HSE must have regard in preparing its service plan. I wish to again formerly congratulate Tony O’Brien on his appointment as Director General.

5. Appointment of CEO to the Children’s Hospital Group

Last month I announced that Ms. Eilish Hardiman has been selected as CEO of the Children’s Hospital Group. This followed an open recruitment process led by the Public Appointments Service. The Children’s Hospital group includes our Lady’s Children’s Hospital Crumlin, Children’s University Hospital Temple Street and the Paediatric Service at Tallaght Hospital. Ms. Hardiman’s appointment as Group CEO follows the appointment in April of Dr. Jim Browne as Chair of the Children’s Hospital Group and the appointment in August of a further nine board members. The Board will oversee the operational integration of the three hospitals in advance of the move to the new Children’s Hospital. As the client for the building project, the Board will also play a key role in ensuring that the new hospital is optimally designed and completed as swiftly as possible while providing value for money.

6. The Health (Pricing and Supply of Retail Goods) Act, 2003

Under the recently enacted legislation the Irish Medicine’s Board is responsible for setting reference prices, this is the price that the HSE will reimburse to pharmacies for all medicines in a particular group, regardless of an individual medicine’s price. The initial list of interchangeable medicines, containing groups of atorvastatin products, was published on the IMB website on 7 August 2013. It is expected that the first reference price will be implemented by year end.

7. Research on benefits of using plain cigarette packaging

Recently launched research, jointly commissioned by the Irish Carer Society and the Irish Heart Foundation shows how effective cigarette branding is and how it is used by the tobacco industry to entice children to start smoking. A coalition of children and health organisations is supporting legislation that will make it illegal for tobacco companies to use colour, text and packet size to market cigarettes. We cannot continue to allow deceptive marketing gimmicks to be used to lure our children into a deadly addiction that will ultimately kill half of those who become addicted. Standardised packaging is the next logical step in combatting this public health epidemic. I request that the members of the Joint Oireachtas Committee on Health and Children give their full support and endorsement to this campaign.

8. The Government’s Future Health Reform Programme

This Government is currently engaged in possibly the biggest reform of a western health care system since the formation of the UK’s NHS. The “Future Health Reform Programme” is designed to replace the current failed model of healthcare and to hand power and control back to patients and professionals. Part of this process involves the establishment of hospital groups – re-organising all of Ireland’s adult public hospitals into six groups which will, over time, become self-governing trusts. The objectives is to create a network of hospitals which are big enough to offer patients a full range of safe, high quality services, yet small enough to be flexible and adaptive to the local and regional needs of the people that they serve.

9. Conclusion

Legitimate concerns have been raised, both inside and outside the health service, as to whether the system has the capability to implement the scale of the changes proposed. The reform agenda for the next three years is particularly complex and requires the health system to implement a series of reforms which have taken other countries much longer to introduce. The recent establishment of the new directorate structure and a Systems Reform Office in the HSE and the creation of a Programme Management Office in the Department of Health are specifically designed to assist and support the implementation process.

Both my Ministerial colleagues and I will be happy to answer your questions on the Future Health Reform Programme and other issues during the course of the meeting.