04/11/2014 Senator Daly addresses the Seanad and Minister for Health Leo Varadkar regarding the Department of Health Budget

Minister for Health Leo Varadkar: I very much welcome the opportunity to address Members of this House on the 2015 Department of Health budget and my priorities for the health sector next year.

Since my appointment as Minister for Health, I have said on more than one occasion that it is my first priority to achieve a realistic budget for the health service. I firmly believe we have achieved that in budget 2015, with an increase in the Exchequer allocation of €305 million when compared to the 2014 allocation. We have also identified one-off increased projected revenues of some €330 million and savings and efficiencies of €130 million. Taken together, this means that the HSE will have over €750 million more to fund services in 2015 than it did when we were preparing the service plan for 2014 this time last year. We are now entering a two-year process which stabilises the budget and allows for existing levels of service to continue, along with some targeted enhancements. Arising out of this, the spending ceiling for the Department of Health in 2016 has already been increased upwards by a further €174 million. This does not mean that all areas of concern across the health sector can be addressed immediately but it does make the funding situation more manageable. It also means that the cycle of cuts in health has come to an end.

Despite our additional spending power, next year remains a real challenge. There are enormous cost pressures. Drivers of demand and cost include our rising and ageing population and the increase in chronic conditions, and advances in medical technology come at a high price. Our progress in diagnosis and screening for cancers and chronic diseases means more people require treatments. Health services all around the world are struggling with the issue of rising costs and Ireland is by no means exempt. We must recognise the additional resource demands that come as a result of these new pressures. In overall terms, therefore, while next year’s health budget remains challenging, its targets are achievable. This challenge will be reflected in the HSE’s 2015 national service plan which will operate strictly within the resources available, deliver existing levels of service and provide for some targeted improvements. The service plan will also continue the programme of health service reform.

In 2015, we will have more control of our resources in the health service. I already mentioned that specific savings and efficiencies of €130 million have been identified. These are in the areas of procurement, drug costs, agency costs and clinical audit and special investigation. However, a significant change for 2015 is that where further savings or efficiencies are achieved over and above this minimum level, these will be retained and reinvested back into the health service rather than being used to reduce the deficit or reduce the debt. I hope that this new development can positively contribute to the reform and development of our health services.

The HSE will also have more autonomy on staffing and human resources in 2015. The end of the moratorium on recruitment provides greater room for the Department and its agencies to manage their own staffing levels. This decision was recently announced by the Minister for Public Expenditure and Reform, Deputy Brendan Howlin. It provides a basis for the health sector to take on more temporary and permanent staff in order to achieve savings on agency costs, subject to compliance with the overall pay allocation. This, in turn, provides the HSE with an opportunity to reduce pay costs where less expensive alternatives to agency personnel are available. I believe this will facilitate a more sustainable workforce and greater continuity of care for patients. The HSE has issued a memorandum to management on measures to reduce agency usage and costs across the HSE and HSE funded acute hospital services. It provides for the replacement of non-consultant hospital doctor and consultant agency posts with fixed-term purpose contracts, and limits reliance on doctors employed on an agency basis to two months. It also provides for the identification of nursing posts currently filled by agency staff which could be directly replaced by two year contracts of employment. These contracts will be offered to nurses currently participating in the nursing and midwifery graduate programme.

With greater autonomy and capacity to reuse such savings for services comes an even greater responsibility for cost containment and cost avoidance.

Greater autonomy and capacity to reuse savings for services must be accompanied by an even greater responsibility for cost containment and avoidance on the part of everybody working in health care. With this in mind, the HSE will continue to develop and strengthen its accountability framework when it is preparing its 2015 service plan. The management of health spending within available resources next year will require an exceptional management focus, with strict adherence by all services and budget holders to their allocations. The HSE’s accountability framework will set out the responsibilities of managers and will detail the means by which the health service, particularly hospital groups and community health care organisations, will be held to account in 2015 for their spending, their efficiency and their control over service provision, patient safety, finance and human resources. It is important that budgets are put in place without delay across the HSE and its funded agencies so that monitoring of monthly expenditure against profile can commence from the start of 2015. This will help to ensure spending remains within budget and appropriate and immediate action can be taken where emerging trends give cause for concern. The return of the HSE Vote to the Department of Health from 2015 as part of this improved accountability framework will assist the HSE and the Department in monitoring health spending throughout next year.

We are continuing to make progress with the health reform programme. Next year is an important year in demonstrating the benefits of key reforms in this sector. We must work collectively to improve safety, quality and the patient experience for those who depend on our services. It is vital that qualitative aspects, such as the personal care and attention that patients receive, are the subject of focused efforts so that people’s experience of the health service is safe, caring and pleasant. This can matter greatly to patients and their families. I want the HSE to take an integrated approach across acute, community and residential care settings to ensure patients are supported at all stages in the care setting that is most appropriate to their needs. This is most important in the context of the establishment and further development of the hospital groups and community health care organisations. 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 highly specialised and complex care is safely provided in larger hospitals. The next phase of the implementation of the hospital groups will involve each group developing a strategic plan in 2015 for implementation in the years thereafter.

The Government remains committed to the introduction of activity-based funding. Under this model, hospitals are paid for the work they do in terms of case loads and quality outcomes. This funding model will drive efficiency and increase transparency in the provision of high-quality hospital services. The HSE intends to further implement this new funding model on a phased basis in 2015. The recent establishment of community health care organisations by the HSE represents an important step in improving how care in the community is delivered. The new structures will improve services for the public by providing better and easier access to services, closer to where people live, in which people can have confidence. I have been very impressed with the work of the national clinical programmes, which have greatly improved services in specialised areas like stroke and cardiology. It is planned to organise these national clinical programmes into five integrated care programmes. I hope to see the new integrated clinical programmes embedded into the HSE service directorates. It is important that they are at the centre of operational delivery and reform. While structural reform is never an end in itself, it is a valuable tool that can help us do more and better with the additional resources we now have. Better structures empower people to deliver better care.

In terms of services, my aim is to ensure that in 2015, the existing level of service is maintained and delivered and some targeted enhancements are introduced. I have signalled that the commitments in the programme for Government with regard to the extension of BreastCheck and the investment in mental health will be honoured. Additional funding of €25 million will be provided to tackle the issue of delayed discharges, which is having a detrimental knock-on effect on waiting times and emergency department overcrowding. We will deliver on the first phase of universal health care in 2015. Some 240,000 children aged six years and under will be able to access a GP service without fees. This accounts for 57% of the total population in this age group, some 43% of whom are already covered by a medical card or GP visit card. Approximately 10,000 seniors over the age of 70, who currently have neither a medical card nor a GP visit card, will be provided with GP services without fees. By the end of next year, almost half of the population – 49% – will have access to GP services without charges.

That is a major step on the way to universal health care.

Budget 2015 provides for an additional €35 million which is being ring-fenced for mental health services under the direction of the Minister of State, Deputy Kathleen Lynch. This will bring 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 re-configuration of adult and child and adolescent mental health teams, alongside other specialist mental health services.

Breast cancer survival rates in Ireland have improved significantly in recent years through a combined approach of screening, symptomatic detection and improved treatment. Additional funding is being provided to commence the extension of the BreastCheck screening programme next year to women aged 65 to 69 years of age. Screening of the extended cohort will commence towards the end of 2015 and will be expanded on an incremental basis. The additional eligible population is approximately 10,000 people and when fully implemented just over 500,000 women will be included.

Senators will be aware that there has been a continuing upward trend in delayed discharges since the beginning of the year, with 788 delayed discharges reported nationally as of last week. These are people who are well enough to leave hospital but do not have a nursing home or home care package in place for them to do so. They are often elderly people and should not be left in hospital where they are at a higher risk of falls, infections and medication errors by doctors and other staff. While there will always be delayed discharges, current levels are resulting in more people on trollies and more people having their elective admissions or surgery cancelled. In response to these concerns, the Government has provided additional funding of €25 million in 2015 to address delayed discharges. The funding will be targeted not just at nursing homes but also at community services and hospital services which can demonstrate initiatives to address the specific needs of delayed-discharge patients most positively and, therefore, improve timelines for admissions from emergency departments and waiting lists. These will include measures to place patients in more appropriate settings through the use of enhanced home care packages and intermediate and long-term care.

We are all very aware of the statistics on the rates of obesity, diabetes and other chronic conditions in Ireland. That is why improving the health of the Irish population must be our first priority in the medium to long term. My Department recently commenced the Healthy Ireland Survey. This will be a major nationwide survey to find out how healthy Irish people actually are. We have not had a comprehensive survey of Ireland’s health since 2007 and there have been huge changes since then. Today, more people are aware of the importance of diet, lifestyle, health, well-being and mental fitness. However, as a nation we now face even bigger challenges when it comes to obesity, physical inactivity, diet and many other issues. This new survey will give us an up-to-date picture of the nation’s health and will provide us with a baseline set of data telling us how healthy or unhealthy the Irish population is. The survey will provide us with a snapshot of key indicators which influence our health right across the population. These include nutrition, alcohol consumption, smoking, physical activity, weight management and general well-being. Participating in the survey is entirely voluntary. Nobody will be asked for their PPS number, by the way. I want to thank in advance everyone who agrees to take part as their participation is of enormous value. We can also then use future surveys to assess whether or not our policies are working.

It is of the utmost importance that patient safety remains an overriding priority across the health service in 2015 and this will also be reflected in the HSE’s service plan. All health service staff, individually and collectively, will continue to have a responsibility for the quality of services they deliver to patients and service users in their care. It is important that they integrate a commitment to quality and safety into their core work and practice. 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.

The Health Identifiers Act 2014 provides the legislative framework for a national system of unique identifier for patients and health service providers for use across the health service, both public and private. Individual health identifiers are designed to make sure that the right information is associated with the right patient at the right point of care.

In addition, identifiers will help make our health service more efficient and will support health reform initiatives, including money follows the patient. Health identifiers are a fundamental building block in support of the eHealth agenda. The HSE is working to establish the necessary health identifier registers and will manage the operation of the identifiers system. The provision of identifiers will commence as soon as possible in 2015.

Patients benefit most from safe and cost-effective care. Therefore, we need suitable and appropriate facilities to support health care delivery. It is important to recognise and acknowledge that we have managed to deliver significant projects, both large and small, since March 2011 and that more have commenced. Investment in high quality health care infrastructure also has an important role in supporting communities. It sustains local employment because of the health care presence throughout the country. Progress to date and future planning demonstrate this Government’s commitment to infrastructure developments in health care as set out in the programme for Government. The priority in 2015 will be to ensure that all projects remain on schedule and are delivered on time.

I take this opportunity to update Members on the capital developments which are ongoing and which will continue in 2015. Since the change of Government in March 2011, 42 primary care centres have been delivered, which is almost one each month. There are approximately 30 underway, including the 14 locations to be delivered by the PPP project and a further 50 locations where projects are at earlier stages of development.

The relocation of the National Maternity Hospital from Holles Street to St Vincent’s hospital is on schedule. The design team has recently been appointed for the new children’s hospital and is working to a demanding schedule. Planning permission will be lodged by the summer and I have asked that consideration be given to applying for outlying planning permission for a maternity hospital, thus achieving tri-location on the site. The strategic infrastructure development planning application was lodged with An Bord Pleanála in September last for the new mental hospital at Portrane. It is expected that a planning decision will be made in the first half of 2015, after which the enabling construction works and contractor procurement process shall commence, thus, at long last, putting us in a position by the end of the year to have work well underway on both the new mental hospital and the new children’s hospital.

There has been considerable investment to date in the community nursing home programme when it comes to new build and refurbishment and this investment is much-needed and ongoing. Earlier this year, the HSE purchased the Mount Carmel campus and we hope to have it opened as a refurbished facility, providing much-needed capacity for the Dublin area and essentially providing what has been missing for a very long time in Dublin but present in all other parts of the country, namely, a place for transitional, step-down and long-term care for elderly people who can be admitted from hospital much more easily. Our objective will always be to provide high quality, safe and supportive settings across the nation.

I have recently written to the HSE outlining its funding allocation for 2015 and highlighting the key areas to be prioritised in the 2015 service plan. As Members will appreciate, it is not possible to prioritise everything and I am sure some people will be disappointed by what is in it and what is not in it. The next step in the process is for the HSE to approve and submit its 2015 service plan for my consideration. The plan will set out in detail the volume and type of health services to be provided next year within the agreed allocation. Considerable work has already been undertaken by the executive on the preparation of next year’s plan. Once the service planning process has been concluded, the HSE will publish the plan and will immediately set to work on ensuring its full implementation.

I take this opportunity to pay tribute to health care staff who have taken us through some very difficult years. It is due to their hard work, commitment and dedication that the Irish health service has survived the most challenging period in its history. We still face many difficulties but there is every reason for optimism and believing that things can become more manageable next year.

Senator Daly: I welcome the Minister and thank him for outlining the situation with the health budget. The choices made in regard to cuts in the health budget are the thin edge of the wedge. It took six months to get the facts and figures on ambulance cover throughout the country, including my county.

It is a stark example of where we are at in terms of being in need of an ambulance today in Kerry. Three people a day who are in a life-threatening situation, be it due to a car accident, a heart attack or stroke, might find they will have to wait for up to an hour. In some instances people must wait for twice as long as HIQA’s standard of 18.5 minutes for an ambulance to arrive.

Apart from the issue of geography, the resources do not exist. Two years ago, four ambulances covered the area. The Millstreet ambulance, which covered north-west Cork and the east Kerry and Killarney area, was withdrawn and then Killarney’s second emergency ambulance was taken away, which meant that instead of four ambulances covering the area, there were two. Twelve months ago the second emergency ambulance disappeared and now two ambulances cover an area previously covered by four ambulances. If one has a heart attack, a stroke or one is involved in an accident in Kerry, one could wait for up to an hour. The situation is that three people every day do not get an ambulance to hospital within the critical time.

As the Minister is aware, when a person who has a heart attack does not get to hospital on time, the recovery period is longer and sometimes the outcome is fatal. Instead of leaving hospital early, such a person must stay longer in a high-dependency bed, and instead of going home, he or she is sent to a nursing home before eventually going home. The associated cost might have been alleviated had the person got to hospital on time. I am just talking about a small area in one county. If one takes the number of ambulances that have been withdrawn from the system, the knock-on effect is enormous.

I accept the Minister will examine the matter but I am aware the ambulance service has been told to cut costs. The long-term cost in terms of ongoing care for those who did not get to hospital on time is exponentially greater. I refer to the worst 10% to 20% of calls, the ECHOs and DELTAs, the critical emergencies, yet ambulances continue to be withdrawn. The Department should provide the Minister with the number of ambulances currently compared with three years ago. The figures are frightening and the outcomes are tragic.

In his address the Minister referred to service delivery. Another issue he could examine is a systems failure of monumental proportions. When one arrives at an accident and emergency department, one would imagine the ambulance crew would simply hand over the patient with data analysis and charts, but that is not the case. Paramedics tell me they must stay with the patient until someone takes the patient from them. Sometimes they must wait for between one hour and three hours, during which time the ambulance is not available to the community. That does not cost anything, it is just a systems failure, but if it were addressed by the HSE, more ambulance hours would be available and paramedics could deal with more emergency calls.

I am aware the Minister has been trying to address waiting lists but there has been an increase of 1,764 in the inpatient waiting list between January and August, bringing the total to 8,692. The question is how to address the problem. We have seen a 333% increase – 9,000 – in the number of people waiting for outpatient appointments, bringing the total number to 41,604. Not dealing with such patients early has disastrous consequences not only for the individual involved but for the health service in terms of how it can better deliver services and care.

If that patient is dealt with quickly it will not cost the service as much in the long term.

On the fair deal scheme, all of us have experienced situations where we were told the waiting time would be 12 weeks but it has now extended to 14 and 16 weeks. That is a waiting period of four months for an elderly person to get on to the scheme. There has been a cap on budgets and money allocated elsewhere but it is another systems failure whereby high dependancy beds in our acute hospitals, Cork University Hospital and others are not being freed up. That has had a knock-on effect on the waiting lists for inpatients because the beds are not available as a result of the fair deal scheme not functioning correctly, and not enough funding is being put into it.

Another knock-on effect has been on the ambulance service. Funding to the ambulance service has been cut so much ambulances do not get to patients in time. Those patients spend longer in hospital, which ties up beds. Our waiting lists with regard to inpatients has gone from 1,700 to 8,692. That is the domino effect of one issue on another. I ask the Minister to examine the ambulance issue nationwide because not only is it a problem in Kerry and Cork but all along the west coast. There is no doubt that distance is a factor. We hear talk of deploying helicopters and dynamic deployment. Dynamic deployment is a good way of saying we are guessing where the accident will happen. If those in the national ambulance service are asked what that means, they will give one a long explanation but it is really that they are dividing resources because resources have been cut. In the long run it is costing the health service and the Minister’s Department more money than it should but it is also having a major knock-on effect on other services in terms of tying up beds and ensuring poor and in some cases fatal outcomes for the patient.

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