Joint Committee on Health & Children
17th October 2013
Opening Statement
by
Mr. Tony O’Brien
Director General
Health Service
Good morning Chairman and members of the Committee.
Thank you for the invitation to attend the Committee meeting today.
I am joined by a number of my colleagues:
· Laverne McGuinness, Chief Operation Officer and Deputy Director General
· Barry O Brien, National Director Human Resources
· Dr Philip Crowley, National Director Quality and Patient Safety
· Patrick Burke, Assistant National Director PCRS
In my opening remarks I would like to update you on the following issues.
HIQA Investigation into the tragic death of Ms. Savita Halappanavar at University Hospital Galway
The HSE requested that HIQA conduct an investigation into the events surrounding the tragic death of Ms. Savita Halappanavar at University Hospital Galway on 28thOctober 2012.
On behalf of the HSE I want to express our appreciation for the considerable work undertaken by HIQA in conducting a thorough investigation and compiling this comprehensive report.
On behalf of the HSE, I once again wish to express our sympathy and to apologise unreservedly for the shortcomings in the level of care afforded to Ms. Halappanavar that contributed to her death.
I have appointed Ian Carter to oversee the implementation of the recommendations.
An implementation team was established by the HSE in anticipation of the findings of the three reports. This team is currently overseeing the implementation of the recommendations from the Coroner and Prof. Sir Arulkumaran’s report.
I have now directed that this team’s work be expanded to include the findings of the HIQA report to ensure that lessons from her death are applicable nationally.
NCHD’s
Implementing the EWTD is a very significant challenge for the health service and has been a vexed issue for some years. I do not for a moment dispute the fact that the level of hours worked by NCHDs needs to be reduced to a sustainable level.
I wish to make the following important points.
The key drivers of NCHD hours are service needs – and the amount of hours NCHDs work is determined by the rosters Consultants, Clinical Directors and service managers identify as needed to meet those service needs. Maintaining services to the public and meeting the requirements of the EWTD poses a significant challenge to the health service.
Part of that challenge is the introduction of new work patterns for NCHDs and Consultants, transfer of work currently done by NCHDs to other grades and the reconfiguration of acute hospital services.
We have accelerated progress in reducing hours in 2013.
Data based on hospital site visits indicates that as of September, 76% of NCHDs were compliant with a 24 hour shift and a further 6% worked no more than 26 hours continuously. It underlines continuing progress – when compared to the date for the first 6 months of 2013.
As part of the ongoing engagement with the IMO, the proposals of 27th September reflect a significant level of agreement between the IMO and health service management.
They include implementation of a maximum 24-hour shift by 30th November - other than in exceptional circumstances - with full implementation by 14th January 2014; full EWTD compliance by 31st December 2014, joint IMO / management verification and implementation at national and local level and referral of a range of other items to the Labour Relations Commission (LRC).
One issue remaining between the sides is the matter of sanctions and the HSE has put proposals to the IMO to resolve this issue.
The HSE and IMO have now concluded negotiations facilitated by the LRC and yesterday the IMO NCHD Committee agreed to put resolution proposals to a ballot of members. It is hoped that this will lead to a final resolution of the dispute.
Medical Cards
Members, in advance of today’s meeting an update report on Medical Cards was circulated. In recent times there has been ongoing discussion in the media in relation to eligibility and the assessment process for medical cards and in that regard I want to say the following:
Almost 2 million people are covered either by a medical card or a GP visit card. This means that 43% of the Irish population have Medical Cards or GP Visit Cards, with the number of individuals with eligibility having increased by 74% since January 2005.
Under the Health Act 1970, the assessment for a medical card is determined by reference to the means, including the income and expenditure, of the applicant and his or her partner and dependants. The medical card scheme does not provide an automatic entitlement to a medical card for individuals with a specific illness. However, where a person’s income exceeds the income guidelines, but where there is undue hardship the HSE can apply discretion and grant a medical card.
In these cases the social and medical circumstances are considered when determining whether or not undue financial hardship exists for the individual in accessing GP or other medical services. HSE medical officers are involved in assessing the circumstances of each case before making a decision.
Separately, Medical cards can be issued in emergency circumstances, where a patient is in urgent need of medical care that they cannot afford.
A medical card issued in emergency circumstances is valid for a period of six months. Medical Cards can be issued in emergency circumstances within 24 hours of receipt of the required patient details and letter of confirmation of condition from a doctor or consultant. All emergency cards are issued on the basis that the patient is eligible for a medical card based on their means and that the family cannot access General Practitioner and other medical services without undue financial hardship. Given the nature and urgency of the issue, the HSE has appropriate escalation routes to ensure that the person is issued the card as quickly as possible.
The HSE can also issue a medical card where a Doctor or a Consultant certifies that there is a terminal illness. Where a patient is terminally ill, the nature of the terminal illness is not relevant in the decision to issuing of a medical card. Furthermore, no means test applies.
The HSE monitors such cases and can renew the clients’ eligibility if necessary. In such circumstances there is no assessment of means.
As at 1st October 2013, 52,733 Medical Cards were issued where the applicant was above the national guideline in relation to means. The HSE exercised some element of discretion in relation to these applications. The number of GP Visit Cards granted in this way for the same period was 22,115.
It is important to clarify that there is only one medical card, as there seems to be an impression that there are two or indeed three types of medical cards. A Medical Card is either approved on foot of a means assessment, which meets the current financial guidelines, or where the applicant does not meet the income guidelines but there is undue hardship as a result of the medical or social circumstances.
The national guidelines include basic weekly allowances having regard to the applicant’s age, status and number of dependants. Additional allowances for necessary expenses incurred are also taken into account such as:
- Mortgage payments
- Mortgage Protection
- Life Assurance premia re mortgage protection
- Fire and Contents Insurance
- Expenses incurred in respect of Rent
- Childcare costs
- Travel to work costs
- Net cost of nursing home
- Maintenance payment
Earlier this year the first €50 of travel to work costs became disallowed for the purposes of these calculations as did the costs of servicing loans related to home improvements. This followed a budget decision in 2012. Changes in the thresholds for Over 70s medical cards, with substitution by GP Visit cards, were enacted by the Oireachtas in April 2013. These are the only changes to affect or limit standard eligibility. The assessment guidelines used in respect of cards issued in the case of an assessment of undue hardship for otherwise ineligible recipients have not been altered by the HSE since 2009.
In February 2012, the HSE reached agreement with the Irish Medical Organisation (IMO) in relation to new flexibility around reinstating and prolonging eligibility in certain cases. Under this arrangement GPs, in certain circumstances, can extend the period of eligibility for a medical card where a vulnerable person has been unable to engage with the HSE to renew their application. It also allows the GP to reinstate eligibility if a patient presents for medical care who has had their eligibility removed, e.g. due to a lack of response to the review process or because of a change of address. It also allows GPs to add new-born babies to their GMS list where the baby's parent holds a medical card.
I want to emphasize again that the assessment procedures used to determine eligibility for Medical Cards and GP Visit Cards has not changed. Rather, through the centralised processing of applications since 2011, where discretion is exercised, it is now applied equitably and consistently based on; standard operating procedures with medical officers assessing medical evidence for cost and necessary expense. This ensures that people, with serious illness, with incomes within reasonable reach of the qualifying scales can qualify. This becomes progressively more difficult as incomes increase to multiples of the qualifying scale. It is important to correct the impression that medical cards are issued 'automatically' or irrespective of means to those with serious medical conditions. No such automatic entitlement exists.
It is also important to stress that the medical card system is founded on the "undue hardship" test. The Health Act 1970 provides for medical cards on the basis of means. The HSE must operate within the legal parameters as set out in the Act, while also responding to the variety of circumstances and complexities faced by individuals who apply for a medical card.
Finally, I want to assure all citizens eligible for either Medical Cards or GP Visit Cards that the Health Service will not be changing its eligibility assessment guidelines. I and my colleagues are as committed to ensuring that all those legally entitled to medical or GP visit cards are able to avail of them as we are to fulfilling our absolute obligations to ensure that those who are not entitled neither receive or retain them.
The probity figure of €113m which featured in this weeks estimates has no impact on the definition of eligibility or on our approach to assessing it in each case.
Service Plan Activity
Members the HSE has seen significant and extended pressure on services in the first 7 months of the year which have required us to respond including with additional capacity.
· Emergency admissions were up by 6,842
· Elective admissions were broadly level with last year.
· GP Out of Hours contacts remains high at 566,914
· At the end of July 1,991,148 people are covered by a either medical card or GP Visit Card. This is 1.36% above July 2012 which was 1,964,500.
· In July 2013 23,166 persons were supported under the Nursing Home Support Scheme (NHSS). In July 2012 this figure was 22,950
Financial Update
In setting out the financial situation it is important that it is considered within the following context:
· There were significant pressures on our services, which impact on our costs as well as on our ability to fully sustain the very important improvements made last year in areas such as access times to scheduled care.
· The total reduction to the HSE budgets/costs of €3.3bn (22%) since 2008.
· The reduction in staffing levels of over 11,320 WTEs since the peak employment levels of September 2007.
In Vote terms, at the end of August, there is a cumulative net current deficit of €70m.
In Income and Expenditure terms, there is a cumulative net deficit of €75m at the end of July. By comparison, for the same period in 2012 the cumulative net deficit was €298m.
The HSE is not flagging any new concerns beyond those which were set out within the National Service Plan 2013 (NSP).
The 2014 Public Expenditure Estimates indicated Health sector Measures totalling €666m, net of demographic and other pressures and the HSE has already commenced the preparation of a service plan for 2014. To prepare the service plan will be very challenging indeed for the HSE.
This concludes my opening statement and together with my colleagues we will endeavour to answer any questions you may have.
Thank You
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