COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 29 Sep 2022

Health Service Executive - Financial Statements 2021

Mr. Paul Reid (Chief Executive Officer, Health Service Executive) and Ms Siobhán McArdle (Assistant Secretary, Department of Health) called and examined.

Chairman

I welcome everyone to the meeting. No apologies have been received. If attending in the committee room or from the precincts of Leinster House, attendees are asked to exercise personal responsibility to protect themselves and others against the risk of contracting Covid-19. Members attending remotely must do so from within the precincts of Leinster House. This is due to the constitutional requirement that in order to participate in public meetings, members must be physically present within the confines of the Parliament.

The Comptroller and Auditor General, Mr. Seamus McCarthy, is a permanent witness to the committee and is accompanied this morning by Mr. John Crean, deputy director of audit at the Office of the Comptroller and Auditor General.

This morning we will engage with the Health Service Executive, HSE, to examine, in the context of its 2021 financial statements, mental health-related expenditure in community health organisations, CHOs, 4 and 8. We will meet the HSE at the same time next Thursday to examine its 2021 financial statements in detail, including expenditure on ambulance services.

We are joined in the committee room by the following officials from the HSE: Mr. Paul Reid, chief executive officer; Mr. Stephen Mulvany, chief financial officer; Mr. Damien McCallion, chief operations officer; Ms Mairéad Dolan, assistant chief financial officer; and Mr. Maurice Farnan, assistant national director, community operations. We are also joined remotely from outside the precincts of Leinster House by the following officials from the HSE: Ms Anne Kennedy, acting chief officer and head of finance, CHO 8; Ms Dervila Eyres, head of mental health services, CHO 8; and Mr. Michael Fitzgerald, chief officer, CHO 4. We are also joined in the committee room by the following officials from the Department of Health: Ms Siobhán McArdle, assistant secretary; and Mr. Kevin Colman, principal officer. As usual, I remind all those in attendance to ensure their mobile phones are on silent mode or switched off.

I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards reference witnesses may make to other persons in their evidence. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected, pursuant to both the Constitution and statute, by absolute privilege. However, three of today's witnesses are giving their evidence remotely, from a place outside of the parliamentary precincts, and as such may not benefit from the same level of immunity from legal proceedings as a witness physically present does. These witnesses have already been advised that they may think it appropriate to take legal advice on this matter.

Members are reminded of the provisions in Standing Order 218 that the committee shall refrain from inquiring into the merits of a policy or policies of the Government, or a Minister of the Government, or the merits of the objectives of such policies. Members are also reminded of the long-standing parliamentary practice that they should not comment on, criticise, or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I now call on the Comptroller and Auditor General, Mr. Seamus McCarthy, to make his opening statement.

Mr. Seamus McCarthy

The Health Service Executive's financial statements for 2021 reflect the continuing impact of the Covid-19 pandemic on the HSE's finances. Total expenditure in 2021 was €22.7 billion, an increase of approximately €1.7 billion or 8% when compared with 2020 and an increase of almost 27% when compared with 2019. Total operating expenditure in 2021 exceeded income by €195 million and this deficit was carried forward to be met from the funding provided from the health Vote in 2022.

The revenue income and expenditure account analyses expenditure between pay and pensions - €7 billion - and non-pay - €14 billion. The biggest components of non-pay are the primary care and medical card schemes, accounting for €3.9 billion, and grants to section 38 and section 39 agencies of €5.7 billion. The section 38 bodies provide health and personal social services on behalf of the HSE, while the section 39 agencies provide services similar or ancillary to those provided by the HSE.

The bulk of the HSE's funding comes from the health Vote, amounting to a total of €21.6 billion in 2021, and including just under €1 billion in funding for capital projects. Other, though much smaller, sources of income for the HSE were receipts of €343 million in respect of patient charges for hospital treatment or for long-term residential care and retained employee pension contributions deducted from staff salaries, which amounted to approximately €356 million in 2021.

The HSE has disclosed its estimates of the expenditure incurred in 2021 on items directly related to dealing with the pandemic in Note 1 (b) to the financial statements. This includes an estimated €719 million on testing and tracing and €530 million on the vaccination programme.

In my report on the audit for 2021 I draw attention to a number of matters disclosed by the HSE. I will briefly outline the matters here but further detail is in the audit report and in the financial statements.

In 2020 and 2021, the HSE spent an estimated €1.1 billion on the procurement, transport and storage of personal protective equipment, PPE, supplies. Impairment charges of €374 million were recognised in the 2020 financial statements, reflecting a loss of value due to falling market prices and expected obsolescence of goods purchased.

In 2021, the HSE incurred further impairment charges of €109 million on PPE. This comprised €25.6 million in respect of hand sanitising gel that the HSE anticipates will pass its expiry date before it can be used, €12.7 million on other PPE items that are unlikely to be used, and €70.6 million in respect of the further write-down of stock values to replacement cost at year end 2021. The 2020 impairment charge included a €64 million provision for obsolescence in respect of protective suits that were unlikely to be used. Due to the fact that the HSE had not decided how to dispose of the suits, it incurred additional costs of €1.25 million to store them during 2021.

Once again, my audit report for 2021 draws attention to non-compliant procurement which remains a significant issue for the HSE. A self-assessment exercise carried out by the HSE on individual invoices above €20,000 estimated that non-compliant procurement in 2021 was around 9%, or 16% if Covid-related procurement was excluded. However, I concluded that this estimated rate of non-compliance with procurement rules may not accurately represent the scale of the underlying problem because in 2021, 44% of the HSE’s total procurement involved invoices under the €20,000 threshold and were therefore outside the scope of the self-assessment exercise, and 13% of the expenditure within the scope of the exercise could not be assessed for various reasons.

Finally, my audit report also draws attention to the disclosures made about the HSE’s actions in the aftermath of the cyberattack in May 2021. Members may wish to be aware that, as part of my annual report tomorrow, I will be publishing a report on the costs incurred as a result of that incident.

Chairman

Thank you Mr. McCarthy. Mr. Reid, you are very welcome back to the committee. I understand this will be your last appearance before the Committee of Public Accounts. You been in situ for seven years. Is that right?

Mr. Paul Reid

No, I have been just over three and a half years in this role.

Chairman

It feels like seven years-----

Mr. Paul Reid

I have been before the Committee of Public Accounts for the past 11 years in various roles.

Chairman

Okay. You are very welcome. As detailed in the letter of invitation, you have five minutes to make your opening statement.

Mr. Paul Reid

I thank the Chairman and members for the invitation to attend today’s meeting to discuss the HSE’s financial statements 2021. The Chairman has already introduced my colleagues, so in the interests of time, I will not repeat the introductions. A briefing paper was submitted to the committee in advance of today’s meeting. Accordingly, I will confine my remarks to a number of specific matters, the first of which is the annual financial statement for 2021 and the financial outturn.

The HSE’s 2021 audited and published annual financial statements reported a revenue income and expenditure deficit of €195 million, as advised to the committee in May 2022. This deficit is due to the pressures arising from the ongoing Covid-19 response, resulting in an excess of Covid costs over available Covid funding. This includes expenditure in relation to the vaccination programme as well as test and trace costs which were key to the HSE pandemic response. In arriving at the net deficit of €195 million, the Covid deficit was substantially offset by a surplus arising on core non-Covid activities which was due to the regrettable suppression of core activity and associated delays in progressing new developments, largely driven by the pandemic and our need to respond effectively to it. Over the two years of the pandemic in 2020 and 2021 the HSE will have recorded a combined revenue surplus of €5 million, or a combined surplus of €65 million over the three years 2019 to 2021.

The Comptroller and Auditor General’s report on the HSE’s 2021 annual financial statement has indicated that these financial statements are properly presented in line with the appropriate accounting standards. The Comptroller and Auditor General has referenced a number of matters which I will focus on briefly today including losses related to procurement of PPE, non-compliant procurement and the cyberattack. The statement of internal control which forms part of the financial statements and which is a requirement of the code of practice of the Department of Public Expenditure and Reform details the management action that is under way within the HSE to respond to these matters. As the committee has received briefings on these items previously, I am happy to respond to any questions during the course of today’s meeting.

The draft revenue income and expenditure financial position at the end of July 2022 shows a year-to-date deficit of €731.4 million or 6.26%. Over 80% of this deficit or €608.2 million is driven by the direct impact of Covid-19, with the remaining €123.2 million driven by core non-Covid-related costs. However, when account is take of Covid–19 related costs, acute income, bad debts and price per nursing unit, PNU, cost of care issues which are embedded in core services, this variance reduces to approximately €50 million in the year to date. This expected reduction in the core deficit excludes costs such as State Claims Agency and the impact of the restoration of pre-Haddington Road working hours. The HSE has developed a financial management plan for the second half of 2022 to co-ordinate a set of required actions to achieve a break-even position on core activities by the end of 2022, notwithstanding the issues I have just referenced..

It is estimated that the total cost of Covid-19 expenditure in 2022 will be in the order of €2 billion which will result in a very significant Covid-19 deficit when compared to the allocated budget in the national service plan for 2022. There has been extensive engagement between the HSE and its funders in relation to the likely Covid-19 deficit and discussions are continuing with regard to supplementary funding.

In 2021 total mental health funding amounted to €1,099 million, representing an increased budget of €68 million or 6.5% on the previous year. Expenditure on mental health services in Community Healthcare Organisation, CHO, 4 was approximately €143 million, representing 12.5% of the overall mental health allocation in 2021. Total 2021 expenditure on mental health services in CHO 8 was €115 million, which is 10.5% of overall mental health funding last year. A detailed briefing has been provided to the committee regarding mental health expenditure in CHO 4 and CHO 8, and I am happy to respond to any questions arising in the course of today’s meeting.

The overall allocation of funding to mental health in 2022 is €1,159 million which is a further increase of €60 million or 5.4% over 2021. Since 2012 mental health funding has increased by €452 million or 64% overall, with €325 million of this relating to priority service enhancements. These targeted investments have been directed by national mental health policy as outlined in a Vision for Change, 2007, Connecting for Life, 2015, Sharing the Vision, 2020, and are also in line with the broader Sláintecare reform programme. The continued development of mental health services is aimed at modernising mental health services by building our workforce and investing in fit-for-purpose infrastructure; promoting positive mental health for everyone; providing accessible, comprehensive and community-based services where needed; and taking a person-centered approach supporting the recovery journey of each individual based on clinical advice and best practice as well as lived experience. The three-year implementation plan for Sharing the Vision launched earlier this year provides a clear road map for the continued enhancement of mental health services in Ireland. Implementation will be driven by a strong outcomes focus and a shared commitment to report on progress in an open and transparent manner.

That concludes my opening statement.

Chairman

Thank you Mr. Reid. The first contributor today is Deputy Colm Burke who has 15 minutes. Everyone else will have ten minutes.

Deputy Colm Burke

I thank Mr. Reid and all of his HSE colleagues for being here today. It has been a very challenging time over the last two and a half years in dealing with Covid. Today my focus is on mental health services and in particular, on services in my own area which is the Cork-Kerry region. I have been looking at data on population changes in that area over the last six years.

The population is now 736,500, which means that it has gone up by 45,000. In relation to workforce planning for mental health services, is that now being looked at to address the need for getting additional staff? I understand from people working in the mental health area that there has been a huge increase in demand for services, which may or may not be related to Covid-19. What plans are being put in place now to try to deal with this new increase and with the pressures that are on staff? What plans are there to look at having a comparable number of employees, compared to the increase in population of the area?

Mr. Paul Reid

I addressed this yesterday at the Oireachtas Joint Committee on Health. We have a focused recruitment plan which is both geographically based and service based. In total this year, we will have recruited approximately 5,000 extra staff. Since January 2020, we are up approximately 15,000 staff in the HSE.

Deputy Colm Burke

Are these to primarily deal with mental health?

Mr. Paul Reid

Yes.

Deputy Colm Burke

If one looks at the reports on mental health facilities, we are running into difficulties. I say this because they are no longer deemed suitable for the number of people in them. We have had to reduce the number of people in many of those facilities.

Mr. Paul Reid

The key part of that recruitment is in the area of mental health, that is, in child and adolescent mental health services, CAMHS, adult mental health services and later years psychiatry services. I will let my colleague, Mr. Michael Fitzgerald, comment on the area that the Deputy referenced. However, we have had a real challenge with getting some of the specialists we require for mental health, as well as with retaining staff overall. It is a challenging service area. We have a significant budget and we have had some success throughout the year. I will let my colleague comment specifically on the CHO area that the Deputy has referenced.

Deputy Colm Burke

Before he goes on to make a comment on it, I will raise the facility in Bantry. The Mental Health Commission report of 2021 stated that Bantry was rated in the top three in CHO 4, at 87%. I understand the Mental Health Commission has now deemed that the number of inpatients or residents there must be reduced. Why has that change occurred in such a short time?

Mr. Paul Reid

With the agreement of the Chair, I might ask Mr. Michael Fitzgerald comment on the CHO area and particularly on Bantry.

Mr. Michael Fitzgerald

In general, across CHO 4, and particularly in the Cork area, we have certain challenges with regard the infrastructure that is regulated by the Mental Health Commission. Bantry is one of those centres. The Deputy will know that in recent weeks, an appeal has been made by the HSE on a particular issue regarding the occupancy of bedrooms in Bantry. That matter will be before the District Court over the coming period. We will continue, of course, in the interim to work very closely with the regulator on any and all of those concerns. To broaden my response a little and in relation to the Deputy's first question, as the CEO said it has certainly been a challenge to attract and retain workforce and we are aware of the increase in demand and in population. I can assure the Deputy that we are working very closely on the ground to ensure that we are taking account of that. In particular, we are working on the Sharing the Vision policy and the three-year implementation plan, which is all part of providing a service that will be in the community and will support people to stay at home as much as possible.

Deputy Colm Burke

Can I just raise the risk and control framework, which contains a statement on internal control. It states:

Management of risk is an integral part of good governance. The HSE has developed an Integrated Risk Management policy which has been guided by the principles of risk management outlined in ISO 31000 (ISO 31000 is an internationally recognised standard informed by experts in risk management).

On risk management, we have had a problem in CHO 4 in relation to a CAMHS area where we did not have a suitably qualified person in charge and now we are in ending up with a serious difficulty. I have raised the issue about increased population and increased demand but are we satisfied that we now have adequate risk management in place for all of our mental health services in the CHO 4 area?

Mr. Paul Reid

I will make a general comment and then specifically reference the CHO 4 area. In general, in our risk management focus, we have placed a huge focus on this over the past three years with the appointment of our board and dedicated audit and risk committee, which was quite right. Separate to that, we have appointed a chief risk officer. We have reassessed the old risk management process within the HSE, have put further resources into it and have developed a new corporate risk register. That is informed by top-down risks from our strategy. Also, it is informed by bottom-up risks from CHOs, acute hospitals, mental health services and disabilities. It is quite a comprehensive approach and is much better strengthened than it has ever been. I might ask Mr. Fitzgerald to comment on the identification of local risks but I want to reassure the committee that we have a much-strengthened, enterprise risk management approach.

Deputy Colm Burke

In relation to CHO 4 and that issue that has arisen, I presume we now have a number of claims in. Do we have an idea of the extent of that number of claims?

Mr. Paul Reid

Specifically regarding the case of CAMHS and the junior doctor in south Kerry, which is the case that the Deputy referenced-----

Deputy Colm Burke

Yes.

Mr. Paul Reid

----- yes, we have completed an assessment of that. I do not have details to hand right now on that. There is a process. There are supports for claims. We have put a national audit in place for the learnings from south Kerry CAMHS to look at prescribing methods and to look at compliance with the 2019 standards that are in place across the country. That audit will be completed before the year-end. We will have further learnings from that. That is a piece of work that we are doing and there is a process for people to go through.

Deputy Colm Burke

However, once there are claims, there is also a cost factor as well, which is what the Committee of Public Accounts is about. So, too, is how to prevent claims by making sure that we have adequate management in place. Are we now satisfied, in view of the increased demand - and in fairness there is only so much every staff member can do - that there is an adequate number of people in place and, where there is a deficiency, that there is an adequate level of controls and cross-checks in place to make sure that we do not have a repeat of what happened in CHO 4?

Mr. Paul Reid

No, and to be frank, we do not have the required resourcing that we want in mental health and in disabilities. We have real challenges in recruiting in the area. I am confident that we have put in all the potential recruitment processes that we can, including doing so overseas to recruit specialists into the area. We are also looking at the pipeline of what is coming through from colleges to see how that can be strengthened. While there are real risks in terms of resourcing in mental health, I am satisfied, based on the case to which the Deputy referred of the junior doctor in south Kerry, that we have put in the processes to identify further risks across the country or any further controls that we have to put in place in CAMHS. Equally, I want to assure the committee and the public all across the country today that people are getting good service in CAMHS and our mental health services and where we have identified issues, we are addressing them.

Deputy Colm Burke

Can we be given information on the likely number of claims as a result of that deficiency?

Mr. Paul Reid

That process is ongoing. Personally, I have been down to south Kerry and have met the families involved, as well as many of the children involved. The Maskey report and the Government have now set out a process for how claims will be dealt with, should those claims come through. I do not have details of it because it is too early in the process.

Deputy Colm Burke

I have raised the issue of Bantry and about the Mental Health Commission. I understand that we have had to reduce numbers in some other facilities, for instance, in Millfield House. We have moved people into Garnish House on Western Road. That is not the ideal setting. It is not a planned setting but it was put in place because we needed to reduce numbers in Millfield House. Where are we now in relation to dealing with residents who were in Millfield House and likewise in other facilities where we have had to reduce numbers? Where are we in respect of long-term planning, dealing with the increased demand and, at the same time, trying to deal with the people who already are availing of the facilities?

Mr. Paul Reid

I will let my colleague comment on Millfield House. Briefly, on all our services, we have a capital plan and there are certain significant challenges in terms of infrastructure and mental health services that we want to invest in. The CHO areas themselves will be bringing back a dedicated capital plan for the CHO area and to address some of the capacity issues.

We have a challenge throughout the country with regard to infrastructure and capital investment, but we have prioritised and put capital funding into mental health. My colleague, Mr. Fitzgerald, will speak about Millfield.

Mr. Michael Fitzgerald

The Deputy will be aware that, initially, Millfield was a 14-bed high-support hospital on the north side of the city. As we entered into planning for Covid at the start of the pandemic, from a risk-management perspective, Millfield was identified as residence where a high level of occupancy and certain environmental issues did not assist us to provide good infrastructure for infection prevention and control. At that stage, an opportunity arose to take a bed and breakfast that had single rooms, which is Garnish House, and to utilise it for the purposes of providing accommodation. At that very early stage of Covid, a wise and judicious decision was made to move people to Garnish House, where more space was available to them, and to a number of other centres where there were multi-occupancy rooms in some residential settings throughout the city also availed of it. We are still in that setting, but just for another number of months. In the meantime, we are doing some minor refurbishment in Millfield. It will not be able to accommodate 14 people by the time we have finished with it but it will certainly accommodate eight to ten.

The Deputy is right that, as the CEO said, we have some difficulties regarding accommodation. It is very well known that we have specific concerns with regard to accommodation around the city. We have purchased Glenwood House in Carrigaline, which is going through a planning permission process with An Bord Pleanála. When that comes through, I am confident that it will provide us with additional space of very good quality.

Deputy Colm Burke

We have now identified problems which also happened in public nursing homes. I think we put in more than €48 million into doing considerable work on public nursing homes. Do we now need to prioritise funding of the infrastructure of mental health services, especially in CHO 4, to make sure we have an adequate number of places and that they are up to the required standard that we need? How long will it take us to put in place a development plan to deal with that? Our backs are to the wall with regard to the challenges facing staff and residents.

Mr. Paul Reid

We have a very dated health service infrastructure throughout our State. That goes for our acute hospitals, mental health facilities, disability services and many of our community services. We have an available capital envelope that we utilise and prioritise on a multi-annual basis. Mental health services have certainly had prioritisation on it, but we have to make calls with a limited capital envelope on a multi-annual basis. The CHOs will prioritise based on the infrastructure that they have but the infrastructure in the health service is very dated.

Deputy Colm Burke

However, have we put a timeframe in place for upgrading facilities in each of the CHO areas and certain targets we wish to reach? If we do not have the facilities, we have difficulty in holding staff. We could have a repeat of what happened in CHO 4 with regard to not having staff and running into a considerable claims problem. Do we not need to prioritise capital expenditure in all of our facilities in order to prevent similar incidents occurring in the future?

Mr. Paul Reid

We have a prioritised capital plan. We have to make calls on which ones are the priority and which ones are the highest risk regarding service users and their staff. We have that prioritised capital plan on a rolling three-year basis. We prioritise based on the infrastructure and risk involved.

Deputy Matt Carthy

I welcome our guests. The issue of the Owenacurra centre in Midleton has come before this committee on several occasions. Who is best placed to answer questions on that?

Mr. Paul Reid

My colleague from the CHO area.

Deputy Matt Carthy

I am trying to get behind the HSE's rationale. As I understand it, in June 2021, residents received a communication from HSE management indicating that the centre was to be closed on the basis of a Mental Health Commission recommendation or standard. Am I correct in saying that was the rationale for the decision?

Mr. Paul Reid

Based on a set of recommendations that came from the Mental Health Commission, we commissioned a report following that to assess the feasibility of completing those recommendations. Our feasibility report identified a range of very significant issues with the infrastructure, the investment required for it and its safety. Such issues were also identified with the human aspect of it, especially with regard to the space that people had within the units and the fact that representatives from a day service literally had to walk through people's residences. The whole infrastructure was completely unsuitable, and the investment profile for it would not have addressed that. Our assessment of all of that, based on the Mental Health Commission recommendations, was to seek alternative accommodation and processes for the well-being of the service users and the investment required.

Deputy Matt Carthy

The HSE's procedure was to seek alternative accommodation. Does it strike the HSE as strange that some of those alternative accommodations - I refer to the ten residents who have already been moved - included placements in shared rooms and on long-stay wards? I am told that alternative accommodations included St. Stephen's hospital in Glanmire and St. Finbarr's hospital in Cork. The Mental Health Commission has raised the same concerns about both of those hospitals that were raised about the centre from which these residents were moved in the first place.

Mr. Paul Reid

I reassure the Deputy and the rest of the committee that we have worked very closely with all of the families involved. There were originally 21 residents. That number is down to nine. If I am not mistaken, it was 11 and it should be down to nine now. We have worked very closely with the residents and their families on suitable and agreed accommodation. In all instances, that is what has happened. We are working with the remaining residents and, frankly, it is only right that we should be doing this and people should be moving to have a better life. People in those residences and their families should have it. I will let Mr. Fitzgerald comment about where people may have gone.

Deputy Matt Carthy

That would be absolutely laudable, were it a situation in which the residents who had been moved were indicating that they were satisfied with the fact that they had been moved. However, that is not the evidence that has been provided to this committee.

Mr. Michael Fitzgerald

For the sake of accuracy, eight residents remain in Owenacurra. We have been working very closely with the families and the people involved, in the first instance, on the basis of their will and preference as well as their clinical needs. One has to take all of those issues into account when considering what the best placement for people is. Some of the people have moved to nursing-home care because that was the care required. Others have been moved to mental health facilities. The Deputy is right in that, as we have said earlier, some of those mental health facilities are certainly in need of refurbishment or replacement, but that is the care that the people may need. I am not aware of any specific incidents of people saying they were dissatisfied or unhappy and I would certainly be very concerned if they were.

We have an aftercare plan very specifically to ensure that wherever people go, even if it is to a nursing home, they are still provided with a specialist service appropriate to their needs and that there is follow through to make sure that they settle well in their new environment. Of course, it is not ideal that we would move people into any place other than a brand new facility. We do not have such a new facility at this point in time. At the same time, it would not be appropriate to leave people in circumstances in which a building is not fit for purpose in the context of being able to be refurbished in any kind of realistic manner.

Deputy Matt Carthy

This is what I do not understand. Essentially, the rationale for taking very vulnerable people out of a residential setting was a deficiency that had been identified by the Mental Health Commission but they have now been moved to other locations which, in some instances, have had the exact same adjudications from the commission and, in all likelihood, they will have to be moved again. Is that a fair assessment?

Mr. Michael Fitzgerald

Not all the buildings are exactly the same. There are specific issues with regard to Owenacurra. That is well documented previously at other committees where we provided a significant level of detail regarding the type of building it is. It is of its time. It was a specific type of construction and is well beyond its lifetime capacity. The probably more pressing-----

Deputy Matt Carthy

I will cut across Mr. Fitzgerald, if I may. Does he accept there are other residential centres that, similarly, are not fit for purpose in terms of the standards to which we all aspire?

Mr. Michael Fitzgerald

As Mr. Reid stated, we have a lot of infrastructure we would like to replace or refurbish. In the CHO, we have developed a strategic plan for the replacement or refurbishment of specific regulated services that we have with the Mental Health Commission, right across County Cork. We also have good infrastructure in some instances-----

Deputy Matt Carthy

Is Mr. Fitzgerald answering "Yes" to the question I asked? I apologise for cutting across him. Is that a "Yes"?

Mr. Paul Reid

I will take that question. On a national basis, we do have infrastructure that is not fit to give people the care they need. We have to prioritise that, and we have done so. I have seen, not just in Owenacurra but also in other cases of people being moved to new settings, that their lived experience has been completely transformed. Yes, we have people-----

Deputy Matt Carthy

It is transformed when they have moved to better facilities-----

Mr. Paul Reid

Yes.

Deputy Matt Carthy

-----or when existing facilities are upgraded.

Mr. Paul Reid

In some cases, they are moved to managed home services or residential services.

Deputy Matt Carthy

As Mr. Reid will be aware, I am a step removed from this. I have spoken to elected representatives in the area who do not have a vested interest in the matter other than wanting what is in the best interests of their constituents. I am asking these questions because this issue consistently comes back before the committee. The question that has not been answered is why this centre was closed in June 2021. Considering all the other centres that require upgrade or potential closure and all the other priorities and strategic plans that Mr. Fitzgerald and others have outlined, why was Owenacurra selected and prioritised?

Mr. Paul Reid

The Deputy said the question has never been answered. We have submitted a number of papers outlining the clear rationale as to why the centre was not fit for purpose and not giving people the care they needed. That clearly articulated why we did it. I stand over it as CEO of the HSE. This was the right thing to do by the CHO and the area. The decision to do it was the right one. I appreciate that members and their colleagues, as elected representatives, get representations on the matter but I assure members that our staff and local management want to give people the right care too. That is what they come to work to do every day. They, we and I believe the right decision was made in respect of Owenacurra.

Deputy Matt Carthy

I have gone through all the responses and the question I am asking that has not been answered is why this centre was prioritised. I will not go through the list provided to me of other centres in that CHO region that, by any objective analysis, are more in need of updating than Owenacurra is. There is no reference to any planned works in that regard. Taking at face value that works were required or that Owenacurra, as it stood, was not to the standard to which we aspire, why it was prioritised above all else is a question that has not been answered to date.

Mr. Paul Reid

The Deputy may not like the answer but I assure him that our assessment or our report on it was that it was completely unfit for purpose. To carry out the work to comply with the mental health recommendations was not the right approach in terms of putting the investment in there. The best investment for people's care and the best use of capital investment was to relocate people to more suitable accommodation.

Deputy Matt Carthy

Does Mr. Reid accept that other centres have the same assessment and status?

Mr. Paul Reid

Not the same standards, no. I have said we have many centres across the country that need capital investment-----

Deputy Matt Carthy

Why was this centre chosen at that time? Why not the others? What criteria were used to determine that?

Mr. Paul Reid

I do not have our paper in front of me but I was clear in it that the criteria were the residents' experience in terms of the accommodation size they had, the fact that day services had to walk through residents' rooms to get to their day services, the fact that mechanical and electrical services were unfit for purpose-----

Deputy Matt Carthy

All those things equally apply to other centres, however.

Mr. Paul Reid

Not all centres, no.

Deputy Matt Carthy

I am not saying they apply to all centres. They apply to some other centres.

Mr. Paul Reid

Many centres have some of those issues. This centre had a number of them.

Chairman

It would be helpful if a summary of the report on the Owenacurra centre were supplied to the committee.

Mr. Paul Reid

I am happy to provide that.

Deputy Cormac Devlin

I welcome Mr. Reid and the officials. I thank them for coming in. I am not sure if this will be his final appearance before the Committee of Public Accounts, but I thank him for the information he provided and all the engagement we have had in the past couple of years, particularly during the pandemic. At the time, he gave significant time to this committee and other Oireachtas committees, and that was appreciated.

I will turn to the issue of CHO 4 as it is specifically on the agenda and Mr. Fitzgerald is here to answer questions. How many children have been involved in the review in CHO 4, particularly in respect of south Kerry, but also in north Kerry and the rest of the CHO area? On the most recent occasion Mr. Reid was before the committee, I asked what actions had been taken to engage with the affected families, and the children in particular, some of whom are now adolescents, to review their medical needs and mental health needs. Has that work been completed?

Mr. Paul Reid

I will come in briefly and then allow Mr. Fitzgerald to respond. I assure the Deputy that there has been engagement with the families. I personally went down to meet with the families to get their sense of it. The families' representative groups were quite satisfied with, and almost complimentary of, the engagement process that we have with them for their children in terms of the process to work through the issues that have been identified. I will let Mr. Fitzgerald comment on the exact numbers but I reassure the Deputy that the engagement with the families is-----

Deputy Cormac Devlin

I appreciate that, but how long did it take for that process to start and the engagement to happen? We are talking months.

Mr. Paul Reid

The engagement started prior to the publication of the report and has continued post publication. I will let Mr. Fitzgerald confirm that.

Mr. Michael Fitzgerald

As the Maskey report outlined, 240 children, now young adults, were affected or put at risk in the context of what happened in south Kerry. I assure the Deputy that I have been personally in communication with those families on an ongoing and regular basis, as has my team. Very quickly after the report was launched, we set up a liaison team of five people who made contact directly with the families on an individual basis and worked with them around accessing services and identifying issues that were of concern to the families. Through that engagement process, which was very much on an individual basis, and through the family support groups that were formed by the families, along with other supporting services in south Kerry such as the family resource centres and the counselling services that were provided, we have been endeavouring to ensure as much as possible that we are supporting the families in every way that we can.

Deputy Cormac Devlin

I thank Mr. Fitzgerald for that. In terms of the children's medication and an assessment of need for each family, has that all been done as well as liaising with each of those 240 individuals?

Mr. Michael Fitzgerald

We have been in contact with all the people who wished to engage with us.

They have been provided with support through the children's mental health services, our disability services in some instances and our adult mental health services. Some of this is ongoing. They were also offered a physical health screening. These have been undertaken in recent months as part of the overall clinical response to their requirements.

Deputy Cormac Devlin

Does the assessment include medication?

Mr. Michael Fitzgerald

Yes.

Deputy Cormac Devlin

I thank Mr. Fitzgerald for this clarification.

I now want to turn to the OECD report that accompanied the briefing documents. There is some very good reading in it. We had an extremely successful vaccination programme with the co-operation and support of the general public. It is stated that 70% of the population received two doses. Does Dr. Reid have an update on the second booster? What is the uptake of this? How is the roll-out going?

Mr. Paul Reid

It is early stages. It continues to be slow and we have concerns about it. From next Monday we will launch a campaign on the flu and getting the booster with the new vaccine that is available. We are strengthening our communications on it. We have seen a slower uptake.

Deputy Cormac Devlin

Does this include the older cohort as well as those at risk? There has been an advertising campaign for those at risk. Mr. Reid said there has been a slower uptake. Does he have a rough percentage?

Mr. Paul Reid

We have the table with the information.

Mr. Damien McCallion

The figure is slightly higher for those aged over 65, which is that 70% have the second booster. It gets lower as we go down through age groups. There is an eligibility factor as people have been prioritised. Given the concerns that we do not know where Covid will take us during the winter we encourage people to get the flu and Covid vaccine. This will form a very strong part of our winter campaign primarily to protect people and with regard to the impact on the healthcare system based on our experience over the past two years. While it has been slightly slower we are also working with GPs and pharmacies. We have also maintained some of the vaccination centres infrastructure to give people the maximum opportunity through the winter.

Deputy Cormac Devlin

The HSE is right to look at other facilities such as pharmacies and GPs to support the roll-out programme and make it easier for people to access it. We do not know what the winter will hold. Is there a possibility of engaging outreach services for larger employers where employees will be based? I know it was not possible during the pandemic for obvious reasons but is this being considered? Will the advertising campaign be used to try to encourage people to go to vaccination centres and other healthcare centres?

Mr. Damien McCallion

There are two threads. There is the broader communication to the public and a very targeted set of communications for particular groups, such as the medically vulnerable through their doctors. We also found that older people have responded much better to talking through their anxieties with their GPs and pharmacists and discussing whether they need the booster. We are trying to encourage it based on public health advice. Separately, one of the reasons the vaccine programme was successful was because our communications group worked closely with all sorts of interest groups, including employers in sectors that were deemed to be at risk, for example, in the meat and food industry. We are looking to continue this through the winter where groups are identified as priorities. For older people and medically vulnerable people, who are two of the key groups, the evidence is that people respond best through their GPs, pharmacies and trusted healthcare professionals.

Deputy Cormac Devlin

I ask the witnesses to forward the table. It would be very helpful to the committee. On the previous occasion we spoke about this we discussed cybersecurity. The attack was in May 2021 and in November 2021 the HSE sanctioned taking on a chief risk officer. Has this role been filled?

Mr. Paul Reid

There are three key roles. One is chief risk officer. This person has been appointed and is in situ. There are two other roles relating to cyber, which are a chief technology and strategy officer and a chief information security officer. Both of these roles have gone through a sanction process and are in the process of being advertised. There is a contract for services for these two roles with a consultancy firm with expertise. The two posts are filled at present-----

Deputy Cormac Devlin

The consultancy firm is liaising.

Mr. Paul Reid

It is filling the gap while we are going through public advertisement.

Deputy Cormac Devlin

That is ongoing.

Mr. Paul Reid

Yes.

Deputy Cormac Devlin

In the annual report risk No. 13 specifically highlighted the cybersecurity ICT systems and infrastructure. With regard to the spend I hear what has been said about the roles being filled but they are individuals and the leads in this area. What other issues and commitments has the HSE made to ensure its ICT capabilities are up to scratch given that on the previous occasion we engaged on this I raised the issue of ICT, laptops and software? We were buying patches for computers. One year later have we moved on from discussing this?

Mr. Paul Reid

The first thing to say is the obvious, which is that we still have risks. All organisations, particularly State organisations, have risks. We have taken significant actions to mitigate some of these risks. I prefer not to speak about them publicly.

Deputy Cormac Devlin

I understand. I do not want detail.

Mr. Paul Reid

We have made an investment of approximately €40 million on mitigation measures this year. Separate to this we have finalised a multiannual business case that we are bringing forward. The cost will be hundreds of millions of euros. The first element of this will be known shortly as part of the budgetary Estimates process and our service plan. We are looking at a five to seven year multiannual investment plan that will require an investment of hundreds of millions of euro to resource infrastructure. We have a legacy network that is a function of having a service that is not integrated. We have put in place a significant number of mitigation measures including a board committee that oversees our actions on it and an executive committee that I chair as CEO.

Deputy Cormac Devlin

Is the HSE working towards having a more integrated system in the five to seven year plan?

Mr. Paul Reid

There are a number of aspects to having more integrated systems. One is the integrated financial management system. This has a funding stream and it is progressing. We have briefed the committee on it previously. It is similar with some of our HR and people management systems. With regard to the wider infrastructure we are looking at greater controls and integration. This is a significant multiannual plan.

Deputy Cormac Devlin

I thank the witnesses.

Deputy Verona Murphy

Who is dealing with the Linn Dara closures?

Mr. Maurice Farnan

I am.

Deputy Verona Murphy

Mr. Farnan might be able to tell me whether the beds have been reinstated.

Mr. Maurice Farnan

As Deputy Murphy knows there were closures earlier in the year and they remain in place, unfortunately. This is as a result of our challenge to recruit nursing staff for the unit. As the CEO alluded to, we have international and local campaigns to attract nursing staff but it is a significant challenge. We had seven additional nursing staff but, as I understand it from the local services, five of them have elected to move abroad to seek opportunities. We have recruitment campaigns internationally and locally.

Deputy Verona Murphy

Just so I understand it, the HSE did recruit seven extra nurses.

Mr. Maurice Farnan

Yes.

Deputy Verona Murphy

This was since the closure.

Mr. Maurice Farnan

Yes.

Deputy Verona Murphy

Five have moved abroad.

Mr. Maurice Farnan

Yes.

Deputy Verona Murphy

Were exit interviews conducted?

Mr. Maurice Farnan

The cohort of staff was younger and attracted-----

Deputy Verona Murphy

Exit interviews were conducted.

Mr. Maurice Farnan

My understanding from the briefing from the head of mental health services in the area is that this was a younger cohort of staff who were attracted to foreign travel. This was their primary reason for leaving the service.

Deputy Verona Murphy

On the basis of an exit interview.

Mr. Maurice Farnan

On the basis of the engagement with the head of services and the director of nursing with the staff on their exit.

Deputy Verona Murphy

They were all young nurses who were just qualified and wanted to travel.

Mr. Maurice Farnan

They were relatively young, yes.

Deputy Verona Murphy

Relatively young.

Mr. Maurice Farnan

That is my understanding.

Deputy Verona Murphy

What age is relatively young? I think I am relatively young but I am probably not.

Mr. Maurice Farnan

Indeed.

Deputy Verona Murphy

I do not feel like travelling-----

Mr. Maurice Farnan

Sure.

Deputy Verona Murphy

What age are we talking?

Mr. Maurice Farnan

I do not have that information available, but we can certainly-----

Deputy Verona Murphy

How many beds are closed?

Mr. Maurice Farnan

Linn Dara has 15 beds closed now.

Deputy Verona Murphy

Does Mr. Farnan know how many people are on the waiting list?

Mr. Maurice Farnan

I do, but I do not have that information in front of me. We can, however, provide that information to the Deputy.

Deputy Verona Murphy

Right. I do not like hearing that the witnesses do not have that information.

Mr. Maurice Farnan

Sure.

Deputy Verona Murphy

We are here discussing the topic of mental health.

Mr. Maurice Farnan

Yes.

Deputy Verona Murphy

This is one of two available facilities.

Mr. Maurice Farnan

It is one of four.

Deputy Verona Murphy

It is from the perspective of CHO 5 that I am discussing this issue. With 15 beds, we do not actually have any adolescent facilities, etc. Other than adult units, we do not have any such facilities in the south east. This has gone off the radar. It does not even seem to be an issue.

Mr. Maurice Farnan

Well, it is definitely an issue for the mental health services. I assure the Deputy of that. My understanding or, rather, I know-----

Deputy Verona Murphy

Is the Linn Dara facility receiving the same budget? Does it still have the same level of funding? Would it be right to say it has 15 beds closed and still has the same money going to it?

Mr. Maurice Farnan

There is no issue in respect of the financial allocation to Linn Dara.

Deputy Verona Murphy

I am sure there is not. I am referring to the situation where there are 15 fewer beds, which could be accommodated somewhere else.

Mr. Maurice Farnan

Sure.

Deputy Verona Murphy

Therefore, there must be a surplus in Linn Dara now?

Mr. Maurice Farnan

I do not understand the Deputy's comment that it would be possible to provide accommodation elsewhere.

Deputy Verona Murphy

I am saying that perhaps we should try to open a facility somewhere else. Is the area the issue, is it too close to Dublin or is accommodation too expensive? What is the issue there?

Mr. Maurice Farnan

Truthfully, our issue is the challenge in recruiting nursing staff-----

Deputy Verona Murphy

Yes, I know that. I am beginning to hear that from anyone who has ever had a job in management in the HSE. I have yet to hear, however, somebody provide a plausible answer to address the problem. How many jobs were offered to graduates this year?

Mr. Maurice Farnan

Every nursing graduate in mental health services was offered a post.

Deputy Verona Murphy

How many occupational therapists were offered posts?

Mr. Maurice Farnan

I do not have that information available, but I can acquire it for the Deputy.

Deputy Verona Murphy

Would Mr. Farnan be surprised if I told him it was none?

Mr. Maurice Farnan

I would.

Deputy Verona Murphy

Mr. Farnan would be surprised.

Mr. Maurice Farnan

Yes.

Deputy Verona Murphy

Would Mr. Farnan know how many occupational therapists qualified this year?

Mr. Maurice Farnan

I do not have that information in front of me.

Deputy Verona Murphy

Is it only nurses that are approached when there is recruitment? Are other staff not bothered with it?

Mr. Paul Reid

Of the 15,000 staff recruited in the last two years, I can give-----

Deputy Verona Murphy

When Mr. Reid refers to the last two years, a document we received in May from the HSE referenced just over 10,000.

Mr. Paul Reid

Okay. That-----

Deputy Verona Murphy

That was sent into this committee.

Mr. Paul Reid

I just-----

Deputy Verona Murphy

There is a big difference between 10,000 and 15,000.

Mr. Paul Reid

If I could be allowed to answer the question-----

Deputy Verona Murphy

I am asking if there is a difference or is that document wrong.

Mr. Paul Reid

Can I answer the question?

Chairman

Yes.

Mr. Paul Reid

I can give the exact breakdown up to right now from January 2020. A total of 15,200 staff have been recruited, since January-----

Deputy Verona Murphy

Did that only start in January 2022?

Mr. Paul Reid

It was January 2020. Of that total of 15,200 staff from January 2020, some 2,700 were recruited in 2022 to date. We are targeting between 4,500 and 5,000 staff this year. Of that figure I referred to, and to give a simple, high-level breakdown, nursing and midwives account for 4,500 of the staff recruited to date. They represent the highest proportion of our recruitment in recent years. These are net increases in staffing, by the way. There were 2,000 healthcare assistants recruited and 2,300 health and social care professionals. Therefore, it is not just nurses and doctors we recruit. We recruit across the board.

Deputy Verona Murphy

How many occupational therapists were recruited?

Mr. Paul Reid

I do not have the breakdown of occupational therapists here, but we can provide it.

Deputy Verona Murphy

That was the question I asked. Why did Mr. Reid interfere if he could not answer the question?

Mr. Paul Reid

Chair, I am sorry-----

Deputy Verona Murphy

That was the question I asked. I asked a specific question regarding how many occupational therapists were offered a job and how many qualified this year. Does Mr. Reid know?

Mr. Paul Reid

I will respond in a professional manner, and I expect the same from the Deputy.

Deputy Verona Murphy

Well, Mr. Reid interfered just to-----

Chairman

I am sorry-----

Deputy Verona Murphy

As far as I am concerned, it was actually-----

Chairman

I am sorry. The breakdown is not available at this point.

Mr. Paul Reid

It is not. We can send a full table to the committee.

Chairman

Do any of the other witnesses have that breakdown?

Mr. Damien McCallion

In respect of health and social care professionals, which includes all the multidisciplinary aspects, over the ten-year period in the mental health services that would be a total of 1,000. We can give the detailed figures by discipline, if the Deputy prefers, in respect of occupational therapists, physiotherapists and so on.

Deputy Verona Murphy

I am only interested in how the HSE engages with the education system. Why do we have the HSE sending the same letters? I have only been elected for two and a half years, and this paragraph has not changed in all that time. A recruitment crisis is mentioned. The letter also refers to the case that, as with all other areas, CHO 5 has been experiencing significant recruitment challenges due to shortages of health and social care professionals. The text has just not changed. It is like a copy and paste exercise for two and a half years. I have yet to see anybody. Turning back to Mr. Farnan, I have dealt with healthcare professionals who have left, and they told me that they were not asked why they were leaving. They were not asked why they were leaving in any way, shape or form, and that was across all the divides. I have been told an exit interview has never been carried out with HSE professionals, in the context of those who have come to tell me what is wrong with the system. They have said that no one in the administration in the HSE has asked.

Mr. Paul Reid

If I could just-----

Deputy Verona Murphy

I am not finished. If I wish to ask Mr. Reid a question, I will, seeing as he is determined to interrupt me. It is just me. I did not see him do it with anybody else.

Chairman

I ask the Deputy to continue with the question.

Deputy Verona Murphy

I am posing this question to Mr. McCallion regarding how the HSE interacts. We need a full-time dietician to deal with very ill, anorexic patients in CAMHS services in Wexford. It took me a year and a half to get the Minister to appoint a full-time equivalent because the HSE was not able to recruit a half-time equivalent. That happened in July 2022. I now have the same letter telling me that the organisation's internal systems have been exhausted. We are now back to it being said it is not possible for the HSE to find anyone. What is the issue? Other sectors are able to recruit on the basis of critical skills permits. Is this not the position in the HSE?

Mr. Paul Reid

I will answer that, Chair, if I can?

Chairman

I call Mr. Reid to answer the question.

Mr. Paul Reid

I will start, and then I will see if anyone else might like to come in. To make one comment, I come in here-----

Chairman

Just regarding the specific question asked by the Deputy-----

Deputy Verona Murphy

I do not want to hear any comments-----

Chairman

No. I ask the Deputy to allow the witness to answer.

Deputy Verona Murphy

-----other than in response to the question I asked.

Chairman

Deputy Verona Murphy has asked a specific question regarding whether staff can be recruited on the basis of special permits. Would the Deputy like to frame that question again?

Mr. Paul Reid

The question-----

Deputy Verona Murphy

The question I am asking is when are we going to have a whole-time equivalent dietician appointed to CAMHS south in Wexford?

Mr. Paul Reid

Chair?

Chairman

Mr. Reid can proceed.

Mr. Paul Reid

I cannot comment, but, regarding the CAMHS person in Wexford, I will make two points, if I can. First, when we talk about a recruitment crisis, there are challenges in recruiting. Having said that, to just stand still every year means we must recruit 10,000 people. That is just because of churn. On top of that, we have recruited a net extra total of 15,500 people. I do not know about the specific post in Wexford, but we will get the details regarding when that post will be filled for the Deputy. To state the obvious, yes, there are challenges. The Deputy might not like that, but we do not like it either. There are, however, challenges.

Deputy Verona Murphy

What I do not like-----

Mr. Paul Reid

I am sorry, Chair, my final point-----

Deputy Verona Murphy

I am sorry, Chair, it is either my question or-----

Mr. Paul Reid

I am sorry, Chair, my comment-----

Deputy Verona Murphy

I did not come in to listen to Mr. Reid. We need to ask questions.

Chairman

I ask Deputy Verona Murphy to let Mr. Reid finish answering the question and then I will let her back in briefly.

Mr. Paul Reid

My last comment is brief. I bring delegations in here all the time and we respect the parliamentary process and the elected representatives. I think we do it respectfully. The tone I heard used with the members of my delegation here has not been respectful and not professional, and it should not be allowed.

Deputy Verona Murphy

It is a bit like what Mr. Reid says in here does not suit him. It does not suit him.

Chairman

Deputy, please.

Deputy Verona Murphy

There are 33 anorexic children in Wexford who are not being catered for, and Mr. Reid is telling me that the HSE looked after the people in Owenacurra because someone had to go into their bedroom to get to another place.

Chairman

Deputy, please.

Deputy Verona Murphy

I will come back to Owenacurra, but I can tell Mr. Reid that his insincerity will not wash for one second here.

Chairman

I thank Deputy Murphy-----

Deputy Verona Murphy

I have full respect for all Mr. Reid's staff, but I do not put up with too much BS. That is it. I did not get an answer to the question.

Chairman

Okay. I will ask the representatives of the HSE to respond to the Deputy with a written answer. They do not have the information this morning. It is a valid question. The witnesses do not have the answer with them now and therefore I ask them to respond to the Deputy with that information in writing. I call Deputy Dillon.

Deputy Alan Dillon

I welcome our guests. I wish Mr. Reid the best of luck in his future endeavours and I thank him for his service in recent years.

Continuing on concerning Deputy Verona Murphy's topic of recruitment, I read this morning about the HSE offering relocation packages to the value of €4,000 for health staff working abroad to encourage them to move back home. Is the HSE planning any further incentives to try to entice people with required skills to come back into disability services, mental health, nursing, etc?

Can the CEO give a quick overview of the measures being taken by the HSE?

Mr. Paul Reid

There is a range of incentives. We recruit internationally as much as we can for nursing and other medical grades. The Deputy mentioned a figure of €4,000. The figure can range between €4,000 up to €15,000 or €20,000 depending on the relocation package. We gave some of details yesterday at the Joint Committee on Health and I am happy to give a breakdown of the figures for expenses. This year, we have recruited about 1,200 international nurses. All graduates are offered placements through the colleges. We are recruiting internationally from India, Pakistan and other countries and we offer good terms.

Deputy Alan Dillon

What are the budgetary costs associated with these incentives?

Mr. Paul Reid

I do not have the total figure.

Mr. Maurice Farnan

There is no specific limit on it. Obviously we have to recruit the posts so we can use the funding we have for the posts to help us get the posts in. So within whatever the parameters the HR directive sets the funding is available to recruit these posts and to pay for the incentives to get them in.

Deputy Alan Dillon

At today's meeting the committee is focusing on the recruitment of mental health staff. Does the HSE employ agency staff, external recruitment or internal recruitment in its trying to fill posts? What targets has the HSE set to look at whole-time equivalents or agency staff? What staffing gap currently exists across all CHOs?

Mr. Damien McCallion

The gap in numbers will, by the end of the year, be somewhere in the of 400 to 500 depending on success in terms of mental health services.

Mr. Reid has mentioned nursing and medical staff. In addition to trying to increase the number of placements which takes time, that has been done over recent years. We discussed this at the joint committee yesterday and we can share that information with the Committee of Public Accounts, across areas like psychology, medicine and nursing both within mental health services and in the wider context.

The other area where we have a lot of challenges is in the multidisciplinary teams, which were referred to. That is occupational therapy, physiotherapy, speech and language therapists, and so on. Similar to nursing, we are trying to introduce an international campaign around that. So that includes attendance at job fairs in other countries and working with agencies to attract people into Ireland in addition to trying to increase the number of people coming through the third level system for those qualifications but we recognise that will always take time to increase. We are trying to address that now. Those multidisciplinary resources are really important for mental health, disability and, indeed, our primary care teams, which we are trying to grow. That is probably one of our most challenging areas at the moment.

Mr. Paul Reid

In response to this question and the previous question, the total therapy professions, which includes speech and language and occupational therapy professions, we are up 858, a 16% increase since January 2020.

Deputy Alan Dillon

How much has the HSE spent on agency staff to date in 2022, and in 2021 or 2020?

Mr. Paul Reid

It is approximately 4% and Mr. Mulvany will give the exact figures for mental health services.

Mr. Stephen Mulvany

Just give me a second, Deputy.

Deputy Alan Dillon

Educational and child psychology were mentioned in terms of the trainee doctors who currently provide front-line mental health supports to community and multidisciplinary network teams. In some cases educational psychologists, EPs, have been excluded from trainee funding. In the context of where we have a skills shortage, can this be addressed in the future?

Mr. Stephen Mulvany

I will deal with the funding question and agency spend. Typically, as we try to move services into the community we often recruit our own staff from some of the more challenging residential services but end up having to backfill those with agency staff and overtime. In 2021, the cost of agency staff was €73 million of which the biggest single chunk was medical and that equates to about 800 staff equivalents. Approximately €33 million was spent on overtime, which equates to about 400 staff equivalents.

Deputy Alan Dillon

Is that funding broken down to mental health and disability services?

Mr. Stephen Mulvany

No, Deputy, that is just mental health.

Deputy Alan Dillon

So €73 million was spent on mental health.

Mr. Stephen Mulvany

It is €73 million for agency costs in mental health in 2021 and €33 million for overtime costs in mental health in 2021. Again, our preference is to recruit permanent staff and to keep the level of agency and overtime costs as low as possible. We have to staff units and keep staffing levels up to particular standards so where we have to we will take in agency staff and pay overtime.

Deputy Alan Dillon

Can I have an example of where the HSE deploys agency staff to work with permanent HSE staff?

Mr. Stephen Mulvany

It can be across services. In mental health, the greatest proportion, I would expect, are in those hard to recruit to and fill posts, which are often in the acute units or in the more residential care facilities as we rightly attract more and more staff into the community. I am not saying they are easy jobs but that is where our bigger levels of investment are going because that is the policy and is what is right for people. It means we find it increasingly hard to recruit and retain people to work in other units so, as a last resort, we will use agency staff.

Deputy Alan Dillon

Last night it was announced that approval was granted to establish a national youth mental health lead as a means to improve mental services for young people. What benefits does the CEO foresee the new role will deliver? What teeth will it have to deliver services for young people?

Mr. Paul Reid

The Minister of State, Deputy Butler, made the announcement yesterday. We are very pleased to work with her on that. The person appointed will be a strong advocate and will lead in order to get consistency across the country in terms of youth mental health. It is a very senior role within the HSE in terms of funding streams, prioritised allocation and public communications.

Deputy Alan Dillon

Will the new appointment mean CHO leads will be appointed across all of the regions who would feed back to national lead? What is the overall strategy?

Mr. Paul Reid

Each of the CHOs will have a head of mental services. There would be key interaction with them in terms of youth mental health services and obviously within that young mental health services will be prioritised.

Mr. Damien McCallion

A key part of the new role will be to co-ordinate all of the elements both in primary care and counselling services such as Jigsaw and other youth groups, and also acute care which involves child and adolescent mental health services or CAMHS. A key part of the new role is to pull all elements together and link that on the ground through the CHOs.

Deputy Alan Dillon

Jigsaw and other outreach services was mentioned. In terms of performance indicators, the level of delivery and value for money, does the HSE conduct analysis of its outreach services across the network?

Mr. Maurice Farnan

Yes. We have invested €9.1 million in the 13 Jigsaw sites and Jigsaw offered 23,750 appointments for young people in 2020. Additionally, we have been investing in a range of digital mental health services which research tells us are more attractive to younger people. Included in that are online cognitive behavioural therapy, CBT, services that are being delivered in conjunction with an Irish company and 80% of these referrals come from GPs. That service has been evaluated successfully. We are in the procurement process to role that out.

I will mention two other services. MyMind provides online counselling. The Text 50808 service is a crisis intervention service for younger people. Again, research is clear that that modality is attractive to a younger cohort of service users in crisis.

Chairman

I suggest that we take a break at 11 o'clock after Deputy McAuliffe concludes

Deputy Paul McAuliffe

I apologise to Mr. Reid if I repeat questions but I was attending a meeting of the Joint Committee on Gender Equality, which had the Tánaiste in attendance.

Before I left this meeting, Mr. Reid acknowledged that mental health and disability services are two of the major pressure points regarding service delivery for the HSE. I think all of us, as elected members, agree they are two points of pressure we see at our clinics. Sometimes, navigating the system is half of the issue among people who come to me.

The delay in accessing mental health and disability services and the resultant anxieties often compound the challenge a person might be facing. Sometimes there are no clear communications to the effect that the person is being handled in a coherent way. The correspondence is often a letter with a date or a letter stating that there will not be a date. There is no feeling that there is a comprehensive, holistic approach to care. That is something we have to think about because, as well as not providing the service, we are compounding the challenge because of poor communication. I will come back to that in the second.

With regard to CAMHS, we have had many questions about CHO 4. From what I understand, the waiting list for CAMHS right across the country is significant. I have heard anecdotal evidence to the effect that it is significantly higher than last year. Do the witnesses have any indication as to what the waiting lists will be given the referrals from last year?

Mr. Maurice Farnan

I will come up with the detail on that. I can confirm that we have six waiting list initiatives as part of the access-to-care programme across our CHOs to work on CAMHS waiting lists. The CAMHS waiting lists are obviously connected to recruitment challenges, but I will come back to the Deputy with full information on this.

Deputy Paul McAuliffe

I have been told the number might exceed 5,000 next year.

Mr. Maurice Farnan

I would be loath to give a figure. I will come back to the Deputy shortly on that, after the break.

Mr. Damien McCallion

The key performance indicators are the targets for urgent referrals, which are really important. The target is to see 90% of these within three days to deal with them. That has been achieved, but the Deputy is right that there are challenges. There are challenges with the general waiting list in light of the gaps in staffing. We can come back to the Deputy with the exact numbers.

Deputy Paul McAuliffe

If I could be given the times taken to see patients on the general waiting lists, it would be beneficial.

To tackle the problem and prevent what has happened in one CHO area from happening in others, bearing in mind that there is a bit of a postcode lottery in that some lists are much longer than others, an audit was to be carried out across the whole country. I do not know whether that has been addressed. I would appreciate an update on it.

Mr. Paul Reid

Based on the finding from the south Kerry CAMHS, we have initiated a national audit into prescribing processes and compliance with the standards of 2019. That audit is progressing well and is due to be completed before the end of the year. We will bring it to our board and the Minister. It is based on the findings from south Kerry CAMHS.

Deputy Paul McAuliffe

Does Mr. Reid expect that audit to be with the Minister before Christmas?

Mr. Paul Reid

Yes. On the Deputy’s comments on communications, he is correct. We have had to put a lot of work in across disability and mental health services in terms of communications. There were some standard letters going out that just were not meaningful and that sometimes could be disrespectful. That is certainly one of the findings we have brought through.

Mr. Maurice Farnan

In 2019, we had 2,327 on the waiting list. In 2020, we had 2,755, and in 2021 we had 3,556. However, in terms of people with appointments who are seen, in 2019 the figure was 204,192. In 2020, the figure was 224,171, and in 2021 the figure was 249,567. While we are seeing more people, equally there is a significant increase in demand for the service. I hope that is helpful.

Deputy Paul McAuliffe

I acknowledge that more work is being done, but clearly there is increased demand. We have to match that.

On Mr. Reid’s point about communications, I want to move on to the disability side because it is one of the areas I find so frustrating. Let me outline my experience. Young mothers and fathers regularly tell me they have had a chat with their child’s school or preschool provider – it is often at school that this matter is highlighted – and were told there could be a red flag in that their child might be on the autism spectrum or have additional needs. Regularly when these children get an assessment, nobody sits down with the family and explains to them what autism is. Nobody explains to them what the additional needs might be. They get a huge report with a lot of technical vocabulary. People of all educational backgrounds genuinely do not know what it means for their child for the rest of their life. They are put into a genuine state of panic because it is as if they have been presented with a problem although nobody has presented them with the solutions. An initial intervention or meeting linked substantially to the assessment needs to be considered, if only from a service-delivery perspective, to explain what the process ahead is. People often come to me and say they want an intervention because they do not know what the roadmap is. That is not to say we have all the interventions available. I would be interested in hearing the delegates’ comments on the roadmap relating to the Progressing Disability Services for Children and Young People, PDS, programme and where this is going. Many parents are very concerned that we are shifting service delivery on to them. I know the HSE would actually say we are actually giving them the tools to make interventions, but we have to be very careful that we do not have a patronising tone that gives the parents the impression they are being taught how to parent their children. Many parents have said they have experienced this.

It has been reported, in the context of the rapid assessment of needs that many experienced earlier this year, that the hours have eaten up the allocation for this year, meaning there is no allocation to make an intervention this year for a child in this category. This seems like a preposterous suggestion.

On the school inclusion model, whose aim is to have more treatments and therapies available in and to schools, is there ongoing co-operation between the Department of Education and the HSE? This has to be the way forward given the pressures on the community teams in the HSE. There is a commitment to retain the therapists in special schools, which are different from the mainstream schools, but there are many children in mainstream schools that I believe would benefit from the same type of school inclusion model. I appreciate that there is a lot in that.

Mr. Paul Reid

I will make three comments and then ask my colleague Mr. McCallion, who has done a lot of work on this, to contribute. The strategy is to continue with the PDS model, bringing the number of resource teams to 91. We spoke earlier about some of the gaps. Particularly in some, the gaps are significant. The Deputy will be aware that the assessment-of-need process was subject to a court finding, so the process we had in place has to be changed. I kicked off recently an engagement process with families, service users and NGOs, which provide some of the services with us, on a redefined assessment-of-need process. It is a challenge, with the volume we have, and it is a challenge to give the right timing. The revised assessment-of-need process will be finalised soon and rolled out through the PDS teams.

My colleague Mr. McCallion is doing some work on the schools model. There were inequities in the schools model in that some schools had expertise and others did not. We are trying to address that in a fair way through the PDS model, and we are engaging with both the Minister for Health and the Minister of State responsible for disabilities on this.

Mr. Damien McCallion

On the roadmap, I hear the point. It is an important one in trying to take a wider, holistic approach. There is a danger that the system will be seen as trying to offload or, as the Deputy said, patronise. We will take that sentiment back because I presume it is something that the Deputy is picking up as a concern. That is clearly not the intention. It is not what we want to do. Given the variety of people involved in delivering the services – voluntary providers, section 38 bodies and section 39 bodies – it is really important that that message does not get out through the system.

On the schools side, there was agreement. We had a number of meetings with officials from the Department of Education to look at reinstating some of the therapists in the schools. I refer to some of the new schools. We agreed to a model based on thirds. The aim was to try to restore one third very quickly, recruit a third very quickly from existing panels to fill them and get the final third from a process kicked off internationally to try to expand the pool of therapists available, not just for disability services but also mental health services, which comprise one of our biggest challenges, and the wider primary care side. Again, I must flag that only some of the special schools had the service previously. It was historical, as the Deputy alluded to, so it is not necessarily equitable. The point of the community teams is that they are based on a population-in-need model so they can in some way start to balance. We are well short at the moment in terms of the numbers we need, and hence we have to look at all possible ways in which to expedite getting more therapists into the community teams. Broadly speaking, notwithstanding the discussions on the schools, people are behind, as a principle, in trying to provide services, but we are-----

Deputy Paul McAuliffe

I have one comment. We have done a lot of work in getting new ASD classes in mainstream schools. The Taoiseach has indicated that we are going to go further and put an obligation on all education providers to include people with disabilities. Many of those teachers are realising the problems parents have. We can open these classes but if we do not have treatments and therapies, we are not doing right by those children. Whatever about parents advocating against something, and they are very strong advocates, we will have the teachers and principals coming after us soon as well because we are just pushing the problem down the road. We will open the classes but we will not have the treatments or therapies.

Chairman

We will suspend the meeting for ten minutes. Many committee members want to come back in.

Sitting suspended at 11.01 a.m. and resumed at 11.13 a.m.

Deputy Alan Kelly

I welcome the witnesses to the committee. As this is the final time he will be with us - I am sure he really regrets that - I thank Mr. Reid for his public service over the last number of years.

I have a number of questions on different areas. Garnish House on Western Road in Cork has been used by the HSE as a facility for mental health services for a while. This is costing €43,000 per month and it could have cost more. It is a significant amount of money. Why is it being used? Is it of a standard to be used? Why is it costing so much? Most of all, if the HSE had the option to purchase it a year or two ago, why did it not do so?

Mr. Paul Reid

I will ask my colleague, the CHO manager for the area, Mr. Michael Fitzgerald, to answer. I presume he is online.

Mr. Michael Fitzgerald

I am indeed. Garnish House is former bed and breakfast accommodation on Western Road in Cork. At the beginning of the pandemic, we did an assessment of the requirements and needs of all our service users, particularly people in residential settings who might be vulnerable to Covid-19. We were not quite sure what that would mean, like everything else at that particular point in time back then in March and April. The opportunity came up for Garnish House to be used as an alternative to Millfield House. Millfield House had particular constraints for the residents of that particular centre because of the level of multi-occupancy of bedrooms and a lack of environmental circulatory space. The view was taken that the risk was sufficient that we would move out of Millfield House on a temporary basis until we saw what happened with regard to Covid-19. That was the initial reasoning for moving into Garnish House.

As bed and breakfast accommodation of its day, Garnish House is a large building. The reason we did not go about purchasing it, even though that was considered, was that there were a number of issues. First, the number of floors means there is a lot of access issues within the building. It is on a flood plain and Western Road experienced quite significant flooding back in 2009. It was felt that due to the cost of refurbishments and for all of those particular reasons, we would not proceed towards the purchasing of the centre.

The cost is high in the context of the ongoing costs associated with Millfield House but we intend to be gone from the facility early next year, certainly no later than the end of quarter 1. We are considering at the moment what we will do with regards to Millfield House and other facilities in the area so that we can find alternative accommodation. We will not be going back to Millfield with the same numbers of people but we will certainly go back there in the short term.

Deputy Alan Kelly

I have one other question on that. I know the building as I hung around University College Cork long enough many years ago. What is the differential between what has been paid in rent versus what the building could have been bought for?

Mr. Michael Fitzgerald

We were never sure what we could have bought it for but we did get a valuation for it.

Deputy Alan Kelly

What was the valuation?

Mr. Michael Fitzgerald

It did not proceed to engaging with a sale that was going anywhere.

Deputy Alan Kelly

What was the valuation versus the amount of rent paid?

Mr. Michael Fitzgerald

Renovations alone that were being considered would have cost about €2.4 million and an independent valuation received in July was €1.6 million.

Deputy Alan Kelly

How much rent has been paid on the building in total?

Mr. Michael Fitzgerald

We pay €43,400 per month, which is the rent and cleaning costs associated with it. We have expended €1.6 million or €1.7 million on it so far.

Deputy Alan Kelly

The valuation was €1.6 million and just over €1.6 million has been spent. Is that correct?

Mr. Michael Fitzgerald

Yes.

Deputy Alan Kelly

My other colleagues will have questions on this. I have a couple of other questions specifically on capital appraisal and the process by which it is done. In previous correspondence to the committee, No. R1364, document 33, dated May 2022, the process by which capital appraisal is done was outlined to us in great detail. This level of detail was very helpful because I have asked a number of questions on this in the past. These related to specific projects throughout the country and in my constituency where there was no political intervention, which to me is a good thing. As regards the actual appraisal process, my questions are for Mr. Reid. There is no need for him to go through it all as members have it in front of them. Obviously there is conversation with the Department. At the end of the day, I take it that the appraisal process is as outlined. It goes through the various processes, which appear strenuous and I welcome that, and is then approved by the HSE board and presented to the Minster. Is that correct?

Mr. Paul Reid

Yes. We have a funding envelope that we work to and build up on a multiannual basis. There is an approval process within the HSE and ultimate approval from our board. Obviously there is dialogue with the Department in terms of some priorities.

Deputy Alan Kelly

Those are priorities as regards policy rather than picking one project over another.

Mr. Paul Reid

Yes. That is within the HSE. The governance structure according to the legislation is the HSE board.

Deputy Alan Kelly

I am aware of that. I have asked numerous questions about this. It is very important for us as a committee, as well as the wider body politic, to understand what that means. I have a few questions about nursing homes, funding and recruitment. Regarding the recruitment of staff for home care packages, I always adopt the escalator approach. The longer we can keep people in their homes, the better for them. It is financially the best option by far. Then they may have to go to a nursing home and then if they are in an acute bed it is more expensive. It is an escalator approach. The longer we keep people at home the better. We have a national crisis in home care, home care packages and staff. I know about this personally outside of my own politics and work. I believe it is necessary that we have some form of registered employment agreement to set hours and set pay for people who work in this sector. The idea that people working for agencies are getting a fraction of the total pay is ridiculous. People are having to go off privately, if they can, to get care. Do the witnesses agree that we need some form of employment agreement process to standardise wages and make it enticing for people who want to do that work?

I do not expect the witnesses to have these figures but I ask them to provide them to the committee. Over the last five years, are there any areas in the country where nursing homes, either private ones or ones owned by various religious institutions, have been bought or taken over by the HSE? They could have been bought and taken over or just taken over. I do not expect the witnesses to have those figures now. I know there are examples but we need to find out where they are because some nursing homes are falling over and I believe more are going to fall over.

My last question is on a Tipperary issue. We have a specific case in Roscrea where the nursing home there will not meet HIQA requirements and is about to be closed. The witnesses are well aware of this because I have raised it with the HSE numerous times. I am referring to the Dean Maxwell Community Nursing Home. We are in a process across politics of trying to get a solution to this. Meetings took place a couple of months ago. Where are we at as regards how we can ensure long-stay beds remain there? Is there an overarching view of how we are going to have nursing home care in one of the biggest towns in Tipperary in the future, considering that the sole public nursing home there is about to be closed because of the HIQA situation?

Mr. Paul Reid

The private provision of home care packages is a concern for us due to the agencies' resourcing levels and their capacity to sustain resourcing levels. That is also an issue with our own staff but we feel we have a stronger base within the HSE of directly employed staff. It is a concern. I know from the Minister and the Department that it is an area to be looked at from a policy perspective because it is a major tenet of the shift of care to keeping people at home. That is not just from a cost perspective but because of people's standard of living and quality of life at a time when they need it. It is a constraining factor. We always try to be careful that we are not cannibalising the sector by recruiting in but inevitably we do and people come to work with us. It is a sector that needs to be looked at. The pay issues are a concern and retaining staff is a concern.

We will get the Deputy a note on the nursing homes. It is a very small number. In some cases the regulator would ask us to go in and take a home over and we would do so. However, it is a smaller number. Our concern in the sector now, although it is a smaller number again, is that nursing homes are deciding not to continue to practise or be a nursing home for older persons. That is a concern for us. While bed capacity has increased over the last few years, we would have a concern about that in some parts of the country.

Regarding the Dean Maxwell home, the Deputy has escalated this directly to me on many occasions. We are working locally both in terms of long-stay and day care services that can be integrated in appropriate accommodation. There is a dialogue going on. There is a private nursing home close by. We are looking to see how we can integrate the services it provides and those we will provide and how to make best use of all resources, as I would encourage the CHO to do. The CHO manager Maria Bridgeman is working on a strategy down there locally and politically. We have a bit more to do on it but we are anxious to come to a resolution.

Deputy Jennifer Carroll MacNeill

I thank the witnesses for coming in. I sit on a number of committees, one of which is the Joint Committee on Autism. Last week we had the privilege of having a number of parents of autistic children before us to outline the different things that were going on in their children's lives and the difficulties they were facing. Specifically, a number of parents highlighted difficulties with the CAMHS service for their autistic children. The timing is excellent. This happened last week in the committee room next door. Karen O'Mahony is the CEO of the Rainbow Centre in Cork, which is a truly excellent centre for autistic children. It does a lot of private fundraising and genuinely helps parents through a load of a different issues. Ms O'Mahony has a son who is 16 and 6 ft 2 in. When he was five or six years old, he was put on psychiatric medication. For the first four or five years of that treatment, Ms O'Mahony told the committee, he was seen every three months and the doctor monitored his height, weight, his general well-being and his reaction to the medication, as is appropriate for psychiatric medication for a child. Then when he was 11, the doctor changed. He was seen once and then the doctor said he was signed off. I asked Ms O'Mahony what "signed off" means. She said she did not know. He has not seen a doctor or had any supervision since. He is 16 and he is 6 ft 2 in. He has had significant physical development, emotional development and personal development, as all adolescents do. He is an autistic child who has been prescribed mind-altering medication by the State and he has not been seen for five years. I understand from the briefing notes provided that there are close to 9,000 whole-time equivalents in CHO 4, some 1,578 of whom work within the mental health service. Whose job is it, of those 1,578, to check this child? Whose job is it to check that the check has been done?

Mr. Michael Fitzgerald

In general, if the child was under the care of CAMHS or any of its services, that child would continue to be under the care of the consultant in CAMHS, along with the multidisciplinary team's input. I am not sure what "signed off" means. I presume it meant the child was discharged, although it may not mean that. If a child was discharged he or she would not be with CAMHS. I can follow it up for the Deputy. That is my understanding of what would be meant.

Deputy Jennifer Carroll MacNeill

There is no possibility of the child having been discharged if he remains on medication. Any child on medication, whether it is psychiatric medication, medication for epilepsy, or any other medication, is monitored and weighed for their reactions, height and weight. Is this not obvious? Is this not a thing that happens?

Mr. Paul Reid

We are more than happy-----

Deputy Jennifer Carroll MacNeill

I am sorry but it is not a question of following up on the individual case. I am not raising it as an individual representation to be followed up, although I would like it followed up. I am raising it because it highlights that it is possible, within CHO 4, for a child going through adolescence not to have been seen for that length of time. We also have the State Claims Agency in here from time to time. I have concerns not just about the well-being of the child and the pure frustration for the mother trying to provide care for the child but about the obvious failure of management by somebody in that child not having been seen and what the systemic response to that is.

I am also concerned about what the Comptroller and Auditor General's concerns may be in respect of liability to the State for that, notwithstanding all of the personal issues.

Mr. Paul Reid

Again, it is hard for me to comment on that case.

Deputy Jennifer Carroll MacNeill

I am sorry to interrupt but there is no need to comment on the individual case. I am asking how the system could allow something of that scale to fall through the gaps.

Mr. Paul Reid

It should not. In respect of the issues that arose in south Kerry child and adolescent mental health services, CAMHS, which we touched on earlier, we are looking at all processes in respect of CAMHS all across the country. We are looking at whether they are compliant with regard to prescription and oversight and the revised standards put in place in 2019. That is an audit we have put in place. I have no doubt it will address some of the issues the Deputy has raised right across country and determine how to do this, what the proper escalation measures should be and how people can have the experience the Deputy has just relayed, which should not happen. I am not trying to reference that case but we will follow it up with the Deputy.

Deputy Jennifer Carroll MacNeill

Ms Margaret Lowndes from Dublin 12 was also there. Her son had the first part of an ADHD assessment in May. She has rung every single week since then but has not had a response. Ms Caroline Poole has two children in CAMHS, one of whom is diagnosed with anorexia and social anxiety. Both children have been put on medication but neither of their cases has been followed up on. The parents are trying to contact the service. Ms Poole outlined to the committee that she has had to guess when to give her son the next medication. She just has a prescription and has guessed about the timing. I relay this to Mr. Reid in this way because this is what we heard directly from parents in the Oireachtas last week. This is their actual experience as relayed to these committees last week. I cannot think of any other way of doing it. We represent these people and interrogate the systems on their behalf. I cannot think of any more direct or descriptive way to show how difficult it is for Irish citizens trying to protect their children and do the right thing to have those children diagnosed by a system but receive absolutely no follow-up. It would not happen in a hospital. How can it possibly happen with psychiatric medication?

Mr. Paul Reid

As I said earlier, I have personally met families who have children in CAMHS, children who are in the CAMHS system and CAMHS management all across the country. There is no doubt but that many children are getting really good care in the CAMHS system. The Deputy has highlighted areas in which there are weaknesses. I believe we will surface these. The whole purpose of the national audit of the CAMHS system is to identify those issues that result in people in the CAMHS system not getting the treatment they should. With the then Minister of State, Deputy McEntee, I co-chaired the young mental health task force which addressed many of these issues with regard to both people progressing through CAMHS and people progressing to adult services and the handover process associated with that, which is not appropriate. I believe we will surface many of the issues the Deputy has raised. They should not exist.

Deputy Jennifer Carroll MacNeill

I apologise if I missed this earlier but will Mr. Reid explain to me how children are transitioned into the adult mental health service?

Mr. Paul Reid

My colleague, Mr. Farnan, is more closely involved with that. I might ask him to comment.

Mr. Maurice Farnan

The normal process for discharge from CAMHS is that young people are discharged to their GP rather than services being simply discontinued. There would normally be engagement between the GP and the CAMHS consultants. Those consultants are and should be available to provide advice to the GP. If that has not happened in this case, we will follow up in that regard. Similarly, I note the cases the Deputy has identified in Dublin 12. I will undertake to follow up on those with the chief officer for community healthcare organisation, CHO, 7.

Deputy Jennifer Carroll MacNeill

That is fantastic. I thank Mr. Farnan. Last week, literally all of the parents had a difficulty. Not only that, but many other parents have difficulties. Perhaps we could do exactly that and follow up. I can get a list of names from the parents who are working with different support groups and Rainbow Centre services. That would be absolutely marvellous because, when they go to their GPs, they can do nothing because it involves psychiatric medication rather than other medications. It is like trying to go to one's GP for neurological medication such as epilepsy medication. You just cannot do it. You have to be seen by a consultant. We have a long list and it would be wonderful for these parents to get an answer to a phone call and some follow-up. I thank Mr. Farnan very much. I feel like I am done.

Deputy Catherine Murphy

The witnesses are all very welcome. I take this opportunity to wish Mr. Reid well. We have met on numerous occasions at meetings of this Committee of Public Accounts and the previous one. If there was an organisation we could have in every week, it would be the HSE because it is so complex. This is part of the reason we chose this particular area and a couple of CHO areas. We wanted to try to get under the bonnet on a couple of things. There is a definition of value for money, which we have talked about here before. It is not just about the balance sheet but about the output and the quality of service. That is part of the reason the Cork mental health service in CHO, 4 was among those picked. What brought it to our attention was issues at Garnish House and Owenacurra. Will the witnesses clarify one question in respect of Garnish House? Were any of the renovations that have been talked about actually carried out in advance of people occupying that building? I am just looking for a "Yes" or "No".

Mr. Maurice Farnan

Garnish House was a bed and breakfast that we leased for the purposes-----

Deputy Catherine Murphy

I have very little time. Were any of the renovations the witnesses have said were required carried out?

Mr. Maurice Farnan

Garnish House is a leased building. We were not renovating any of those, including Garnish House.

Deputy Catherine Murphy

It was valued at €1.6 million and no works were carried out before people went into it. I do not know what the current valuation is but that is the amount of money the HSE has expended in rents. One of the things that has come up in this regard is that what is happening here seems very chaotic and inconsistent, including for the service users. How many of the people who have received services in either Owenacurra or Garnish House have now gone to nursing homes? How many of them have been located in other facilities where they are in shared rooms? I understand there are about 20. What is the profile there?

Mr. Maurice Farnan

They are coming from two different facilities, Owenacurra in Midleton and Millfield House. There was a full move from Millfield House to Garnish House.

Deputy Catherine Murphy

Will Mr. Farnan just answer those questions because I have very little time?

Mr. Maurice Farnan

To clarify, in the move from Millfield House to Garnish House, people were moving into single rooms in that facility because we were dealing with it in the context of Covid. With regard to Owenacurra, many of those who moved went to nursing homes and were placed in either single rooms or shared rooms. Having taken account of their needs and everything else, some were placed in shared rooms in mental health services.

Deputy Catherine Murphy

Mr. Farnan talked about Covid in this context. The locations at highest risk, from very early on, were nursing homes. The HSE moved people out having assessed that there was a Covid-related risk but moved them to adverse environments. Is that a fair comment?

Mr. Maurice Farnan

In ideal circumstances, people would be moved to purpose-built accommodation but unfortunately we do not have that level of purpose-built accommodation in Cork mental health services. That is unquestionably a particular issue for us.

Deputy Catherine Murphy

It is very difficult to make sense of the thinking behind this in terms of patient safety and the instability people who are going through significant turmoil in their lives are experiencing because of a lack of a definite pathway to permanent accommodation. If Mr. Farnan cannot tell me now, will he let me know the number of those 20 people who went into nursing homes and the number who went into facilities in which they shared accommodation? If he cannot give me that information now, will he pass it on to the committee after the meeting for us to consider afterwards? More generally, the witnesses have talked about recruitment presenting a challenge. We know that because we have talked about this before. It is a recurring theme.

I understand there is a national panel for counselling for primary care and the HSE then offers contracts out of that. The HSE will have done some assessment of what is needed. There was one CHO area where, after having been on the panel, two candidates were offered a job, but after a service financial review, the offers were withdrawn. The HSE has a problem recruiting and then this kind of thing happens. How would that happen? I got this reply to a parliamentary question on 5 September. I cannot understand how that would happen if there is a panel and the HSE knows what the needs are. Why would the HSE offer positions and then withdraw them? It seems incredible.

Mr. Paul Reid

I am not sure of those two cases. I am trying to imagine a scenario where it may have been a service that is not funded on a recurring basis, so there would be multi-annual funding for it. That is one possible scenario. I would be surprised if those two people were not taken up in another part of the service because, as I mentioned earlier, we are recruiting across the board and, as indicated, they are the skills we need.

Deputy Catherine Murphy

We recall the debacle with the dialogue between the Department of Health and the HSE on recruitment and whether the targets were real. It is one in particular I would be watching. I might take that up with the HSE separately as to how this came about, given it had decided there was a need and offered jobs, and then there was not a need.

Mr. Stephen Mulvany

We might check that for the Deputy. In this context, a lot of counselling primary care is provided through externally sourced contractors as opposed to recruited staff.

Deputy Catherine Murphy

This is from the panel.

Mr. Stephen Mulvany

Yes, but we form panels for some of those contractors. I might check the detail of that.

Deputy Catherine Murphy

I will come back to the HSE on that specific one because I want to understand it. I want to raise a more local issue that relates to a couple of funded palliative care positions in St. Brigid’s Hospice. I think the hospice is an outlier in that there is no place for families to be referred for life management. For example, let us say a parent is dying, there are young children, and management of that is required. We can understand how sensitive that is. If it is not dealt with well, it will be dealt with as a mental health issue later. It is very important that is in place. Although I am not religious myself, I can understand somebody requiring chaplaincy services. This is another position that was funded for 2022 and it has not been recruited yet. St. Brigid's Hospice seems to be entirely an outlier. I would have thought these were basic services and they seem to be basic services everywhere else. Why would services that are funded not be delivered? The HSE might come back to me with reasons it has found it so difficult to fund those particular areas in a growing part of the country where many healthcare professionals live. I have serious concerns about the way it is being handled.

Mr. Damien McCallion

I will have to come back to the Deputy as I do not know the individual case. As the Deputy said, it seems unusual, particularly in regard to chaplaincy services. If the Deputy wants to give us the details, we will look into why those matters have arisen.

Deputy Catherine Murphy

I will come back to the HSE on that. On another point, I do not understand the thought process in regard to purchase as opposed to rent in regard to the one in Cork.

I want to pick up on a point made by Deputy Carroll MacNeill about the audit of CAMHS services. Does that audit include the service users and their parents? They are sometimes the ones who are capable of telling us where the shortcomings are. Does it include an input from people who use the service? If it is just an audit from the inside, it is only a half-audit.

Mr. Paul Reid

Yes, the audit includes engagement with service users and families, but its particular focus is on prescribing methods and compliance with the standards. There is an engagement process. I will let Mr. Fitzgerald comment, if he can.

Mr. Maurice Farnan

I will answer that. Yes, the national process will include an engagement process with the families.

Deputy Imelda Munster

I want to ask in regard to community psychologists. I tabled a parliamentary question in March of this year about community psychologists at Crosslanes psychiatric unit and Singleton House in Drogheda, in the CHO 8 area. I was told there were five posts and that one of them was filled and there were four vacancies. I was again told in June that those vacancies had not been filled. There were 89 people awaiting psychological assessment in April and that number was the same in June. Has that situation changed? Have they recruited more staff or is there still just one psychologist and four posts vacant?

Ms Anne Kennedy

I will ask Ms Eyres, head of mental health services, to deal with that directly.

Ms Dervila Eyres

I will come back to the Deputy on the exact status of the vacancies, if that is okay. As far as I am aware, those four vacancies are still present. I will get the information on whether offers have been accepted.

Mr. Paul Reid

I can tell the Deputy that, nationally, there is a net increase of about 90 psychologists. I cannot comment on the particular CHO area but, nationally, there is a net increase of 90, which is about 9%.

Deputy Imelda Munster

It was 14 June when I got that response that there were still four posts vacant. I am going to give examples of cases I have been made aware of, and this can be replicated throughout the country. These relate to the Crosslanes psychiatric unit, where people presented themselves at the unit, were turned away, and subsequently went on to take their own lives. There were several such cases. One young man, who was 24, presented there in a very distressed state. He was told to go home and take his medication, and he took his life two days later. There were other cases where people attempted to be admitted when their lives were in imminent danger. Some had referrals from GPs. They did not get the help they needed, they were not admitted and, subsequently, they took their own lives. There were people who were turned away because they were told they either had drink or drugs taken and, obviously, their mental health in such a desperate state was the reason they had done that. They were turned away and subsequently went on to take their lives, in one case actually in a field across the road from the centre.

Another case was brought to my attention. A man had been diagnosed with schizophrenia and had been engaged in abusive behaviour. His father took him to the unit and begged for him to be admitted. He was in such a distressed state that he was threatening suicide. He had been sleeping rough and was highly distressed. His arms were ripped to shreds through cutting himself up. They refused to admit him and they said it was because he was not psychotic. This is just one unit. There are other cases where people were left seven hours. They were told to wait outside in their car for seven hours through the night and nobody made contact with them throughout those seven hours. The duty psychologist came out at 7.30 that morning.

The parent said to me that person looked absolutely exhausted from working through the night. It is not only a total systems failure. At what stage are management held to account for this? As I said, that is one unit about which I can give horrific stories of people desperate for help who are turned away and take their own lives. What sort of a system is that? How can that be called a proper system when it is failing people on a daily basis? There are still four vacancies there. Can somebody please tell me who is held to account? Who is held accountable when situations like this arise every other day of the week?

Mr. Paul Reid

I am not sure if the CHO wants to come in, but I will just make one general comment. Obviously, I cannot comment on any of those individual cases. They all sound like awful tragedies. The Deputy has the information on them; I do not. In many cases, where some people have been failed by the service, it is raised with us. The coroner or others might do so. I cannot comment on those cases but across our services throughout the country, many of our staff and service users are delivering good care in mental health services and they are highly committed. I have been in many of our centres, including CAMHS, adult-----

Deputy Imelda Munster

I am not disputing that.

Mr. Paul Reid

-----and older age services.

Deputy Imelda Munster

I am not disputing that. I am flagging up where the system has failed drastically to provide the service the HSE is tasked to provide to people desperate for help who are turned away and, within a couple of days, take their own lives because the system has failed them miserably. When the HSE hears of cases like this, what changes? I can see that nothing changes. Four posts are still vacant. Where is the urgency?

Mr. Paul Reid

What happens in any serious incident is a very strong and disciplined serious incident management process kicks in across the health service when harm has happened. That is a very focused process where people are held to account about it. That is the process in place for serious incidents, as alerted to us and as investigated. I cannot comment on the individual case, as the Deputy said.

Deputy Imelda Munster

I do not expect that.

Mr. Paul Reid

The CHOs might want to comment, in particular, on mental health services in their area. I will ask them to come in now.

Ms Dervila Eyres

I will make just one comment, if that is okay. If the Deputy wants information on those individual cases, I ask her to please come to me on it. I will raise one point in relation to patients who arrive at the unit in Crosslanes and have been seen but not admitted and who may be intoxicated with drink or substances. That is a stand-alone unit and it does not do medical detox. Unfortunately, when people turn up who are in an intoxicated state, they have to go to a medical facility for detox before they can be admitted to our unit. That is just a fact in terms of the process provided.

Deputy Imelda Munster

That is just one case I mentioned. I outlined horrific stories. The HSE came here today to talk about this particular issue and to give us information. I asked about four out of five posts that were not filled in this one particular unit and the representatives cannot give me the information.

Ms Dervila Eyres

I do not have that-----

Deputy Imelda Munster

The witnesses talked about priority.

Ms Dervila Eyres

I will come back to that.

Deputy Imelda Munster

Surely recruiting is a priority. The HSE representatives cannot give me an update and then they wonder why people look upon the service as dismal, as it is.

I will ask one other question on the status of pandemic bonus payments for HSE workers. What percentage of workers have been paid?

Mr. Paul Reid

A total of 123,000 workers have received the pandemic bonus payment. Just short of 90,000 of those are within the HSE. The remainder are in section 38 organisations. Separate from all of that, a separate process has been initiated by the Department for section 39 and other organisations of the State for payment but the vast majority of people directly employed by the HSE, or who are in funded section 38 agencies, have received their payment.

Deputy Imelda Munster

Does Mr. Reid know the numbers that have not been paid either by the HSE or the Department? What is the percentage of workers who have not been paid and are still waiting for their pandemic bonus nine months on?

Mr. Stephen Mulvany

It is less than 10% or approximately 40,000. We are getting through those very quickly this week.

Deputy Imelda Munster

It is about 10% of workers.

Mr. Stephen Mulvany

It is less than 10%. We would agree with that.

Deputy Imelda Munster

Is the HSE now employing a third party in relation to those payments?

Mr. Stephen Mulvany

That is for staff of section 39 organisations and private nursing homes who are not our employees.

Deputy Imelda Munster

Has that tender been issued?

Mr. Stephen Mulvany

I do not know if we have actually appointed someone.

Mr. Damien McCallion

Yes, it has. We expect to conclude it over the next week.

Deputy Imelda Munster

Is that just for health workers or will it cover, say, fire brigade workers who were brought into the front line?

Mr. Paul Reid

It will include fire services or any agency of the State, or otherwise, that provided services during Covid.

Deputy Imelda Munster

Is there a timeline for those payments to be made? Will they be made before Christmas?

Mr. Paul Reid

It is certainly our intention through this process to have those payments made.

Deputy Imelda Munster

The will be paid before Christmas to those workers.

Mr. Paul Reid

That is the intention.

Deputy Neasa Hourigan

I welcome our witnesses. As Deputy Catherine Murphy mentioned, we are holding this session so we can do a deep dive into particular CHOs. I would like to direct my questions to the senior national management present and to the Department because we have done a little work on the CHOs across a number of committees.

In the past decade, the HSE invested only €428,000 in upgrades to the Owenacurra Centre in Midleton. The centre accommodated 20 residents until 2021 in a community-based town centre location. It was considered an excellent service. I talked to the residents myself. They were exceptionally happy there and many had been living in the centre for more than a decade. By contrast, the HSE invested far more money in institutional dormitory-style, out-of-town wards in the same ten-year period, which I have also visited in the past year. For instance, the HSE spent €1.9 million on St. Catherine's ward and €2.9 million on wards and a day centre in St. Stephen's Hospital.

We also learned recently through freedom of information, FOI, records released to me, almost a year late, that out of the eight mental health facilities in CHO 4 discussed by management in 2019, the Owenacurra Centre was the only one mentioned as possible for sale. I will add that having talked about this issue a number of times at committees, that is directly in contrast to what we were told during committee meetings, which is that it had never been discussed that the site might be for sale. The FOI records indicate that the HSE advised limiting capital expenditure on the excellent service at Owenacurra, the replacement of premises, such as Mount Alvernia in Mallow and unit 1 in St Stephen's at a cost of millions was mentioned but there was not one mention, in any of the FOIs or parliamentary questions, of replacing Owenacurra, or replacing that service, or making it so that that service could continue. All of this suggests that there was an agenda over a significant amount of time during the past decade to close Owenacurra long before the closure was actually announced last year and, when it was announced, many of those residents were given around three months to get out of their home of more than a decade.

We are way past a discussion around the quality of the building at Owenacurra and whether it was in good nick. It is perfectly clear from the FOIs I have received that there was tacit agreement by CHO management in Cork, and by estates, that they were going to run that service into the ground and sell off the site. That is the reality of the decision-making. The HSE was going to move residents to substandard premises, to shared accommodation and shared rooms in places very far away from Midleton, their families and even a local shop or community group. They were going to be cut off from their communities and put into shared rooms. I want to ask senior HSE management about this. Mr. Reid is moving on soon and I would particularly like to hear from him because this concerns estates and capital funding. I would like to hear from the CFO and the CEO. Do they stand by that decision-making?

Mr. Paul Reid

I will come in first. I said earlier that I stand over the decision in relation to Owenacurra. The CHO will comment on other buildings in particular.

Deputy Neasa Hourigan

To be honest, I do not want to hear from the CHO. I want to hear from senior management whether they stand by the setting aside of clinical advice and the running into the ground of a building that could have been held onto?

Mr. Paul Reid

I stand over the decision in relation to the Owenacurra centre. There were originally 21 residents, if I am correct. Mr. Fitzgerald confirmed this morning it is now down to eight. We are not giving people a time-limited period to get out. We have worked with all the families-----

Deputy Neasa Hourigan

I am sorry, and I do not wish to cut across Mr. Reid, but just to be clear, the reason the HSE is not giving people a time limit is because of the very hard work of some local representatives and the families. The HSE did give them a time limit originally, which was three months.

Mr. Paul Reid

We are working with the families very thoroughly to find suitable available accommodation that meets their needs. There are different needs for each of the residents. We have done that over recent months. It is down to eight residents now with whom we are still working. To answer the Deputy's question substantively, I stand over the decision in relation to the Owenacurra centre-----

Deputy Neasa Hourigan

That decision sets aside all best practice in terms of our national policies and clinical advice. In July and August this year, after an intervention from the Information Commissioner, I eventually received a large volume of freedom of information, FOI, records which, by the way, I was told at first did not exist. Within the records we found evidence of two senior clinicians from different disciplines voicing serious concerns about the possible closure of Owenacurra and the impact on residents and, of course, the impact on the wider day service for people in the east Cork area. Now, we are left with almost no services and certainly no 24-hour residential services in the whole of east Cork.

We found records on the possible sale of Owenacurra being discussed by senior management. We found records on one key decision-maker who was complaining last July that there are only seven placements available in St. Stephen's Hospital for Owenacurra residents, again in a ward setting, which is absolutely contrary to national policy.

What is actually most striking is the complete absence of records. I would have assumed this is of great concern to the national running of the HSE. For example, there is no record of any clinical decision-making process that led up to the Owenacurra centre closure. There is no serious available and transparent decision-making process there that actually talks about the patients' welfare.

This is about estates. This is, and we talked about this at many committees, like moving people around on a chessboard or playing Monopoly and saying I am going to buy a building over here. We have building reports issued by HSE estates in June 2021. Then, Mr. Fitzgerald, Mr. Scully and their colleague, Mr. Morrison, held a completely unminuted meeting on 22 June and decided to close that service. We have no minutes and we have no clinical intervention. I am sorry, but just to be clear, the HSE is fine with that.

Mr. Paul Reid

To be clear, the Deputy's representation of us treating people as moving them around a chessboard does not represent the people with whom I work.

Deputy Neasa Hourigan

How would Mr. Reid describe this?

Mr. Paul Reid

It does not represent the people I work with or those I have met in relation to this service, and it does not represent the engagement we have had with staff, families and service users.

Deputy Neasa Hourigan

That is fantastic. Can Mr. Reid provide me then with the clinical process and decision-making of closing the Owenacurra centre? That is how he proves he is not moving people around like chess pieces. He proves it by providing transparent minutes of the decision-making. These people were living there for more than a decade.

Mr. Paul Reid

We provide good, available, suitable accommodation that meets the needs of the people who are living there. One of the reasons the Deputy just mentioned was in relation to day services. It was highly inappropriate that people availing of day services were having literally to walk through people's residence.

Deputy Neasa Hourigan

Then why did the HSE underinvest in the building for more than a decade and invest more than €3 million in ward-based settings?

Mr. Paul Reid

We went through our capital investment process and our decision-making and prioritisation earlier. We have an available capital envelope that we utilise. We prioritise it based on risk.

Deputy Neasa Hourigan

Okay. That is a fair answer. I would like to now turn to the Department. The HSE very clearly said just now that it is prioritising settings for 24-hour mental health placements that are directly in contrast to our national policies and what we know is best practice for patient care. At what point does the Department step in here when it is very obvious the HSE is not doing its job in this regard?

Ms Siobhán McArdle

With regard to mental health policy, it is important our service users across both our acute and residential services are provided with high-quality accommodation, and that the services are provided in locations that meet standards. Therefore, it is not an either-or scenario. It is around-----

Deputy Neasa Hourigan

Okay, so does St. Stephen's Hospital offer a better quality of care for these people than the Owenacurra centre did, if it had not been actively run into the ground?

Ms Siobhán McArdle

There is a capital plan in place that looks at our residential services as well as our acute hospital services. As Mr. Reid has outlined, there is a prioritisation that takes place. That is not about one competing with the other, however. It is about the timeliness of ensuring we can deliver against those plans. For instance, in the Cork area and in the south, there is a commitment around the replacement of residential services where they fall below certain standards-----

Deputy Neasa Hourigan

I am sorry, but I want to be clear on how the Department sees the HSE investing far more than €3 million in settings such as St. Catherine's ward and St. Stephen's Hospital. Some of the clinical specialists in the area voiced concerns. It was inspected three times by the Mental Health Commission in December 2021 and March 2022. The lead inspector, Dr. Susan Finnerty, said:

I was particularly concerned to note that the culture in one unit was reminiscent of a model of mental health care that might have been provided decades ago. There was a general attitude of negativity about the possibility of improvement in the lives of the residents. There was an emphasis on what they could not do, their potential for aggression, and the fact that they would always require this type of care.

This is before we are talking about the fact that people are sharing rooms and they are not in a community setting. They are basically off in a field in the middle of nowhere. I went and had a look. It really is something from the 1950s, and Ireland obviously has a very grim legacy in that regard.

I am sorry, Chairman, because I want to put my hand up to come back in on Garnish House in the next round of questioning, but is Ms McArdle telling me that when the HSE made a decision to underinvest in a building that provided an excellent service, which was right in the middle of a town where people were living in their own rooms, the Department at no point intervened in estates management in the HSE to ask whether the cost-benefit analysis is in line with national policy?

Ms Siobhán McArdle

That is an important point. We have a ten-year national policy called Sharing the Vision. It is very important that any investment in our capital infrastructure aligns with that. The Deputy is absolutely right. It is a move towards community infrastructure but it has to be balanced against the need to ensure the services and infrastructure we have are-----

Deputy Neasa Hourigan

I know I am at the end, Chairman. However, Ms McArdle is-----

Chairman

I am sorry, but I will have to close this slot. Unfortunately, we have a day with full attendance so I have to make sure everyone gets in.

Deputy Neasa Hourigan

I could have done the two hours by myself.

Deputy James O'Connor

I will follow up on an excellent round of questioning by Deputy Hourigan with this question. Was the Office of Public Works on site in Owenacurra carrying out measurements or surveying the building?

Mr. Paul Reid

I will have to ask the community healthcare organisation, CHO, manager to comment on that.

Mr. Michael Fitzgerald

I am not aware of the Office of Public Works being on site. I have not heard of that. The Office of Public Works would not normally be involved in HSE estates unless it was approached.

Deputy James O'Connor

That is why I am asking. The reason I am asking Mr. Fitzgerald that is that there are other buildings in close proximity in the immediate site next door to the Owenacurra centre over which the Office of Public Works would have maintenance remit. That is what is plugging my curiosity, as it were. It has been brought to my attention by people in the local community that the Office of Public Works was in that area viewing the building in Owenacurra. I would like Mr. Fitzgerald to check that out, please, and come back to me immediately with an answer.

Mr. Michael Fitzgerald

Sure.

Deputy James O'Connor

What has been extraordinarily frustrating from my perspective, and Mr. Fitzgerald can attest to this because we raised it immediately with him at the first Oireachtas forum that took place for counties Cork and Kerry in Ballincollig following the HSE's decision, is the constant changing of the story around why the centre was being closed. First, the decision was postponed. Then we heard of plans for decongregated settings potentially to be set up in Midleton. Now, plans are being touted for the establishment of a new centre.

How long will that take? What is the plan? Is there an envisaged opening date for a new ten-bed centre that has been promised? Can Mr. Fitzgerald rule out today that the site where the Owenacurra centre is currently located will not be sold, as was promised that day at the forum? Deputy Stanton and I were the only Cork East Deputies in attendance that day when we were told that site was going to be retained for mental healthcare services. Can Mr. Reid and Mr. Fitzgerald rule that out for me here and now?

Mr. Michael Fitzgerald

It is certainly an evolving position with regard to it. Importantly, from a Midleton perspective and an east Cork perspective, we are committed to the development of a ten-bed rehabilitation residential-type facility in the town.

We said we will undertake an analysis and an options appraisal with regard to what is the most appropriate location - whether it is the current site in Owenacurra or a nearby site across the road from it in Midleton hospital or a new site in the area. On another important issue, we said we would seek the purchase of a community residential-type of house because we have to bear in mind the type of services for east Cork.

Deputy James O'Connor

I have to pause there because my time is limited. I asked two questions and neither has been answered. To be fair I asked the questions of Mr. Reid as well. I will be very clear and ask them one at a time. First, will Mr. Fitzgerald rule out here and now that the Owenacurra Centre site will be sold for any purpose other than mental health care?

Mr. Michael Fitzgerald

From the perspective of the CHO, as I said, we are going to do an analysis of all the different sites. Our first and important piece is to build that ten-bed unit. We have to build it in an appropriate location and that is first and foremost.

Deputy James O'Connor

Mr. Fitzgerald should bear in mind that he told me and other Oireachtas colleagues of mine that day in Ballincollig that site was going to be retained by the HSE for mental health care services. That is news to me now that we are getting a watered-down commitment here at the Committee of Public Accounts in that regard. As Mr. Fitzgerald knows, no cameras are present at those HSE meetings with Oireachtas Members, but that is what we were told.

Mr. Michael Fitzgerald

I am not suggesting that the HSE will not retain that site. I am not suggesting that at all.

Deputy James O'Connor

Mr. Fitzgerald is not committing to it either.

Mr. Michael Fitzgerald

I am talking about the development of the ten-bed unit.

Deputy James O'Connor

In my defence, he is not committing to it either so that is worrying.

Mr. Damien McCallion

I do not think anybody can give guarantees about the forever future of every site but what we can say very clearly is the policy is that where mental health service lands are sold, if they are surplus to requirements at some point in the future, we have agreement in policy that the money stays in mental health and is, therefore, available for mental health services going forward.

Deputy James O'Connor

Will Mr. Fitzgerald come back to me about the OPW first and foremost? The second question I asked relates to a timeline. Can I get any indication as to how long this is going to take?

Mr. Michael Fitzgerald

We have approval for a full capital submission, which we recently received through our internal processes in the HSE. It will be dependent on sufficient funding being available in the capital plan for the development of the site, no more than any other development we put forward. It will take a number of years for it to be built, unquestionably. We are talking about four to five years until we have a ten-bed facility. There are two other important issues locally from the Deputy's perspective. The four-bed house that we sought is now at "Sale agreed" and we also intend that the developers will be on-site for the community hospital across the road in Midleton by the end of the year. They are important developments in Midleton in the broader sense of health services. It actually also affords the opportunity for the use of Midleton sites. It serves the Midleton Community Hospital complex inside for future purposes on that site.

Deputy James O'Connor

This issue is important for the families of the eight remaining residents who are there. What is the immediate plan for those residents in the coming years? Mr. Reid has stated he will not ask anybody to get out. Is it the intention to move the eight remaining residents who are not in need of nursing home care due to advanced age but who are currently resident on that site? Will they be offered accommodation in this new unit?

Mr. Michael Fitzgerald

We will keep working with each of the people and their families. That process has brought us to a situation where ten of the residents have moved from the Owenacurra Centre at this point. I was asked earlier how many of the ten were in single rooms in whatever residential centre they were. Nine out of the ten are in single rooms at this point in time. I am confident we can keep working with the families. It is a balance of the people's will and preference as well as their clinical needs and working through the remaining number of people with regard to that.

Deputy James O'Connor

In the short run it goes without saying that we have gone from having a capacity of approximately 20 service users in early 2021 and reducing that to a three- and four-person placement with this new residential house. That is not acceptable in the short or medium term. There is an urgent need to increase that. The service plan in the immediate future has been covered in depth by Deputy Hourigan. I cannot stomach the idea that people in Midleton are going to be asked to move to St. Stephen's Hospital and other HSE locations despite the Mental Health Commission reports clearly outlining that there are serious problems. So much about this decision does not make sense. It has been hard as a Government representative trying to seek the answers that families need when the HSE changed its story on so many different occasions. I want to outline my disappointment and frustration with that. It is the second time I have told Mr. Reid. I said it to him the last time he was before the committee. I also ask about the day care service and it is critical that Mr. Fitzgerald gives some explanation for this. Emergency respite care was deeply valued by people in the community. People working in the Owenacurra Centre who provided that care to the community had a good deal of discretion. Will he indicate what is being done on the respite care front and on the day care front please?

Mr. Michael Fitzgerald

The day care service has been restored in Midleton on an adjacent site. Once the development is completed across the road in Midleton Community Hospital, it will afford an ability to provide it on a permanent basis on that particular site.

With regard to respite care, it is important for members and for Deputy O'Connor, we are trying to establish a community-based service because that is the need of the people and that is the challenge for us in the context of delivering on the policy for mental health services.

Deputy James O'Connor

Without being flippant, Mr. Fitzgerald is talking about establishing a community-based service. The service that was there was outstanding. It was the heart of the community. It was a few minutes' walk from the main street in Midleton, next door to the biggest supermarket in east Cork. Everything was there for the service users' needs, and it has been taken away. Irrespective of individual's views on the state of the building, that could have been rebuilt. It is appalling how it has been handled.

Chairman

I have some questions for Ms Kennedy regarding CHO 8. I will keep the questions short and the answers should be as short as possible. The capital spend on CH0 8 for 2021 was €5.9 million. which appears to be very low. Will she confirm that €100,000 was spent on Erkina House in Rathdowney, County Laois? I do not want to be abrupt but a yes-no will do.

Ms Anne Kennedy

No. The spend there was on a feasibility study.

Chairman

With regard to the €3.6 million for older people, will Ms Kennedy confirm whether that was spent on the hospital in Abbeyleix?

Ms Anne Kennedy

I do not have the breakdown of the figure for Abbeyleix; that capital spend is ongoing at the moment. If the Chairman allows me one minute, I will double-check my figures for minor capital. The older person spend of 2021 was €1.917 million. The capital spend in Abbeyleix is ongoing so that would not be the complete figure for the capital spend there. I can get that capital spend figure if that is okay.

Chairman

I will come back to Abbeyleix in a moment. How many inspections were carried out on Erkina House by the Mental Health Commission?

Ms Anne Kennedy

Only one.

Chairman

Will Ms Kennedy or Ms Eyres outline briefly what led to the closure of Erkina House? Was there one reason, or two or three reasons? Please outline what they were.

Ms Anne Kennedy

Just to confirm, Erkina House is not closed. Erkina House is still operating and has remained operational throughout. I will pass over to Ms Eyres regarding the development plans for rehabilitation and recovery centres in Laois and Offaly.

Ms Dervila Eyres

In regard to Erkina House, the Mental Health Commission reported in 2018 that many of the 24-hour supervised residences for high support, were too big and in poor condition and had an institutional feel about them.

With that, we were examining our whole stock in terms of residential accommodation. Certainly, the report had noted three things in relation to the premises in Erkina House. These were that all residents needed to have access to single-room accommodation and they needed to have access to kitchen facilities, which were not available within that facility, and other adaptations to the house to bring it to a standard would be required.

When the Covid pandemic hit in 2019-2020, we moved to provide single-room accommodation, which was done, and also, I suppose, tried to look at the policy direction in terms of Sharing the Vision in 2020 which recommended that residents be supported to have secure meaningful employment opportunities that fostered hope, participation and a sense of a better and brighter future. In order for that to happen, we were looking to see where plans for replacements for some of our older stock could be found. Certainly, it was in consideration at that point.

Chairman

Can I ask Ms Eyres a question in relation to this? The HSE in Laois-Offaly, as I understand it, the Laois-Offaly part of CHO, 8, has said, and the management team have told me and others at meetings, that the plan is to provide four ten-bed units. Is it correct that there were 12 patients in Erkina House during the pandemic who had single-room accommodation, that there is only one large room that could be described not even as dormer, but as multi-occupancy where one could have two or three, and that they were all accommodated?

Ms Dervila Eyres

That is correct.

Chairman

I thank Ms Eyres. Is Erkina House being considered in terms of the option appraisal as being for use as one of those four units in Laois-Offaly that the HSE requires for residents with mental health issues?

Ms Dervila Eyres

There is an options appraisal being carried out by an independent organisation which will make recommendations for the HSE to consider in relation to the best future for Erkina House and the residents there.

Chairman

I met the consultants who are doing that option appraisal. What I am asking Ms Eyres is, from a geographical and strategic point of view, from the HSE's position, obviously, it has asked the consultants to carry out that work. That is fine. I met it and that was satisfactory, and I thank the HSE for that. I am asking is Erkina House in the frame as one of those units.

Ms Dervila Eyres

All options are still open.

Chairman

What has been the spend on Erkina House in the past three years in terms of refurbishment work, repair work or renovation works?

Ms Dervila Eyres

I do not have the last three years' list in front of me but I know there was a significant spend on the roof - up to €40,000 - last year. However, that is still causing difficulties. It is still leaking. There are issues with the basement as well.

There is currently an independent architectural firm in there to give me a report on the cost of the refurbishment of that house as part of the options appraisal because estates are suggesting that it would be in excess of €5.3 million to do the necessary works to bring Erkina House to a specification that would be required for modern mental health delivery of care. We are waiting on the independent architectural firm to come back with its appraisal of what is required.

Chairman

Will there be a second opinion given from a second architectural company or specialists in the construction area in terms of what is needed? It will not be one only.

Ms Dervila Eyres

Yes. Estates have given that figure, which is internal to the HSE, and we are currently wait on an independent architectural firm's report.

Chairman

Ms Eyres might keep us appraised of that.

Ms Dervila Eyres

Of course.

Chairman

Moving on to Abbeyleix nursing unit or, as it is referred to locally, Abbeyleix hospital, I ask Ms Kennedy for brief answers. There was €4 million spend on it, according to previous discussions that we have had with the HSE on this and with Mr. Des O'Flynn, the chief officer. This has been ongoing now for a few years. It has capacity for 28 beds. Today, I understand, there are still only seven beds open. I have raised this at every opportunity. Every time I have been in contact with Ms Kennedy throughout the year and at meetings that we have had, I have raised with her the fact that there are only seven beds in use in it.

The capital works were carried out to a very high standard. The staff are there to staff it. The day care centre remains closed despite the fact that there have been several dates given for it reopening and 21 beds are not in use. Some of those beds will be sacrificed to facilitate the day care unit but one is still talking about 22 or 23 beds. This is an intolerable situation that we have such a crying need for nursing home beds in the county and we have these closed.

I will run through quickly one of the reasons for it. When it was ready to be reopened or near the date, it was discovered that the shower heads had still to be fitted or changed. That held up progress for a number of months. When that was sorted, it was discovered that fire doors needed to be changed. Six doors needed to be upgraded. When the HSE was getting the solution to that, there was a ramp needed for the day care centre.

I am saying to the HSE senior management team here today that this is a problem that one has come across in the HSE over the years in trying to get a decision made. In my view, an engineer, a clerk of works or, for that matter, a carpenter, or a foreman on a building site would go in and snag that out and state the four things that need to be done. This drags on and delays the process of reopening for the best part of a year. That is not a tolerable situation. Where works are being carried out, we should be able to ascertain what is on the snag list and whether there are other works that need to be carried out fairly quickly to get the place open. We cannot run public services like that. It is ludicrous. Will Ms Kennedy tell me when the day care centre will finally be open and when those 21 or 22 beds will be brought into use?

Ms Anne Kennedy

On the state of project, at present it is undergoing finally snagging which is due to complete tomorrow. At that stage, the certificates of compliance will be undertaken and they will be sent to HIQA. HIQA needs to re-register side A of the hospital in advance of moving patients back in. That will give us the ten single en suite rooms on side A. Side B is then being vacated. There will be the opening up of the 11 intermediate care beds and also the opening up of the day care facility on the site. The day care facility is a temporary facility. Once that is reopened, the development control plan will be reviewed to see how a day care facility can be accommodated on the site. Once day care is in its permanent home, the additional seven beds in the intermediate care part of the hospital will be opened. That is the sequence of events as it needs to happen.

Snagging will be complete tomorrow followed by certification followed by registration. Those are the key next steps.

Chairman

The last date I had was 30 June. Can Ms Kennedy give me an indicative date now for when the day care centre will open?

Ms Anne Kennedy

That is completely dependent on HIQA registration and we do not have control of that process.

Chairman

Okay. Would Ms Kennedy expect it to be open within the next two months?

Ms Anne Kennedy

I would expect it to be open within the next two months but it is completely dependent on the registration process.

Chairman

Will Ms Kennedy keep me up to date on that because it is frustrating locally?

Ms Anne Kennedy

We will indeed.

Chairman

Finally, on Abbeyleix, the location for the day care centre has to be on that site. The HSE went through a process of going around other towns in the area and seeing what was available, in terms of houses or premises. The location is there because it has the services onsite. There is a four-acre site there. The HSE has loads of space on it. It is right in the middle of the geographical area in south Laois where the HSE needs a day care centre. Any attempt to move it out would be resisted. Also, it does not make financial or management sense to move it out of there. I would ask Ms Kennedy, and I have said this to Mr. Des O'Flynn as well, that the HSE keep an eye on that.

Lastly, how much has been spent to date on the car park facility at St. Fintan's campus, the mental health facility, in Portlaoise?

Ms Anne Kennedy

Just one second until I find the Laois car park.

Chairman

I refer to the total spend on the car park.

Ms Anne Kennedy

Unfortunately, it has not been broken down. There have been several capital spends on car parking in the St. Fintan's campus - the latest one in the past year and the previous one in relation to Tusla. I do not have the breakdown of minor capital in the St. Fintan's campus. I will have to revert to the Chairman on that.

Chairman

I appreciate that, but can Ms Kennedy come back to me with a figure for the total spend-----

Ms Anne Kennedy

I will indeed.

Chairman

-----on the car park at St. Fintan's campus over the past five years and the number of car parking spaces now available there?

Ms Anne Kennedy

I have information on the number of car parking spaces and the increases in car parking there over recent years. The car parking spaces available initially were 240. Tusla provided an extra 57 spaces in 2019 and 2020, and the new car park has 140 spaces. In total, we now have 437 car parking spaces on the campus.

Chairman

Will you come back to the committee with-----

Ms Anne Kennedy

I will come back to the committee with the data on expenditure, yes.

Chairman

Thank you very much. Please include a reminder of the number of car parking spaces. I will let members back in now in the original speaking order.

Deputy Verona Murphy

My questions are for Mr. Mulvany. The contract with DXC Technology for the IT of the integrated financial management system, IFMS, was terminated. The original contract was valued at €19 million, including VAT. How much of that was paid?

Mr. Stephen Mulvany

We have not determined the final amount yet. While we terminated the contract in April, the engagement with DXC to close it out and pay over a final amount is still ongoing.

Deputy Verona Murphy

Mr. Mulvany does not know how much it is yet-----

Mr. Stephen Mulvany

I know how much-----

Deputy Verona Murphy

He appeared before another committee in June and did not know. He still does not know.

Mr. Stephen Mulvany

It is not about not knowing. There is a commercial process we have to close out with a commercial entity and we are doing that------

Deputy Verona Murphy

Will it be more or less?

Mr. Stephen Mulvany

We are doing that in the best interests of the State. I am not going to discuss the amount now because that will influence the amount itself.

Deputy Verona Murphy

I asked if it would be more or less than the €19 million.

Mr. Stephen Mulvany

It will be an awful lot less than the €19 million.

Deputy Verona Murphy

An awful lot less-----

Mr. Stephen Mulvany

Yes, an awful lot less than €19 million.

Deputy Verona Murphy

Are legal proceedings on either side taking place?

Mr. Stephen Mulvany

No. I expect no legal proceedings and it has not impacted us in terms of moving on.

Deputy Verona Murphy

Is there any termination penalty for the HSE?

Mr. Stephen Mulvany

No, absolutely not.

Deputy Verona Murphy

Do we know how much was spent?

Mr. Stephen Mulvany

On what?

Deputy Verona Murphy

Do we know how much DXC Technology has been paid to date or is Mr. Mulvany saying that has not been calculated yet?

Mr. Stephen Mulvany

I just do not have the figure to date. It is -----

Deputy Verona Murphy

Is the equipment or whatever the company provided obsolete now or can it be used by the new contractor?

Mr. Stephen Mulvany

The company did not provide equipment. It provided software and that software is being used. Effectively, the company designed the new system and we are simply validating and moving that design on to build and test.

Deputy Verona Murphy

DXC Technology does not have a copyright on what it has provided and it can be used by-----

Mr. Stephen Mulvany

No, not at all. That is our intellectual property.

Deputy Verona Murphy

Does the new contractor, IBM, have any difficulty with that?

Mr. Stephen Mulvany

No, none whatsoever.

Deputy Verona Murphy

We are not going to run into a scenario where there will be a problem that was created by-----

Mr. Stephen Mulvany

No, we are not.

Deputy Verona Murphy

I have just one more brief question. What is the expected completion date for the IFMS?

Mr. Stephen Mulvany

The IFMS will go live in the first part of the HSE in the middle of next year and we will be 100% complete across the entire HSE by the middle of 2025.

Deputy Verona Murphy

Will we have extended the budget, which was originally €82 million?

Mr. Stephen Mulvany

The budget will require some extension because it was originally set back in 2016, but that extension will be modest in terms of the overall amount. The budget will require some extension to complete it all the way beyond the HSE and into the voluntary organisations. We also intend to go to the larger section 39 organisations and to all of the section 38 organisations.

Deputy Verona Murphy

One more quick question, if I may. Are there systems in place now to prevent the difficulties that arose with DXC Technology arising again?

Mr. Stephen Mulvany

Are there systems in place? Well, we have learned lessons from the engagement with DXC Technology. One learns from every big procurement process. The IFMS was a very large and complex procurement process and we have learned some lessons from it.

Deputy Catherine Murphy

I want to go back to the issue of St. Brigid's Hospice in Kildare. Funding was provided for a social worker role three years ago, but the governance and the advertisement, as I understand it, has not happened. Funding was also provided in 2022 for a chaplaincy role, but there was no advertisement for that role either. What happens to the funding for roles that are not filled?

Before we finish the meeting I would like to invite Mr. Reid to tell us the main message or advice he would give to his successor, based on his experience. It has been a pretty unusual few years, thanks to the intervention of Covid and its impact on the role he expected to be undertaking.

Mr. Stephen Mulvany

I will respond to the first question. The normal practice is that the funding stays until the post is recruited unless the service decides the post cannot be recruited and there may be some alternative way to deliver the same benefit. If none of that works, there has to be some sort of reparation. Normally, the money stays until the post is recruited.

Deputy Catherine Murphy

If there is no person recruited for a particular role, then the organisation has a surplus. If the hospice got money three years ago and somebody is only recruited this year-----

Mr. Stephen Mulvany

What services will generally do with once-off savings because they cannot recruit a post is use them for agency or locum staff or for work related to being ready for when the post is in place, or they will use them to cover some other issue. It is rare for the money not to be put to some purpose. That is not a challenge I have faced so far, as chief financial officer.

Deputy James O'Connor

I have two quick questions related to my constituency. The SouthDoc service is very important to the people of Cork East, Kerry and County Cork in general, but it is at enormous risk because of the potential reshuffling of existing centres. Will the HSE to commit to meeting a delegation of public representatives from the area to discuss this problem? I am happy to do this on an apolitical basis and ask for a commitment from the HSE that it will engage with me and my Oireachtas colleagues from Cork East.

Mr. Michael Fitzgerald

I have no difficulty with that. Deputy O'Connor knows where I am and I will reach out to him after this meeting.

Deputy James O'Connor

I thank Mr. Fitzgerald. Second, on the delivery of primary care in east Cork, it is impossible to get a doctor at the moment if one moves into places like Youghal and other areas of my constituency. The delivery of a primary care centre in Youghal is one of the largest capital projects the HSE will undertake in County Cork over the next few years. Will the HSE give me some indication of the status of that project, which is critically important in the provision of healthcare services in east Cork, including additional acute services? I ask for an outline of where that centre stands.

Mr. Michael Fitzgerald

I will come back to the Deputy on that, but my most recent understanding is that we are hopeful of being able to make a positive statement with regard to commencing it shortly. I will come back to the Deputy with the definitive position on it.

Deputy James O'Connor

Okay. I have one final question for Mr. Reid. Would he consider engaging with the families of Owenacurra?

Mr. Paul Reid

Personally?

Deputy James O'Connor

Yes, as CEO-----

Mr. Paul Reid

At a local level, the HSE has engaged and that is appropriate-----

Deputy James O'Connor

Will Mr. Reid engage, as CEO?

Mr. Paul Reid

Tomorrow is my final day in the HSE. I have engaged with families at local level. I have been down with Mr. Fitzgerald in relation to CAMHS and have met families and children.

Deputy James O'Connor

In hindsight, does he regret the decision on Owenacurra?

Mr. Paul Reid

No. As I said, possibly three times today, I fully stand over the decision on Owenacurra. It was right for the families and the people in the residence there. It is right to provide a better service. I have seen what good looks like in that area in Cork in terms of residential care and it is the right way to go and the right strategy.

Deputy James O'Connor

Why?

Chairman

The question has been answered a number of times but Mr. Reid may want to give Deputy O'Connor a brief reply on the question of why.

Mr. Paul Reid

On the why, I will say it again that when the commission made its findings known, the HSE and Mr. Fitzgerald at a local level carried out assessments. Our assessments, including of safety risk, the asbestos, the mechanical and electrical equipment, the investment that was needed there but also, more importantly, of the conditions and the space in which people were living and the fact that day care services were being mixed with services for people in residential care, concluded the centre was highly inappropriate. The right decision was made, in line with the strategy and policy of moving people into residential care.

Deputy Neasa Hourigan

I cannot let that comment go, I am afraid. The decision to close Owenacurra was appalling and it is even more appalling to hear the HSE doubling down on what was a wrong decision. What we have heard about today is a decision with no clinical oversight and one that was probably put in train in 2012 in terms of deciding to run that building into the ground. It is really shocking that the HSE at a national level would defend that.

Our guests have taken exception to my characterisation of the decision-making in Cork as moving people around like chess pieces on a chessboard but I would like to move to the issue of Garnish House.

The HSE rental agreement with Garnish House started in April 2020, during the Covid emergency. A family member of a resident told the Irish Examiner earlier this year that their relative was moved with a few hours’ notice. As of April this year, according to the Irish Examiner, the HSE has failed to communicate with the families of residents in County Cork mental health facilities in the last two years since their relatives were suddenly moved to this new accommodation. We have covered the impact of prolonged uncertainty for people in mental health services around where they will be living. My questions are on: the impact that has; the fact that it seems there is no clinical oversight to those decisions; or that they are not recorded in any way; and that the HSE and Department of Health are fine with that.

The Irish Examiner article in April this year said there had been consultation with those Garnish House residents and families about their ultimate placements. Could the witnesses outline what that consultation was? The HSE has informed me, through a parliamentary question response, that it will not be renting Garnish House again beyond quarter 1 of 2023. Has it informed the residents or did they find out through that parliamentary question response? When did they first hear about it? The HSE has been telling people from Owenacurra, up until recently, that they will be moving to Garnish House. Is the HSE informing those residents and their families that if they move to Garnish House they will have to move again in early 2023?

Mr. Michael Fitzgerald

I might take that. At all times it was understood that Garnish House was not a place where people would be resident for the long term because it was always a leased building. It was done at short notice at the time because we were preparing fast for what we did not know with regards to Covid. That is a hugely important issue with regard to the decision to move from Millfield House to Garnish House, which is at issue. Importantly, though Garnish House is not an ideal location from a residential perspective in terms of the consequences around the building itself, as I outlined earlier, it afforded more space and more single spaces, especially at that first stage and at the early stages of Covid when we did not fully understand what the implications might be for residential settings in mental health, such as they were.

Deputy Neasa Hourigan

I asked three specific questions and I am wondering if I can get an answer to them.

Mr. Michael Fitzgerald

The Deputy also asked about the consultation-----

Deputy Neasa Hourigan

I will give Mr. Fitzgerald an overview. What consultation has the HSE had with Garnish House residents about their ultimate placements? Had the HSE informed residents of these plans before the details were released in a parliamentary question response to me? How has the HSE been dealing with the Owenacurra residents who it has been telling for the last year and a half are going to go to Garnish House? Has the HSE informed them that will not be long-term and that it will be a matter of months before they are moved on yet again?

Mr. Michael Fitzgerald

Anybody who would be moving into Garnish House would have an understanding that it would be for a period of time. It might have been a defined period at the time because we would want to make sure to keep our options open on it. Everybody who was in there understood that it was not a centre that we were going to be staying with over a long period of time. That is the understanding.

Deputy Neasa Hourigan

These are vulnerable people. Can Mr. Fitzgerald define what he means when he says they understood? What was the consultation?

Mr. Michael Fitzgerald

There was a discussion because all of these-----

Deputy Neasa Hourigan

In what format?

Mr. Michael Fitzgerald

-----residents of Garnish House have a clinical team who provide support to them and they are under the care of consultant psychiatrists so there is oversight, on an ongoing basis, of all the residents of Garnish House. There is constant communication between that clinical team and the residents.

Chairman

I have a question on the child disability network teams, the census and the workforce review 2021 and I am looking at CHO 8. The vacancies in CHO 8 were as follow: speech and language therapy had 32% vacancies; occupational therapy had 36% vacancies; psychology had 41% vacancies; physiotherapy had 26% vacancies; and social work had 37% vacancies. We get constant complaints from parents that they cannot get assessments or access therapy for their children. Unfortunately time does not allow us to go into this matter in depth, and we could devote a session to it. What is being done to fill these positions? Is there workforce planning? Are the third level institutions being contacted about this? Are people being encouraged to take up study for these positions? What is the current situation? I am just giving the example of CHO 8 but if you look at it up to 40% of positions are empty across some of these therapy positions. Services cannot be provided and there is a constant problem. What is being done about it?

Mr. Damien McCallion

The health service-----

Chairman

The children's networks.

Mr. Damien McCallion

Disability network teams.

Chairman

It is just about the network teams.

Mr. Damien McCallion

That is a challenge and the numbers the Chairman has given for CHO 8 are similar in other CHOs. They might vary a little but broadly speaking we only have two thirds of the resources in place for those teams. A lot of it is the health and social care professional areas, which is the biggest gap. There are a couple of things and we discussed this in the Joint Committee on Health yesterday with the Department as well. At national level there is engagement with the Department of Further and Higher Education, Research, Innovation and Science to try to increase the numbers in all those disciplines and to try to improve the numbers coming through.

Chairman

When people come out of university or whatever and are offered a job, are they being offered a career path or are they being offered one- or two-year contracts?

Mr. Damien McCallion

They are permanent jobs across, not just the children’s disability networks but often mental health, primary care and other areas.

Chairman

I take it the pay grades would be similar to what is being offered in other English-speaking countries. Would that be right?

Mr. Damien McCallion

The challenge for us is that we do not have enough people coming through every year when it comes to the demands for children's disability network, CAMHS, primary care and other areas. In addition to trying to increase the numbers coming through the education system, which will take time, we are also undertaking international recruitment and we are trying to look at other models for how we might increase the numbers. We are challenged in that area. We have a strategic workforce unit within our area looking at this to try to project the numbers over the next five to ten years and we are working with the Department.

Chairman

I ask the HSE to send a written update to the committee on the situation in CHO 8 across those five therapies. I also ask for a written reply from Ms Kennedy to the following question as I do not expect her to have the details with her, nor do we have the time to go into it. In 2019 there was €138.6 million for dental health, with €62.3 million for public dental health services, which I presume is the PRSI scheme. For orthodontics there was €20.3 million and there was €56 million for the dental treatment services scheme, DTSS, in 2019. I presume it is a similar figure or maybe there has been an increase. Could Ms Kennedy send the committee a note on the dental health budget across those three areas, including public treatment, orthodontic treatment and the DTSS in CHO 8 and specifically in Laois-Offaly? I ask her to send us a breakdown of that and of what the situation is with dental health services because I want to try to understand what has happened. I think I have discussed this before with Ms Kennedy and with Des O'Flynn. We do not have a service in some of the counties so I want to try to understand what is happening in between. I ask Ms Kennedy to send me that information as a starting point.

Ms Anne Kennedy

Which years? Is it 2021 and 2022?

Chairman

The figures I have are for 2019 but I would like an update on the situation in 2022 on the budget across those three areas, including nationally, with the breakdown for CHO 8 and a further breakdown for counties Laois and Offaly.

Ms Anne Kennedy

We will do that.

Deputy Catherine Murphy

I invite Mr. Reid to respond to the question I asked.

Mr. Paul Reid

I thank members for their kind comments. I hope they have seen, from myself and the teams who come in here regularly, full respect for the parliamentary process, the Oireachtas committees and the Committee of Public Accounts. We spend a lot of time researching for these meetings and we do not always have the individual answers for specific areas but we spend a lot of time paying due respect for the roles members play in Oireachtas committees. The Deputy's question was what would my passing comment be to, in this case Stephen, who will take up the acting role. It would be that it is all about the services. We cannot ever forget everything we do every day, no matter what roles we are in. We have to ask if we are adding value to the people who use the services. If we are not adding value then we are not doing our jobs.

Chairman

I want to acknowledge the work done over the last three and a half years. I thought it was longer since Tony O'Brien went but it is not, although it seemed like it. I acknowledge that and that Mr. Reid was there during a difficult period. Covid was a wartime case and it was very difficult.

There were many needs that had to be met very quickly.

Major reforms of the health service are necessary, but there is something that I find frustrating. I am sure other public representatives and people in the HSE do as well. We have a substantial budget, one that is rightly increasing again this year, and it will be voted through by the Oireachtas, but the services at the far end of that process are what count. When we meet HSE management, we get long-winded answers. While I understand it is a complex process, we must try to move to a situation where the public can see that we are actually providing a budget, given that, although it is larger than other European countries' health budgets, some services at the other end of the process are very weak. Good work is being done within the HSE, but there is room for improvement. The health service will never be perfect. I acknowledge the work that Mr. Reid has done. I hope that, if we pursue Sláintecare, we will move towards a better and fairer system of healthcare delivery over the coming years.

I wish Mr. Reid well in whatever position he takes up. I am sure he is not going away.

Mr. Paul Reid

Throughout Covid, it has been the 140,000 staff working in the HSE who have got us through Covid. I played one part in that, but it has really been about everyone else.

Chairman

I acknowledge that. The staff's work on vaccinations has been successful.

I thank the witnesses from the HSE, CHO 4 and CHO 8 for attending. I thank the Comptroller and Auditor General, Mr. McCarthy, and his staff, including Mr. John Crean, for providing information and assistance for this meeting. Is it agreed that the clerk will seek any follow-up information and carry out any agreed action? Agreed. Is it also agreed that we note and publish the opening statements and briefings provided for today's meeting? Agreed.

The committee will resume in private session at 1.30 p.m. before moving into public session shortly thereafter to deal with correspondence and business of the committee.

The witnesses withdrew.

Sitting suspended at 12.52 p.m. and resumed in private session at 1.30 p.m.