Dáil Éireann debate -
Thursday, 3 Oct 2024

In 2019 I attended a meeting with the then Minister for Health, Deputy Simon Harris, and Oireachtas Members from all parties in the south east. At that meeting the then Minister for Health committed to a national review of cardiac care. It was to look specifically at cardiac services in the south east, but also at wider services. I know that was disrupted by Covid and the work Professor Nolan subsequently did in the National Public Health Emergency Team, NPHET. My understanding is that the report has been with the Minister for Health for some time. When did the Minister receive the report and when does he intend to publish it?

I thank the Deputy for the question. The national review of adult specialist cardiac services is finalised and I have received the report. I do not have the date but I have received it and I will move to publish it very shortly. I want to bring it to Government. It is a very good and comprehensive report. One of the reasons I did not publish it right away was I did not want to publish a review that did not have any money behind it.

The report makes a lot of recommendations. Additional funding for cardiovascular services is required. I wanted to wait to make sure I had money to back all of this up. That is what the budget was about in this particular area. As the Deputy will be aware, we put a big focus in the budget on cardiovascular disease, which is still one of the biggest killers in the country. Unlike cancer care, women's healthcare and other areas, it has not had the strategic investment, with a plan, that it badly needs. This week I have put a cardiovascular health package together in the budget, with an allocation of €8 million. This includes €600,000 for the all-island congenital heart disease network; €4 million for 45 posts for the first year of the review so we can get on and hire the extra cardiologists and put the extra services in place; and €4 million to support the expansion of early supported discharge teams and, critically, access to acute stroke units, so the stroke strategy has been funded as well. I have also allocated a €600,000 investment in the Irish Heart Foundation to support two fantastic programmes it runs. In addition, from next year onwards, the GP chronic disease management programme will expand to cover three different areas of cardiology.

It national review is a good review. It is not an implementation plan so we will pull the cardiologists together now and tell them that we will have several million euro of permanent funding and ask what is the best way to begin to deploy it.

We cannot compare apples and oranges. My understanding of the review is that it was into acute services, especially primary percutaneous coronary intervention, PPCI, services. It was to look at location and what regions would have full 24-7 PPCI services. There is a separate need for a new cardiovascular strategy that will look at prevention, community care and cardiac care in its totality. As the Minister well knows, the current national cardiac strategy has ceased. It has come to an end, so there is a need for a new strategy. I have been informed by officials in the Minister's Department that they cannot start the work on the new wider strategy until the report into the acute services has been published. As such, it needs to be published. The Minister said that will be "in a few weeks". There is a lot of speculation as to what might happen in the next few weeks. No political party can go out and make promises on any issue unless we have full sight of the independent report into emergency cardiac services. That report needs to be published well in advance of an election. Can the Minister be clearer and firmer about what he means by "the next few weeks"? Will he give an indication of what recommendations the report makes for the south east, in particular University Hospital Waterford?

I fully accept the Deputy's point. We will bring the review to Government imminently and it will then be published. The review kicked off after the focus on University Hospital Waterford. That was the genesis of it. I thank Professor Nolan and his team for their work. When the Deputy sees the report he will see it is a comprehensive piece of work. What Professor Nolan and his team have done goes well beyond where 24-7 care should be. They did the work around cardiovascular diseases. As the Deputy will be aware, more than one in four deaths in Ireland is caused by cardiovascular disease. The report Professor Nolan has authored speaks to a lot of issues raised by the Deputy. It looks not only at acute care but also cardiovascular disease across the country. That is why we have put this package together. We have funding for the report, the stroke strategy, the Irish Heart Foundation and GPs as well. That element of this week's budget was intended to say we would apply funding right across the board, be it for GPs, community care, diagnostics or acute care.

As I said yesterday, I welcome every single additional cent that is put into any area of healthcare, particularly cardiac services. We will wait to see exactly what funding is being allocated and from where before we pass full judgment on that.

As the Minister stated, the genesis of this review was a meeting with the then Minister for Health, Deputy Simon Harris, attended by me, Deputy Butler, and others. It was to look at whether full 24-7 cardiac care would be provided to Waterford. A second cath lab is in place, and I welcome that. Additional hours of emergency services, extending them from 8 a.m. to 8 p.m. seven days per week, will eventually be provided whenever we get the staff to provide them. I also welcome that. There is still a question mark over whether there is a commitment to full 24-7 cardiac care. The people of the south east and Waterford deserve to know the answer to that question. Is it in the report? Has that been recommended? Is that the position of the Government? I could raise issues about what politicians have said in the past on this issue but I will not do so today. I am only interested in what is in this report for the State and, of course, specifically for Waterford and the south east. Will the Minister give an indication of whether it commits to full 24-7 PPCI services for Waterford and the south east?

I will not do the topic justice here. There has been a lot of careful thinking. We will publish the report and allow everybody to look at it in the round. The Government has progressed substantially in terms of the second cath lab in Waterford University Hospital. As the Deputy will be aware, the second cath lab opened in September of last year. That was an important milestone.

The opening hours of the first cath lab were extended the year before that from 8 a.m. to 8 p.m. from Monday to Friday. We are going further than that. Recruitment is now in process for the provision of full staffing to complement the existing services so that the opening hours of the cath lab will be 8 a.m. to 8 p.m., seven days per week.

Will the Minister give me his view regarding the feasibility of the proposal to extend the opening hours of the medical assessment unit at Nenagh Hospital? The idea and principle of expanding the opening hours of the medical assessment units at Nenagh and Ennis are understandable and logical. This could work if implemented properly. It would create more activity in Nenagh Hospital and mean that patients from north Tipperary could be referred by GPs to Nenagh rather than to Limerick. Patients could be assessed and triaged in Nenagh and only those who needed to be would be sent to Limerick. It would alleviate the pressure on accident and emergency services at University Hospital Limerick. It would also help to rotate beds faster for patients from north Tipperary who need acute care in Limerick. There is only one big problem - it is not working in practice. The existing medical assessment unit in Nenagh is malfunctioning and not being used to its full potential.

I thank the Deputy for the question. I support his call for ongoing investment in the medical assessment unit in Nenagh Hospital. The unit has been providing a valuable service locally. In many cases, it is an alternative to the emergency department for GP referrals. It is currently open seven days a week from 8 a.m. to 8 p.m. Last year, more than 4,000 patients were referred to the medical assessment unit in Nenagh. Already this year, the number of patients is in excess of 3,000 and climbing rapidly.

The Deputy will be aware that there was considerable investment of €2.3 million in the medical assessment unit in Nenagh. That allowed an extension to a seven days per week service from a five day per week service. Opening hours increased to 12 hours per day in July 2024. The service was provided five days per week and is now provided seven days per week from 8 a.m. to 8 p.m. I confirm that the policy is to move to 24 hours per day. Recruitment is under way and the posts have been sanctioned for that. There is ongoing discussion with the representative bodies and unions. They have raised concerns around rosters and working patterns with which the HSE is engaging. I would like those issues to be resolved because, as I said, the funding and posts are there. I want to get those posts hired into as quickly as possible so that we can open a 24-7 service, as the Deputy said. Once the ongoing engagement with the unions ends, we can move in that direction very quickly.

The problem is that the medical assessment unit in Nenagh Hospital is currently staffed and available but every day, several available slots are not used. Patients are not presenting to avail of the service. Consultants, nurses and support services are assigned to the hospital but there are not enough patients to treat. That is the reality. Considering that the current hours of service are not being used, what is the point in extending the hours of opening? We are not taking up what is available at the moment. It is a big issue that has been brought to me by the union and staff in the hospital.

Why are GPs reluctant to refer patients to the medical assessment unit at Nenagh Hospital? Why are they referring them directly to Limerick instead? A discussion needs to be had to get the considered views of GPs as to what are the stumbling blocks and why they are not referring directly to the assessment unit in Nenagh.

The number of presentations does not reflect the concerns that people are bringing to the Deputy. I will share the relevant numbers. In 2021, there were 1,300 referrals. In 2022, there were 2,500 referrals. Last year, there were 4,100 referrals. This year's number will be in excess of that. Between 2021 and 2023, years for which we have the figures, there was a 300% increase in the number of referrals. The referrals are climbing rapidly. If the Deputy has specific concerns that have been raised with him, he should by all means bring them to me.

The unions have raised concerns with the HSE. My advice is that those concerns are not about the use of the medical assessment unit but are about objections in respect of the staffing rosters. If legitimate concerns are being raised with the Deputy and he shares them with me, I will be happy to go back to the HSE with them.

The fact is that the front-line staff, the people in the hospital, are asking me what is the point in extending hours when the existing slots are not taken up. Consultants, nurses and everyone else are waiting around with no patients. That is the reality. There is a problem with the referrals from the GPs. The GPs obviously have good reason for not sending patients to Nenagh Hospital and we need to know what that reason is.

Management must engage with the staff in the hospital. Those in management must listen to the staff and respect their opinions. They must make decisions in conjunction with the staff. None of that is happening. That lack of consultation has led to uncertainty, confusion and resentment. That resentment is now manifesting in the fact that the Irish Medical Organisation, IMO, is to ballot its members on strike action. Whatever information the Minister is getting is not accurate. I am getting information from people on the front line, people on the ground, those who are working in the service every day. They are completely disillusioned.

This is probably the first conversation I have had where any Deputy has called for a reduction in healthcare service provision in a constituency. I do not think I have ever heard hospital staff calling for fewer services to be provided. We need to treat this carefully.

As I said, the number of referrals is not in line with what the Deputy is hearing. The number of referrals tripled in just two years. There is a run rate of nearly 100 referrals per week. If there is more that the GPs can be doing and there is a need for engagement with the GPs to make them aware, let us do that. However, rather than saying there are slots available so we should reduce the service or not increase the service, and I know the Deputy is not saying that-----

I know the Deputy is not saying that, and of course we will do as he says. It is interesting that the concerns the unions are raising with the HSE are that they do not want to work the rosters that are being offered. That is what the HSE is hearing. The Deputy might share specific examples of unfilled slots and I will ask the HSE about it on the back of this conversation. It goes without saying that we must fully use the capacity we have. Perhaps further engagement with the GPs is required. Let us see.

The saga around the national children's hospital, unfortunately, continues. When the Minister gets to his feet, he might give us some indication from his perspective as to when he believes the handover will happen and when the hospital will open and treat patients. Is he satisfied that the transitional plans are in place to ensure that when the hospital is ready for the handover and is handed over, a proper transition plan is in place, whereby staff can be decanted from the other hospitals quickly and we can get the hospital open and treating patients?

I thank the Deputy for his question. As we are all aware, the main contractor has now missed its own deadline 14 times. It missed its own deadlines four times this year alone.

Neither the HSE nor the Government has confidence in deadlines that a contractor puts forward when the contractor misses its own deadlines 14 times. Our position and that of the board has been clear, in that the contractor needs to fully resource the project. The board’s view is that the contractor has consistently failed to do so. In my last meeting with the board a few weeks ago, the board’s view was that the contractor had fewer than half the staff on site that were needed. Deputy Cullinane and I go into, as we should, the details around contracts, withheld money and so on, but at a simple level, if any of us paid a builder to build us a wall and the builder put half the number of bricklayers on the job that was agreed, the wall would take longer to build. Much of this issue boils down to that. The contractor has not resourced the project.

I believe it was in March of this year that we were all expecting handover in October or November. The contractor then said it would be in March of next year, then June. The contractor has to fulfil its obligations on this project. A vast amount of commissioning work is being done – I spoke to the chief executive and the chair of the board about the commissioning this morning – to ensure that everything that can be done is done. We need to accelerate the commissioning and move into the hospital before the final completion date. There is commissioning work that could be accelerated.

There is an obvious role for the contractor to resource the contract and I have called on the main contractor to do exactly that. I am interested in the hospital being built as quickly as possible for children. My main focus is on ensuring that we have a world-class, fit-for-purpose children’s hospital that is open and treating patients. The Minister used the example of a wall being built in someone’s house, but a houseowner would not accept all of these missed deadlines and would not just be telling everyone that it was terrible. The owner would be taking action and using whatever levers were available to them.

In everything I have heard from the Government, there has been a dodging of responsibility on its side. There is plenty of blame to go around, including for the contractor, but cheques are still being written. The contract does not contain the necessary levers to hold the contractor to account. The Government’s strategy is not to give the contractor any more money, and I see the wisdom in that, but that is not progressing the hospital. I asked the Minister a question today, so when he speaks again, he might answer it. All these years later, he is still not in a position to tell me, children or the people of Ireland when the hospital will be completed, handed over, open and treating children. He might prove me wrong when he takes to his feet, but I have not heard that date from him or anyone else in government.

The Deputy raised a few points. Let me be clear, in that I wanted the State to take ownership of the hospital around now. The contractor told us it would be in October or November, but it has missed its deadline. It has under-resourced the project repeatedly and failed to meet its deadline.

I agree with the Deputy about how the hospital development board, which is acting on our behalf, must use all of the levers available to it in the contract. Having met the board and been in regular communication with its chair, I am convinced, and the board is clear, that it is using all of the levers available to it under the contract. That is what makes this situation deeply frustrating.

I still expect the State to take ownership of the hospital next year. We should have accelerated commissioning and the hospital open next year. What is happening is deeply frustrating. As I wrote to the Taoiseach, and as the board told me when I met it, the board’s view is that the contractor is holding the Irish taxpayer and, arguably, the children of Ireland to ransom.

That is no good to the people of the State who are still funding the hospital or to the children who need it. Does the Minister accept that the levers for holding the contractor to account do not exist? All the levers he has mentioned have been used before and clearly do not work. Does he accept that that has to do with flaws in the contract? Despite all of the tough talk and Ministers sticking their chests out and saying they will take on the contractor, we are no closer to the hospital being built than we were this time last year. I have had similar exchanges with the Minister in this Chamber and we have had debates at the Oireachtas health committee. No one can tell us when the hospital will be built and open. All the while, we have a blame game, with the contractor blaming the board and the board blaming the contractor. We go around in circles and we make no progress. There has to be political accountability as well as a holding of the contractor to account. For all the Minister’s talk of levers, brakes and other measures to put pressure on the contractor, they are not working. Is the problem that they do not actually exist and that the State is powerless to hold the contractor to account, all the while writing cheques even though children are waiting for the hospital to be built?

At this point, it would be a futile exercise to second-guess the contract. The contract is what the board has and we must manage the project within it. The board is using the contract to the fullest extent possible.

I acknowledge the Deputy’s role in this. He must, and should, put pressure on us. I would were I in his chair, and did. There is value to us speaking with one voice at least in terms of shining a light where it must go, namely, on the contract.

I just acknowledged that. I will cite an example that the Deputy’s colleague, Deputy Doherty, raised with me at the health committee. I believe Deputy Cullinane might have been present for it. It had to do with grilles. Clearly, he had been given information. I believe he was acting in good faith. He made an impassioned contribution and said that this was a design flaw and, therefore, the fault of the board, designers or whoever it might have been in the State. We can all guess where that information may have come from. It only served one party. According to the information on which Deputy Doherty made his claims in good faith, this was going to cost-----

Will the Minister act on the urgent need to upgrade and extend the building from which the Gurteen family practice in County Sligo operates? I visited the practice two weeks ago. It is run by Dr. Helen Fitzsimons and was named rural practice of the year for 2024. I saw first hand the urgent need to upgrade the building.

Sadly, I wish to extend my most sincere sympathy to Dr. Fitzsimons and her children on the sudden death last week of their beloved husband and father, Tom Bradley. May he rest in peace.

I join the Deputy in offering my sincere condolences to Dr. Fitzsimons, her children and the entire family on their recent bereavement.

The Gurteen health centre is located in south Sligo. The centre houses a public health nursing service, a day centre for older persons and the local GP practice. Local HSE primary care management has advised that it is aware of the issue of restricted space within the building for the GP practice. While it is not possible to extend the building, the HSE is conducting an options appraisal process to scope out options for the reconfiguration and refurbishment of the building. It is intended that this process will be completed in the coming weeks and, following appropriate discussions with stakeholders, a priority submission for capital funding is to be put forward. This is a long, official way of saying that the HSE is aware of the problem and is looking to solve it. The HSE will finalise some options in a matter of weeks, which is welcome to hear, and will prioritise whatever the preferred option is.

I thank the Deputy for raising this matter. I will ask my officials in the HSE to keep her updated on progress.

I am pleased to hear that the process will be completed in the coming weeks and a priority application for capital funding will be put forward.

When I visited the practice two weeks ago, I could see for myself the urgent need to upgrade the building. The reception area is tiny and cramped. There are three receptionists. There are wires trailing over sinks. It doubles as a kitchenette and a storage area. There are holes in the floor. The building is unsafe. That practice sees between 4,000 and 5,000 patients; it is a huge practice. The most crucial issue, which is pretty disgusting, is the fact that the wastewater system is malfunctioning. I am told staff have to come in nearly an hour before the practice opens in the morning, run the taps and flush the toilets continuously, and open the windows so that people can come in an hour later. The Minister will hear from what I am saying the urgency in this matter.

It is clear that urgent remediation is required. It is welcome that the HSE intends to conduct the assessments and will be back within a couple of weeks. There is important additional good news for the area. The planned primary care centre in nearby Tubbercurry is due to commence building early next year, which is welcome. The existing primary and mental health care centre in Ballymote is to provide the majority of HSE primary services in the area. It is intended that this will allow for the reconfiguration and refurbishment of the Gurteen health centre for all of the very pressing reasons the Deputy has articulated today.

I thank the Minister. The people in Tubbercurry and Ballymote will be very pleased with that. What is at issue here is the Gurteen health centre. They told me the HSE maintenance manager has been as helpful as he can. He has done everything he can but the problem is a severe one and it is just papering over the cracks.

I know the Minister is really interested in women's health. Dr. Fitzsimons runs a women's health clinic two days a month in Manorhamilton and many patients come to her clinic for women's health issues specifically in Gurteen. That is one of the reasons she and her brilliant staff are so busy. It is a really important service and we must ensure the building in which it is being provided is up to standard. I am pleased with the Minister's response and look forward to working with him and his officials to progress this matter.

I thank the Deputy. I acknowledge the work of Dr. Fitzsimons on women's health. I was delighted earlier this week to be able to expand that. This will be our fifth budget in a row where we really do prioritise women's healthcare. There have been a few important additions which Dr. Fitzsimons and all the other GPs will be aware of and will be part of. One is the expansion of IVF eligibility, which will make a big difference to a lot of couples. The first step on that fertility journey is with the GP. It is they who refer into the six regional centres, who then refer on for IVF. HRT is being made free. This has been welcomed around the country. The medical professionals and GPs are saying it is great because it removes barriers. I was talking to one lady in Wicklow yesterday who said she was spending €1,000 a year on HRT. I commend Dr. Fitzsimons and all of our GPs around the country on their championing of the women's health priorities over the last years.