Martin Daly: Criticises agency spending and calls for health reform

Thank you for coming here today, Minister Butler, Minister O'Donnell, and your team from the Department of Health. Firstly, in relation to the pay expenditure projected on the budget, I just note here that whilst we are not underspending on core pay, we're overspending on agency. And I mean, to me, that's bad value for money. And I'm wondering, why are we spending so much money on agency? And this has been a recurring problem over a number of years. And I have to say, the public would say that this is bad planning, bad workforce planning, and sometimes short-termism in terms of year-to-year making changes in recruitment. So I'd just like to know what your reflections are on that in terms of agency staff. Thank you, Deputy. And you're absolutely right. And this is a key focus for us. And I met the Chief People Officer recently on this because the conversion from agency has not been strong enough. And while we've managed to stay within our budget by taking a total pay approach of whole-time equivalence and agency, and that, there's no question, has been a step forward in terms of financial control instead of just continually adding, adding, adding. That has been a step forward. There hasn't been sufficient agency conversion. And part of the reason for that is a short-term emergency reliance on agency and insufficient depth, I think, in the planning work that is necessary to identify those people that can and would convert and those who, for different reasons, are never going to come within the HSE system. Nevertheless, I want to develop a system within the HSE where staff can apply for additional hours, where they want to work for additional hours, but within the HSE system and not through agency, not through external funding. No, and I accept your answer, Minister. I suppose at the core of this is that agency, whilst it's absolutely necessary at times, provides workers into the HSE, but you don't get the continuity of care that you get with permanent staff. And so, on one hand, we say we're down on core pay, but we're up on agency. To me, I'd prefer to see our core pay overspent, because we have permanent staff and continuity of care, proper planning within the health service, rather than spending money on agency. And that's just a reflection, but I accept your answer. It's a limitation, for sure, and even in Mullingar, in Deputy Clark's area, for example, there's far too much agency, and it's hampering their ability to hire other people, and they are largely process issues that have to be resolved. And it's just a time issue, it's not so. On the issue of productivity and value for money, it's clear, it seems clear to me, that we are making significant investment in our health services, that we have reached international averages now. But are we getting value for our money? And one of the areas that you have outlined in your statement was that we've spent considerably extra money, but we're getting less productivity from, for example, for consultant-led clinics in our hospitals. Why is that happening? I don't know that I can speak to the why, but I certainly think that it can be improved with a different reorganisation. For example, we're seeing with the outpatient toolkit, making sure that there are the different scheduling of outpatient clinics in different primary care facilities, where there are three clinics running a day instead of two clinics running a day, where the focus is not on making sure the time is spent so the consultants are seeing patients rather than doing the in-between things that have been happening in the past. And it's very, very clear. And of course, you know, there's no different way of practising now than before that accounts for that loss of time. And it isn't okay. Louise, do you want to add anything to it? There's multiple factors, I think. So there is the complexity, of course, of different things, but there's also very much the way we organise. The fact is we have put 25% more staff into very much the same working patterns that we used to have in the same old ways of working. We haven't increased the output, like, you know, the amount of patients, exactly, as the Minister said, and other things. So flow and scheduling is key. There's two... Oh, sorry, Minister, go ahead. Just for example, I mean, even then, if you look at theatre utilisation, and I have consultants coming to me and saying, we want to do more. But if the theatres have to start, you have to be knife to skin at, you know, 7.30 or 8am, not different people coming on a shift at 7.30, 8, 8.30, and you're knife to skin at 9 o'clock. If you can be, you know, if the first team are in and knife to skin at 8 o'clock, you know, you can get extra surgeries done throughout the day. It's how these assets are organised, and that really is... That's not necessarily the consultant's responsibility to do that, but you can see that they want to do more, and we have to organise our services and our infrastructure so that they can do more. But you can see how the public might have a jaundiced eye in relation to the management of our public services, as opposed, for example, we went through the insourcing issue. So we were seeing a productivity gap there between someone who is doing some insourcing work on a Saturday morning and getting through, say, for example, 30 patients, whilst in a public clinic, fully supported, they were getting through 10. Now, that's it. I'm asking the question on behalf of public, and they're the questions that people ask me on the ground in my constituency in Roscombe and Galway. It is the most reasonable question, Deputy. Yeah, and not finally, but this is really important, and I know Mr Tierney is coming in next week and on December 3rd to talk about digitalisation. And I know you're very committed to it, but I have to say I'm 25 years attending the Department of Health, HSE, before that health boards. We are an unmitigated disaster in terms of digitalisation of a health service. And it is my impression that you can only throw so much money at a structure and an organisation that's not fit for purpose. And in this modern era, not having our health services digitalised means that we can throw as much money as we like at it. We're not going to achieve the productivity we require. What would you think about that? Well, I just, that's just not going to be acceptable. So that's why we're investing. But that's why we're also trying to harmonise what we're doing through financial management systems so that we can see what's happening and how money is being used right across the health system. 80% of the system is on the IFMS now, and it really is the voluntary hospitals that need to come on board. That represents 5 billion euros worth of funding. We absolutely have to have the same digital system. It's not acceptable, for example, for somebody to spend money. Or for example, I was in Mayo University Hospital, and there are different diagnostic systems between Galway and Mayo in the same region. And how that has ever been enabled to happen is beyond me. And that is not okay. And that's why we have to have the same systems throughout at every turn. We are a small country with a small integrated health system. People move between regions. People move between public and private. It has to be integrated. Without labouring on this, because we're going to have this next week, the public still aren't understanding how we have so many different systems. There's no sense that there's one big heave coming to try and get this over the line. We are a small country. Other jurisdictions have done this. And we are so far off the graph. It's unbelievable. So I'll leave it at that, because I know we will be dealing with it. And I do accept your commitment to the digitalisation. But we need significant funding to do that. Well, I'm very glad to hear you say so, Deputy, because, of course, I have tried to secure very significant funding in the National Development Plan for specifically that. And, of course, I'll be coming back to you many times to explain how we're getting on with that. Of course, Derek Tierney here, who has been responsible for it, is giving the committee a full technical briefing, I understand, next week or the week after, very shortly. And there might be something that you'd like to say at this stage, Mr. Jane. I don't disagree with the deputy. I mean, we do suffer from fragmented data. And data is our only way to gain insight to drive performance. So that's really about how do we use all our available resource, as the minister said in our opening speech. So how do we get best value out of the 95% of the resource that we have, as well as pursuing a reform agenda? Because you're right, deputy, we have to enable the health service to deliver integrated care and move away from siloed and fragmentation. And my ambition by the end of this year is to bring a memo forward for a national EHR rollout. And that is, I think, the game changer that you speak about. Thank you, Mr. Jane. We need to move away from a situation where we have junior doctors running around the hospitals, spending hours, unproductive hours, clinical hours, seeking out tests. And that is not in the interest of patient service. Moving on to the voluntary hospitals. I have considerable concerns that we, again, in a small country, have parallel services operating within our country. That we have the HSE on one hand and we have voluntary hospitals on the other hand, all effectively working in silos. Now, it doesn't make any sense to me. I see there's an overpay of 40 million that you're going to have to supplement now. But I know from your own statement and from the report we got, there's concern written in there about lack of governance, lack of control and lack of accountability. Yes, Deputy, the reality is that it has been difficult with different elements of the health system to agree, for example, data sharing in relation to patients and population-based health data. And that has been a struggle over the last number of years with the voluntary systems and with the private systems. But the patient is still the patient and now we have a situation where the state funds public health and the voluntary hospitals nearly completely. I'm just off the top of my head. The National Maternity Hospital, for example, has a couple of hundred of public servants and 112 million euros this year. The Mater Hospital has close to half a billion euros. The St. James' has half a billion euros and hundreds and hundreds of public servants. These are state-funded entities that are, in some cases, actually directly governed by I am the sole shareholder. And the CNAG has oversight of them. And it is essential that, and everybody there is operating as a public servant with a public service pension, they work for the state. And it is very, very important that that is understood. The Irish state is at the centre of health care, both in public and in private in different ways. And it is simply essential that we have the opportunity to implement the financial management system that this committee should demand. And I know I've already heard the support in the committee for that project. Thank you. Thank you so much. Thank you.