COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 6 Oct 2022

Health Service Executive - Financial Statements 2021 (Resumed)

Mr. Stephen Mulvany (Interim Chief Executive Officer, Health Service Executive) called and examined.

Chairman

I welcome everyone to the meeting. Apologies have been received from Deputy Munster. If attending in the committee room, which everyone is this morning, 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, which I hear is back again. 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.

We engaged last week with the Health Service Executive to examine, in the context of its 2021 financial statements, mental health-related expenditure in community health organisations, CHOs, 4 and 8. This morning we will examine the HSE's 2021 financial statements in more detail, including expenditure on ambulance services.

We are joined in the committee room by the following officials from the HSE: Mr. Stephen Mulvany, interim chief executive officer; Mr. Damien McCallion, chief operations officer; Ms Mairéad Dolan, chief financial officer; Mr. Robert Morton, director of the National Ambulance Service, NAS; and Professor Cathal O'Donnell, clinical director of the NAS. We are also joined from the Department of Health by Mr. John O'Grady, principal officer, and Mr. Keith Comiskey, principal officer. The witnesses are all welcome. 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, witnesses are expected not to abuse that privilege and it is my duty as Cathaoirleach to ensure that privilege is not abused. Therefore, if their statements are potentially defamatory to an identifiable person or entity, I may direct witnesses to discontinue their remarks. It is imperative that they comply with any such directions.

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. The Comptroller and Auditor General, Mr. Seamus McCarthy, introduced the HSE's 2021 financial statements at last week's meeting. This is on the record and was circulated to members. Before we proceed, I ask the Comptroller and Auditor General if he wishes to add to his opening remarks from last week.

Mr. Seamus McCarthy

Thank you, Chair. I have nothing further to add.

Chairman

I welcome Mr. Mulvany back to the committee and I wish him well in his new role. He is back in a different position today. We might say he is in the hot seat. It is detailed in the letter of invitation that he has five minutes for his opening statement.

Mr. Stephen Mulvany

I thank the Chair and members for the invitation to attend today’s meeting to discuss expenditure on emergency services, particularly ambulance services, in the context of the HSE's financial statements 2021. The Chair has identified the colleagues who are here and introduced them so I will not repeat that. As requested by the committee, we submitted in advance of today’s meeting a briefing note that provides information and a detailed breakdown of HSE expenditure on the NAS. At last week’s session, we provided in the opening statement an overview of the annual financial statements for 2021 and the financial outturn. I will therefore confine my opening remarks today to the following matters.

The NAS operates from over 100 locations throughout Ireland and its services are delivered by over 2,000 staff members. The NAS operates under the HSE’s performance accountability framework, which sets out the means by which the service is held to account for its performance in relation to access to services and the quality and safety of those services. The clinical governance of NAS is provided by a full-time clinical director who is supported by a number of other senior clinicians. The NAS received a budget allocation for 2021 of €202.1 million, representing approximately an 8% increase when compared with 2020. The actual expenditure for 2021 was approximately €202.9 million, which included Covid-related services.

This expenditure saw the NAS responding in 2021 to over 366,000 emergency 999 and urgent calls; transporting approximately 24,000 intermediate care patients; more than 1,000 aero-medical and air ambulance calls; 2,047 calls via the NAS critical care retrieval service; and the delivery of mobile swabbing and vaccination services in relation to Covid. Other key activities progressed in 2021 included implementation of the out-of-hours cardiac arrest strategy; continuing development of alternative care pathways - hear and treat or refer and see and treat or refer; a new service commencing in Connemara; supporting implementation of the strategy, a trauma system for Ireland; and improvements to the NAS critical care and retrieval service for adults, children and neonates.

As of August 2022, NAS expenditure is in the order of €131.7 million against a year-to-date budget of €133 million. The full year allocation of budget for the NAS is of the order of €202.6 million.

Based on the outputs of a capacity and demand analysis commissioned in July 2021 and new developments set out in the NAS draft strategic plan, the current NAS workforce plan recommends 2,161 additional staff across a broad spectrum of roles that would be required to meet the future needs of the service. Given the scale of workforce growth required over the coming years, it is expected to take up to ten years to effectively double the workforce.

In 2022, 62 graduate paramedics have commenced work and the NAS expects to recruit up to 180 student paramedics and 90 emergency medical technicians by year end. For 2023 recruitment planning, a submission has been made to recruit up to a further 192 student paramedics across NAS programmes starting in January and September 2023, as well as growing educational capacity by opening a fourth campus in 2023 in the south of the country. In addition, in 2023, recruitment competitions are planned for 50 medical emergency controllers and 25 intermediate care operatives.

Last winter, the NAS put in place a capacity action plan which sought to engage with all of the capacity that is available in Ireland, including remobilising all of the community first responder schemes that had unfortunately been stood down in March 2020 due to the Covid pandemic. The service engaged with voluntary ambulance organisations and the private ambulance sector as part of the contingency plan for winter.

The HSE continues to invest and develop our urgent and emergency care systems. There was significant investment in capacity and people in the past 18 months. We are in the process of preparing the national service plan, which will include the NAS plans for 2023.

Despite the challenges of recent years, the continued investment by Government in the HSE in the National Ambulance Service is contributing to progress on the shift to reorient healthcare away from a hospital-centric model. Recent measures are particularly evident within the NAS in the areas of ehealth, telemedicine, and community-delivered care and service integration, that is, community paramedicine, pathfinder programmes and alternative pre-hospital pathways. The NAS is currently finalising a strategic plan for the service that will provide a roadmap for the continued development and enhancement of the service.

Deputy Matt Carthy

I welcome Mr. Mulvany and his colleagues. I just want to touch briefly on the cyberattack of last year and specifically the individuals whose data may have been exposed. Have they been informed by the HSE that their data was incorporated into that?

Mr. Stephen Mulvany

In my first address as CEO, it is important that I acknowledge all the hard work of all the healthcare and social care services staff across the system during both Covid and the criminal cyberattack.

On the Deputy’s point, as I understand it, there is a significant volume of work that is progressing so we that can get to the point where we can appropriately communicate with those individuals who need to be communicated with. We are very anxious to do so in a way that does not cause unnecessary upset. We are conscious that it is taking longer than people might expect. However, the volume and complexity of what we are dealing with is substantial. We are engaged with the Government data protection officer, DPO, to make sure that we are seen to and are doing this in an appropriate way. I do not believe, specifically, we have made any direct contacts yet with individuals around the data. However, I understand that is in the near future. As I said, it is a complex task to be approached appropriately.

Deputy Matt Carthy

What is the near future? Is that days, weeks or months?

Mr. Stephen Mulvany

I think it is in the coming months. I can get the Deputy an update on that; I do not have the specific detail as to when that process will compete. However, as I said, it is a process that we are heavily engaged in and investing in. We are also making sure that we are engaged with the DPO on it.

Deputy Matt Carthy

Mr. Mulvany mentioned a complex process. I do not think anyone would dispute that. We can all appreciate that would be the case and that a number of steps will need to be taken in response to it.

My difficulty is getting an understanding of what step is informing those people whose data may have been exposed. It clearly was not the first or even the second. Where down the line is it? What does Mr. Mulvany envisage has to be done before we get to the point where people who are affected are informed?

Mr. Stephen Mulvany

It cannot be the first or the second step. There are a number of steps to be gone through in assessing the data. Does Mr. McCallion want to comment?

Mr. Damien McCallion

I can add to what Mr. Mulvany said. We stood up a team who will be making contact with people, so all of that part of it is in place. The scoping out of those who need to be contacted is what is being closed off at the moment. As the Deputy said, it is complex in relation to just being precise about who needs to be contacted following the attack. As he can imagine, trying to work that through is complex. That is the piece that is being closed out at the moment. In addition, there are ongoing discussions with the DPO and others just to make sure that the process is fully robust and when we start that process off, it is clear in how we deal with people who may concerned as a result of it. It is, as Mr. Mulvany said, getting closer, but there are just a number of final steps around that scoping and making sure we are clear what that contact is. The teams have been stood up and are ready to move once we need to move. We utilised some of the resource that we had in the pandemic in terms of contract tracing. We reassigned some of those people so that we will have a team ready to go once we clarify the scope of it and some the legal and other data protection issues.

Deputy Matt Carthy

As the HSE gets close to clarifying the scope of it, what is the estimate at this stage of the number of individuals who will have been affected?

Mr. Damien McCallion

I do not have a final figure on that at the moment. That is still a work in progress. There are decisions to be made on some of the groups. I do not want to throw out a number that is not correct. We are trying to finalise that. However, it is a substantial number of people who will need to be contacted.

Deputy Matt Carthy

Are we into the tens of thousands?

Mr. Damien McCallion

I do not want to get into trying to speculate on the numbers to be honest, because it is just that we do not have that final picture until we finish the process.

Deputy Matt Carthy

I assume that if the teams are put in place to contact all of these people, there would need to be some form of an idea as to how many people they would be expecting to contact.

Mr. Damien McCallion

We set up a certain level of the team, but because the contact tracing clearly has gone down, those people are also doing other activities as well. We can redeploy people to that to strengthen it up based on what the final numbers will be.

Deputy Matt Carthy

On the self-declared risk rating, it is essentially up to the HSE to categorise the associated risk in terms of the exposure. Have any or all of those who have been affected been rated at this point?

Mr. Stephen Mulvany

That process is under way and nearing conclusion. It is self-declared but there is a pathway one has to follow. As I said, we have to follow that and we are in conjunction with the data protection officer. It would not be appropriate at this stage to comment on what those ratings are. That information will be available in the future.

Deputy Matt Carthy

In respect of the National Ambulance Service, Mr. Mulvany’s briefing indicated that the NAS budget in 2021 was €203 million. Was the outturn in line with that?

Mr. Stephen Mulvany

Broadly. Other than Covid costs, yes.

Deputy Matt Carthy

What were the corresponding figures in 2019 and 2020?

Mr. Stephen Mulvany

I do not have those with me. I am not sure whether my colleague, Mr. Morton, has them.

Mr. Robert Morton

It was approximately €8 million less than the previous year.

Deputy Matt Carthy

In 2020.

Mr. Robert Morton

Yes, in 2020. I do not have 2019's figure.

Deputy Matt Carthy

Okay. Does Mr. Morton have an expected figure for 2023?

Mr. Robert Morton

Not yet. The Estimates process is still ongoing.

Deputy Matt Carthy

Why did the HSE annual report and financial statements not contain financial information relating to the expenditure of the NAS?

Mr. Stephen Mulvany

The format of the annual financial statements, AFS, is set out in the accounting policy set by the Minister. They detail the kind of costs that the organisation experiences. There is an element in them and also in the annual report of which they form a part that shows larger care groups and it will show acute hospitals and national ambulance services. That type of detail is not published in the AFS as it is not part of the policy. However, in our monthly performance reports, which are published quarterly, that information is available, and we can make that information available.

Deputy Matt Carthy

Is it the intention to incorporate those figures specifically into the financial reports?

Mr. Stephen Mulvany

As it is, the monthly financial reports incorporate those figures and they are published quarterly, typically. The AFS follows a certain format that has been set out by the Minister. Unless the Minister chooses to change it, it will not change. We provide supplementary information within the annual report, of which the AFS is part, and we can certainly look in the future to calling out ambulance service financial information. I am fairly sure there is ambulance service activity information in a section on the ambulance service in the annual report.

Deputy Matt Carthy

In respect of the fleet, what is the number of ambulances under the auspices of the NAS?

Mr. Robert Morton

At the moment, there are 577 vehicles. Of that number, approximately 340 are emergency ambulances. The balance is a range of other vehicles, including intermediate care vehicles that are used for interfacility transfers and rapid response vehicles.

There are 90 specialist vehicles or specialist equipment carriers, most of which were procured during the Covid period. These are the vehicles that set up mobile swabbing and vaccination centres and so on. That is the overall breakdown but in terms of the number of emergency ambulances, we have about 340.

Deputy Matt Carthy

That is the figure for the ambulances as we all would know them. On what basis are they distributed nationally? Where would they be based predominantly? Are they allocated on the basis of hospital, CHO region or county?

Mr. Robert Morton

In general terms, we have about 104 locations around the country which are effectively the starting and finishing points for ambulance crews, where they would park their cars, hang up their coats, pick up a vehicle and so on. After that, for the duration of their shift, they are a mobile resource. The aforementioned locations are reporting posts. Essentially, the allocation of vehicles is based on the shift patterns in each location and those shift patterns are determined by local demand. If we take the example of Letterkenny, there might be four crews while in Cavan, Monaghan there might be three crews. The vehicles are assigned based on the workload demand and the rostering demand, with a view to making sure that there is always latent capacity of about 40%. Of the 340 vehicles we have, there would not be any more than 180 or 190 in use at any given time. That is to make sure there are sufficient vehicles available for the oncoming crews. The oncoming crews need separate vehicles and we also have to have backup vehicles available.

Deputy Matt Carthy

What is the breakdown of the age profile of those emergency ambulances?

Mr. Robert Morton

At the moment the average age of the fleet is three years. That compares very favourably with 2011, for example, when the average age was 11 years. There has been tremendous investment in the fleet. This year we will spend €20 million on the fleet and equipment. The oldest vehicle on front-line duty is five years old but the average age of the fleet is three years.

Deputy Matt Carthy

There is no ambulance in the fleet that is more than five years old. Is that correct?

Mr. Robert Morton

Not on the front line. There might be some reserve vehicles that are older but they would be rarely used and would be approaching decommissioning. Our fleet replacement policy is five years and/or 350,000 kilometres, whichever comes first. That is with a view to performing preventative maintenance and making sure that we reduce, if not eliminate, the prospect of breakdowns.

Deputy Matt Carthy

I thank Mr. Morton for that. My next question is for Mr. Mulvany. In terms of staffing cohorts, there was workforce review in June which set out a requirement for a net additional 1,317.5 whole-time equivalents by the middle of 2024. On the current trajectory, we are nowhere near reaching that. Is that correct?

Mr. Stephen Mulvany

In the context of the ten year plan or the five to seven year plan, it may take us eight to ten years to get to the required level. The aim is to double the ambulance service staff overall. A lot of work is going on in that regard, some of which I listed, in terms of being able to increase the placement of staff in training. Mr. Morton will provide specific details on progress to date.

Mr. Robert Morton

The workforce plan that was shared in June outlines the need for standstill recruitment but also new development recruitment. The capacity review highlighted the fact that we have a huge capacity gap but we already knew that. Indeed, that is on the record of this committee from September last year. Colleagues discussed that at committee at the end of September 2021. Essentially, the capacity plan is telling us that from a core ambulance perspective we need 2,161 additional staff by 2028. Ideally, we-----

Deputy Matt Carthy

Sorry, but could Mr. Morton repeat that please?

Mr. Robert Morton

We need 2,161 additional staff by 2028. That is what the capacity review is telling us. That also includes a number of new service developments that will be focused on preventing many patients from needing to go to hospital, particularly older, frail patients. We are developing a lot of services to treat patients at home and some of those have been mentioned-----

Deputy Matt Carthy

I am sorry to interrupt but is that a gross figure that Mr. Morton quoted?

Mr. Robert Morton

Yes, that is a gross figure. That is new growth. That is not to stand still. In addition to the 2,161 growth figure, we also need to recruit 854 posts just to stand still. That is to allow for retirements, resignations, internal movements-----

Deputy Matt Carthy

The overall figure is around 3,000 then. Is that correct?

Mr. Robert Morton

The overall figure is 3,018 by 2028.

Deputy Matt Carthy

Last year, for example, the figures I have indicate that 70 staff were added-----

Mr. Robert Morton

That is right.

Deputy Matt Carthy

There is a requirement for much greater improvement-----

Mr. Robert Morton

Yes, absolutely. This year we have ramped up recruitment explicitly. There has been a massive public campaign with a particular focus on student paramedics and intermediate care operatives. That has been very successful. We started three groups of 30 student paramedics between 6 September and 19 September and we will start three more groups on 19 December as well, with a view to them commencing the degree programme in January. As the CEO has mentioned, we have a finite capacity for placements in education at the moment. In his opening statement the CEO mentioned the fact that we want to develop a fourth educational campus. At the moment we educate paramedics in Dublin, Ballinasloe and Tullamore but over the next three years we propose, subject to Estimates, to expand that capacity into Wexford, Cork and Sligo so that we can effectively double our educational capacity to meet the future workforce needs.

Deputy Matt Carthy

I ask Mr. Mulvany to give me an update on the big debate we have all been having on ICU beds. We all became experts in the preferred number of ICU beds for a population of our size and it was broadly accepted that we were nowhere near the level that would be required when the coronavirus pandemic struck. If we were to face another similar pandemic, would we have enough ICU beds in place?

Mr. Stephen Mulvany

The Deputy is absolutely right. We did not have enough ICU beds but thanks to the significant investment in permanently strengthening the health service in recent years, we have increased that number. We are still hovering at just under 300 ICU beds which is not enough. We know that. We need more beds than that and it is our intention to put in place the infrastructure and train and recruit the very specialised staff that we need as quickly as we can. In fairness to the Government, we have been supported to do that in terms of new service developments, including in ICU. In the last three years about €1.7 billion worth of investment has been made and we are working hard to recruit all of the extra staff----

Deputy Matt Carthy

Did Mr. Mulvany say €1.7 billion?

Mr. Stephen Mulvany

Yes, €1.7 billion on what we call new service developments. That is separate to the cost of standing still and separate to Covid. In 2021, 2022 and 2023, the figure is about €1.7 billion for new service developments. That is the support the Government is giving the health service and the staff in the service. We-----

Deputy Matt Carthy

That is a lot of money.

Mr. Stephen Mulvany

Yes, it is.

Deputy Matt Carthy

In September 2019, before any of us had ever heard of Covid or corona viruses, the ICU bed numbers were 255. It is hard to believe that we have come through the past two and a half years, an additional €1.7 billion has been provided and we still have fewer than 300 ICU beds.

Mr. Stephen Mulvany

My colleague might have more detail but I would point out that the €1.7 billion was across a range of capacity-----

Deputy Matt Carthy

I understand that.

Mr. Stephen Mulvany

This is a particularly complex piece of capacity to put in place. The increase is north of 25% or 30%. That is nowhere near what is required and that point is accepted. Mr. McCallion will elaborate further.

Mr. Damien McCallion

We plan to have over 300 ICU beds by the end of the year. A key point about ICU beds is their very high staffing requirement and the very high skills requirement, alongside the physical requirements. Tallaght opened recently and other centres are being opened but staffing is crucial to that, in terms of training people. In parallel with the infrastructure and the capital, there is also work on the staffing side but we aim to be over 300 soon. We will definitely be over 300 by the end of year.

Chairman

Deputy Devlin is next.

Deputy Cormac Devlin

I welcome Mr. Mulvany. I want to stay with the National Ambulance Service because it has formed the main part of our questioning today. My question may be most appropriately directed to Professor O'Donnell. In the Dublin metropolitan area, there is obviously cover from the National Ambulance Service as well as the Dublin Fire Brigade. However, there is an anomaly in CHO 6 or the south-east area, where there is no paramedic cover by the Dublin Fire Brigade. What is being done to rectify that particular issue?

Professor Cathal O'Donnell

The Deputy is referring to cover in which area?

Deputy Cormac Devlin

In CHO 6, the south-east area.

Professor Cathal O'Donnell

We work very closely with Dublin Fire Brigade and together we provide ambulance services in the capital. It has its very distinct geographical catchment area and we have ours. Obviously, that crosses over quite a bit. There is an issue around call taking and dispatch that is ongoing and about which we have concerns. I do not have responsibility for the specifical geographical operations. My colleague, Mr. Morton, may have more information on that.

Mr. Robert Morton

In south county Dublin, we have a large ambulance station in Loughlinstown. That station provides most of the services in that area on behalf of the National Ambulance Service but as Professor O'Donnell said, we also work very closely with Dublin Fire Brigade.

There is a lot of blurring of boundary lines and interactivity on a daily basis. We speak to colleagues in the Dublin Fire Brigade usually at around 3 o'clock every day. There is a pass-over of calls and a checking-in with one another to see who has capacity and then the sharing of resource where possible.

Deputy Cormac Devlin

That works really well across the rest of Dublin, but there is an anomaly in the catchment area of Dún Laoghaire-Rathdown where there is no additional cover. If a person suffers a stroke or is involved in a car accident or, God forbid, some other sort of incident anywhere else apart from the Dún Laoghaire-Rathdown area, they have dual cover under the NAS and the Dublin Fire Brigade. Both resources can be called on at any given time. I understand this has been rumbling for a number of years but where does the HSE stand on resolving this? There is not the same equitable service in the Dún Laoghaire-Rathdown area as there is elsewhere in the Dublin region. It is an anomaly that has been ongoing for a long time. Does the HSE have an update on this?

Mr. Robert Morton

I guess you could probably say the same about the rest of the country. The rest of the country has one ambulance service as does south county Dublin. The longer-term plan, from a capacity development perspective, is to relocate Loughlinstown ambulance station. Where it is currently, it is hemmed in by residential growth. There is a need to grow services and capacity in the south Dublin area. We have a significant growth pattern in Bray, an area that is often served by the Loughlinstown station. We are planning to have new capital development somewhere at the bottom of the M50 area in which to grow services in that whole area generally. We have a range of services operating there, including pre-hospital emergency care services and intermediate care services, as well as a motorcycle response unit. By way of a support to the services in south county Dublin, as St. Vincent's is a model of a large tertiary receiving hospital, many of our resources that will feed into St. Vincent's will often respond to calls while travelling back down the N11. There is a longer-term plan on the part of the NAS to grow services in the south county Dublin.

Deputy Cormac Devlin

That worries me more now that Mr. Morton said that the ambulance base in Loughlinstown will be relocated. That will leave the Dún Laoghaire-Rathdown area with one service whereas the rest of Dublin enjoys two services. As I do not have enough time to delve into it today, I ask him to send on a note on the future plans for the NAS in the Dublin region, specifically the south-east area.

I refer to an issue relating to the 2021 statement that also relates the 2020 financial statement, which is the storage of protective suits. The figure of €1.25 million spent on the storage of those suits jumped out at me. I understand from reading the documents that some of these suits will not even be used. Why was the HSE not able to store those itself? Why would it incur such a cost?

Mr. Stephen Mulvany

I will give a bit of the background first. The Covid pandemic was the equivalent of a global storm and, as we know, after every storm there is an element of a clean-up required. The volume of personal protective equipment, PPE, in storage was immense to the extent that we had to contract significant additional external storage to manage the logistics around it, which was essential in keeping staff at work and keeping them as safe as we could. I again acknowledge that staff put themselves in harm's way, in many cases. The reason we ended up with so many protective suits was because of that particular time. It should be borne in mind that most decisions around purchasing PPE and ventilators, etc., were made in March and April 2020. As we sit here today behind a wall of vaccines, we all feel somewhat different about things now compared to how we felt then. Back then, we did not know if vaccines would be available and, if they were, when they would be provided. Europe was identified as the centre of the pandemic in March 2020. That is not an excuse; that is by way of context.

Deputy Cormac Devlin

I appreciate that.

Mr. Stephen Mulvany

Typically, we would not have bought protective suits. We would have bought a different type of full-bodied gown. At the time they were not available, these protective suits were acquired at a significant cost, as everything was at that point. Subsequently, we acquired the appropriate gowns. We have not had a use for these and have had to store them. We have been seeking an appropriate alternative use for them, which has proven more difficult than we would have expected. We have ended up having to store them at a cost. More recently, we have rationalised the storage bringing more of it in-house. We are storing less of it. We are using less PPE and can move it on. This is one of those legacy issues that we have not fully closed out and we need to do that, which we accept.

Deputy Cormac Devlin

Staying with that point, Mr. Mulvany mentioned ventilators. The figure of €42.5 million was provided for the procurement of ventilators, and according to the financial accounts of 2021, I understand €12.1 million of that amount was recovered. How is the recovery of that money proceeding?

Mr. Stephen Mulvany

In summary, we paid out a total of approximately €103 million on ventilators, €81 million of which was for new suppliers. The amount between the €81 million and €103 million was paid to normal suppliers through normal delivery with an average price of €37,000 or €38,000 in line with sanction. Most of the ordering decisions were made in March and April. We deliberately ordered more than we needed on the basis that it was the only way to get them.

Deputy Cormac Devlin

Of course.

Mr. Stephen Mulvany

Without getting into the eBay-style bidding-war comments, we paid out - again unusually but that was the way it had to be done - €81 million to new suppliers. To date, we have received value on just over €50 million of it, approximately 60%. We have either got a refund or, in one case, we received PPE to the value. Of the rest, we have not got value for approximately 10% and we will not get direct value for the health service. That amounts to approximately €8 million. Some €6.6 million of where we have not got direct value, we donated to five large medical schools in India and they have certainly got value out of it. However, we accept it was not a direct value to the Irish health service.

The balance is approximately €22 million, half of which we now have in payment plans or we are looking to finalise payment plans where we have gone through a legal or an arbitration plan or a bit of both. Of the remaining €10 million, we are about to enter a legal arbitration process. We think our case is good. We have to win the arbitration and then get a payment plan. We are not saying we will get that €22 million but we are pursuing it in the interest of the State.

Deputy Cormac Devlin

I have a little over a minute left and will have a rapid-fire question section. I refer to the annual report and appendix No. 4 starting on page 100. The second MRI machine for St. Vincent's is extremely welcome and it is good to see it included under the projects completed and operational by the end of 2021. I was struck by a completion delay until after 2021. The report refers to a lease agreement for a primary care centre. My understanding was that the HSE owned many of the sites in the community healthcare organisation, CHO, 6 area, but it states that it is by lease agreement on page 102. I do not expect Mr. Mulvany to have that information to hand, but he might furnish that to the committee after today's meeting.

Page 103 refers to the National Rehabilitation Hospital, which is based in CHO 6. Phase 1 is complete while phase 2 is ongoing with discussions under way between the Department of Health and the HSE. I also note there was a 35-bed unit with possible use by acute services, which does not fall under phase 1 or 2. It is welcome nonetheless. I ask that information on that be furnished to the committee. It relates to the refurbishment of an existing vacated building.

I refer finally to appendix No. 5 on page 106 of the annual report. It struck me that the attendance of members at some of the subcommittees is quite low. What will be done about that? Is Mr. Mulvany satisfied with the attendance of the members of the committees, including the audit committee and the performance and delivery committee and others? If not, what will be done to rectify that?

Mr. Stephen Mulvany

We will get the Deputy the information on leases. We buy them, we build them and we lease them. We also have public-private partnership arrangements with them. We will look into the piece about the hospital.

The page numbering must be different in the document I have. The committees are committees of the board and their operation is a matter for the board. The committee meetings I attend are well-attended-----

Deputy Cormac Devlin

Yes, some of them are.

Mr. Stephen Mulvany

-----and do good work. I do not have the page number the Deputy was referring to.

Deputy Cormac Devlin

Page 106.

Mr. Stephen Mulvany

I am looking at that page. Is this from the 2021 report?

Deputy Cormac Devlin

Yes. Mr Mulvany can come back to me on that. It struck me that some of the meetings were under attended.

Mr. Stephen Mulvany

In a number of cases, it is not that there is low attendance but that the membership is changing.

Deputy Cormac Devlin

I saw that in one or two of them, but some of them were quite low. It is something to take note of. There was one where the attendance was ten. There was one with two. That was a resignation, I understand, after a short period on the board. There was another where the average was seven and the attendance was four. A number of them seem low. If there are members of the committees-----

Mr. Stephen Mulvany

We will get the Deputy a note but I do not believe any of them indicate low attendance.

Deputy Verona Murphy

Who is addressing the National Ambulance Service on the team?

Mr. Stephen Mulvany

I will start and my colleagues will come in as needed.

Deputy Verona Murphy

No bother. Will Mr. Mulvany clarify whether it is myth or fact that the NAS sends two ambulances to callouts in case one breaks down? Does that ever happen?

Mr. Stephen Mulvany

The simple answer is not in case one breaks down, but they will often send more than one response vehicle. Mr. Morton might comment.

Mr. Robert Morton

It is a myth, not a fact. If we send two vehicles, it depends on the clinical criteria of the call. In the case of a cardiac arrest, for example, we send two resources as a matter of clinical requirement, to make sure there are three to four practitioners or responders on scene. That is the only circumstance where we send two vehicles. We never send two vehicles because of a mechanical issue.

Deputy Verona Murphy

I am glad to clarify that because it seems ridiculous but that is what is said. Page 94 of the HSE annual report has a national scorecard on key activities for 2021. As set out in that scorecard, can the witnesses provide detail on why the targets relating to ambulance response and turnaround time were not achieved?

Mr. Stephen Mulvany

Overall, the answer is we do not have sufficient capacity yet. I do not mean to say these are gold standard targets, but these are the targets we aspire to and we need to increase capacity to make that a practical reality.

Mr. Robert Morton

That is basically it. Delivery of targets is a feature of a match between capacity and demand. Demand far exceeds capacity and, therefore, we are not able to meet the targets. On the 19-minute target, there is a growing question mark about the relativity of those targets.

Professor O'Donnell is developing the realm of clinical key performance indicators, KPIs - in other words patient outcomes. I will give a brief example to articulate that point, then hand over to Professor O'Donnell. For a patient in Dingle who experiences a stroke, the nearest ambulance is Dingle ambulance station but that ambulance might be dropping off a patient or en route to Tralee, as the main receiving hospital. The ambulance will not get there in 19 minutes because it is at the end of a peninsula but, in real terms, that will not change the outcome for that patient. The target is 19 minutes but the key target for that patient is to get to a hyperacute stroke unit within four and a half hours of the onset of symptoms. We are moving to a clinical, rather than response-time, way of thinking about it. That is not just in Ireland, but in a general global setting. I ask Professor O'Donnell to comment on the development of alternative KPIs.

Professor Cathal O'Donnell

I thank the Deputy. It is a good question. Ambulance response time targets are a blunt instrument for measuring the capability of an ambulance service. They are easily understood, intuitive and make sense. If I dial 999, I want an ambulance to come quickly. That is reasonable, but a 19-minute response time over the breadth of clinical presentations we see often does not impact on patient outcomes. From a clinical perspective, we are more interested in how we can improve the patient's acute healthcare need there and then. We send two highly trained clinicians on a call. If they get there within 19, 20 or 15 minutes of a person having a heart attack or stroke or with a broken leg, that is a blunt instrument in measuring success.

We currently measure four clinical KPIs. There is cardiac arrest, when your heart stops. We measure the proportion of patients we get to an emergency department where we have restarted the heart prior to arrival. That is one point on that patient's clinical journey. We compare favourably internationally on that one. This year we have introduced three new ones. Two are related to stroke care, which Mr. Morton mentioned and which are very important. One is on pain relief. If you are in pain and we come out to you, how good are we at relieving your pain? We have a further suite of these that we will continue to add to in the coming years.

Deputy Verona Murphy

Relative to the HSE's 2021 data, how does it compare in 2022? Is it better or worse?

Mr. Robert Morton

Is that in terms of the clinical KPIs? The long-standing one is cardiac arrest. We had a dip during Covid for a lot of reasons. People did not call 999 as much. They were afraid of going to hospital and waited before they called us.

Deputy Verona Murphy

No. How is the NAS performing in 2022?

Mr. Robert Morton

There was a dip in Covid but we are back up again. We are getting back up to where we should be. The dip was small.

Deputy Verona Murphy

When Mr. Morton says the dip was small, what does he mean by that?

Mr. Robert Morton

Our target for return of spontaneous circulation on arrival at the emergency department, ROSC at ED, is 40% of the Utstein subset of cardiac arrests. We consistently met or exceeded that for many years. It fell below 40% during Covid.

Deputy Verona Murphy

What was the reason for the fall during Covid?

Mr. Robert Morton

There were a couple of things. We went back and looked at this. International experience was similar. First, people were slower to call 999, particularly in the early stages of Covid. They did not want to go to hospital because they were afraid. They had a pain in their chest and stuck it out. That was a bad decision for them and it went on. In the early stages of Covid, crews had to put on PPE on arrival at scene. That took time

Deputy Verona Murphy

So it was all of those-----

Mr. Robert Morton

There were a number of factors that contributed.

Deputy Verona Murphy

-----that we do not any longer have, so there should be an improvement.

Mr. Robert Morton

Broadly speaking, that is correct.

Deputy Verona Murphy

I have a question for Mr. Mulvany on the MRI scanner for Wexford. When is it proposed construction will start?

Mr. Stephen Mulvany

I do not have the specific detail on that. Unless my colleagues do, we will come back to the Deputy with a note on that.

Deputy Verona Murphy

I would appreciate that. There is a 96-bed unit for Wexford, which is a fairly substantial project. I assume the HSE knows when that will start.

Mr. Stephen Mulvany

I do not have specific detail.

Deputy Verona Murphy

Anybody?

Mr. Stephen Mulvany

We will come back to the Deputy on that.

Deputy Verona Murphy

Right. We touched on home care support packages last week. In County Wexford, 545 people are approved for home care support service but have not yet been given it. How is that being tackled?

Mr. Stephen Mulvany

In general, the progress we have made in getting more funding for home care has been substantial in recent years.

Deputy Verona Murphy

What did Mr. Mulvany say? I did not hear correctly.

Mr. Stephen Mulvany

We used to be here and before other committees talking about the fact we had a lack of funding for home care and could not provide enough. We still have a problem but we have a different problem. The problem has moved to not being able to recruit enough staff. We are focused on that. We employ approximately half the staff in home care and the rest are in voluntary and private organisations. There is a shortage of those staff. We are working with those agencies on how to make it a more attractive profession, improve the continuity of staff-----

Deputy Verona Murphy

How long has the HSE been doing that?

Mr. Stephen Mulvany

Three years ago, we had a budget of approximately €430 million for home care. It is touching €700 million this year. It is only in the past two or three years, coming across Covid. 2021 was the big year for investment so we have not yet been able to catch up and grow the level of people willing to be home carers. It is a hugely important service.

Deputy Verona Murphy

Can Mr. Mulvany see an end to it? That is a huge number - 545 in Wexford alone.

Mr. Stephen Mulvany

It is and it will be-----

Deputy Verona Murphy

These are vulnerable people. A system was set up to keep them out of nursing homes because the understanding is people are better off at home, but the service cannot be delivered.

Mr. Stephen Mulvany

Totally. We want the route of home, or home and support, to be chosen before the route to nursing homes.

Deputy Verona Murphy

Is there any methodology relating to critical skills or are home care support services left with the national workforce? Does the HSE not look outside?

Mr. Stephen Mulvany

Most of the advertising and the way of recruiting these people will be local. We just need to figure out how to make it a more attractive profession overall for people we directly employ and people employed by the private and voluntary bodies.

Deputy Verona Murphy

I am at a loss. I get it but I have been getting it every time I have asked the question for the past number of years and the situation is not improving. I speak to people who have left the service. They were not asked why or they have gone to private service, which is doing the same thing - supplying the service to the HSE - but they are being paid more.

Mr. Stephen Mulvany

It is likely that the staff are coming from voluntary or private bodies to the HSE rather than the other way round. Which is the predominant service depends on the part of the country. It is about half and half-----

Deputy Verona Murphy

It does not seem like the HSE has a solution to the problem and if it does, it is not working.

Mr. Stephen Mulvany

We do not yet have a solution to the problem. It is not a difficult market to get into. The training levels are not overly substantial. There is a particular type of work and we want a particular type of person who will go into that caring profession. Yes, we have not yet cracked it and we know we need to do so because that is a very important area.

Deputy Alan Dillon

I will start by looking at the HSE high earners review. Perhaps Mr. Mulvany can explain the issues discovered by the internal audit of the high earners review in the HSE.

Mr. Stephen Mulvany

I might call in my colleagues. A number of reviews were carried out as part of the high earners review. Our audit and risk committee sought some extra assurance around the area of high earners. It looked specifically at the top of the organisation and found no issues in terms of high earners. When we look across the organisation, and we looked at salaries over €300,000 that go across services and in fairness, relate mostly to consultant staff, we found some issues. It is important to provide some context before we get into any of the detail.

Deputy Alan Dillon

What type of issues were found?

Mr. Stephen Mulvany

I will discuss the context first and then address the issues. We have very able and dedicated consultants. We know we do not have enough of them and that in certain parts of the country, it is very difficult to recruit them, particularly in certain types of hospitals where services may be under pressure. In order to keep services going, local services will sometimes end up making local arrangements.

Deputy Alan Dillon

I am short on time so I just want to know what type of issues were found.

Mr. Stephen Mulvany

Apologies - a number of issues were around those local arrangements and whether they were entirely appropriate in terms of the norms of people's attendance patterns or the total hours they were working. Often services were seeking to balance providing a service and managing patient risk with those. We have established a process to go around the country and identify and log all those practices. One of the big issues with this audit was that regarding a big chunk of what was identified, the fact was that they could not confirm whether they were appropriate or not so we are going around to identify that, log current practice, identify practice where we believe it needs to change-----

Deputy Alan Dillon

Let us get down to the figures. How many high earners earning in excess of €300,000 have been identified as being an issue within the internal audit?

Mr. Stephen Mulvany

My colleagues might answer that question.

Ms Mairéad Dolan

A total of 68 people - mainly consultants - earned in excess of €300,000 as reported in the annual financial statements for 2021.

Deputy Alan Dillon

Has the HSE associated a cost with that?

Ms Mairéad Dolan

The total cost of that is in the order of €25 million, of which about €16 million related to basic pay. The remainder involves things like overtime, on-call arrangements, allowances and rest days.

Deputy Alan Dillon

In light of this review of the individuals who earned in excess of €300,000, has the HSE reviewed individuals below that threshold or has it only identified-----

Mr. Stephen Mulvany

We are working first of all on those identified as being above the threshold remembering that a starting salary for a consultant is €150,000 to €200,000. We are seeking to identify within that cohort whether there are issues that should not be sustained and we had to figure out a different way to help services to balance the risk of service provision versus not. Our audit and risk committee is also considering in the audit plan for next year extending below the €300,000 threshold to see if there are any issues. We should not be simplistic about seeing what looks like a problem. As I said, the context behind these issues is important.

Deputy Alan Dillon

For this committee, it is important that we do get the recommendations that flow from this internal audit review. Have these recommendations been published yet? How many of them have been implemented?

Mr. Stephen Mulvany

Typically, our internal audit reports are released quarterly in arrears. If they have not been released, they will be released very soon. I think that one probably has been released and we are working on implementing its recommendations and going further. We do not want to give the impression that we are saying that our consultants generally or specifically doing anything wrong. We just need to identify where better practices might be required. We see this as a serious issue but one to approach with an acknowledgement of its complexity.

Deputy Alan Dillon

We do acknowledge that the HSE governance and internal audit system is working in this instance and is identifying issues like this. I will move on to section 38 and 39 agencies. How did they perform financially in 2020 and 2021?

Mr. Stephen Mulvany

That is a very big question. There are about 38 section 38 bodies, most of which are hospitals-----

Deputy Alan Dillon

Let us focus on section 39 bodies that provide support to intellectual disability services that complement the HSE. From its review of financial statements, does Mr. Mulvany feel that section 39 bodies are in a good financial position?

Mr. Stephen Mulvany

Again it varies. Some have small surpluses they have built over the years. Remember that there are about 2,000 organisations funded under section 39. At the top end, the organisations referred to by the Deputy are typically north of €3 million. Some of them are under financial pressure while others are under less pressure. Sometimes it relates to whether they have had to provide residential services and how they have been able to respond to regulation in recent years, which has put pressure on our own services. While we say in the first instance that it is a matter for the boards of the voluntary organisations, we are aware of our role in that too. If you look across the larger section 39 organisations in the disability sector, a number have financial issues while others are in a reasonable position or have moderate surpluses.

Deputy Alan Dillon

Recently we have seen real issues around pay parity and significant difficulties with retention and recruitment. Without these agencies, the HSE would not be able to deliver services on the ground. It is very important that we continue to support them to ensure we can deliver services locally. Western Care Association in County Mayo is a significant provider of intellectual disability services and without it, the entire service would fall to pieces.

Mr. Stephen Mulvany

I agree with the Deputy. Not all section 39 bodies are the same but as the Deputy noted, we rely on the larger organisations just as much as we rely on any of the services and they provide services as good as and sometimes better than other parts of the service. We are aware that pay parity is a very significant issue. Many of those organisations would have had links to what we call the consolidated salary scales pre-recession. We are aware of and concerned about what would be a shift from section 39 organisations to section 28 organisations that can recruit because they have the consolidated salary scale. It is not an issue we can yet solve but it is one we recognise because we do value and rely significantly on a number of those section 39 organisations.

Deputy Alan Dillon

Regarding the HSE's role in the delivery of the Covid pandemic recognition payment and not taking responsibility for the payments for section 39 organisations, where are we in terms of trying to deliver that payment? Perhaps somebody from the Department of Health could also answer that question because they were to the fore during the pandemic response.

The delay in them receiving this payment is causing huge difficulty for those people who have contacted us.

Mr. Stephen Mulvany

I agree they were to the fore. It is a question of "when" not "if". We are working the Department on this. A lot of our own staff and a lot of section 28 staff have been paid. A firm has been engaged to help us look at section 39 workers. The private nursing home sector-----

Deputy Alan Dillon

The HSE-----

Mr. Stephen Mulvany

Sorry, Deputy. There are a number of other sectors that also have to be paid out. The issue is the scale of the task to do so.

Deputy Alan Dillon

When will we see progress on this?

Mr. Stephen Mulvany

As the CEO probably said last week, the intention is to have these payments substantially made by the end of the year. I do not have the specific timelines for it but we understand our colleagues and section 39 workers need to get this recognition. We absolutely do. It is simply a question of the practicalities of it and making those payments. We appreciate the point raised.

Deputy Paul McAuliffe

To continue that line of questioning, will that also include Dublin Fire Brigade paramedics?

Mr. Stephen Mulvany

As I understand it, the fire brigade is included. The Department and the Minister intend that it will be included. It may turn out to be more practical for the Department and some of those agencies to work directly and not put them through a private process because it involves another public body as well and the HSE would not add any great value to that. I know the Minister is looking at ways to see can some of those payments, including those to the fire brigade, be accelerated.

Deputy Paul McAuliffe

There is no doubt that somebody who sat in an ambulance for those first few weeks of the pandemic, with Covid-positive patients, were at the front line and were immediately impacted by the virus. They are paid by a public body, Dublin City Council, and to my mind there should be no question but that there should be an immediate payment.

When Mr. Mulvany said "Minister", was he referring to the Minister for Health or the Minister for Housing, Local Government and Heritage?

Mr. Stephen Mulvany

The Minister for Health. He is very anxious to make sure that all those who should get the recognition get it because-----

Deputy Paul McAuliffe

I now know which of my colleagues to collar so I appreciate that.

On the broader issue of section 38 and section 39 organisations, the Comptroller and Auditor General carried out a review of governance in 2016 and the financial implications around their structure. Does the HSE believe it has the correct value for money from section 38s and section 39s?

Mr. Stephen Mulvany

It is difficult to generalise. The most important thing to say is that we rely on and hugely value the service provided by section 38s and section 39s. In some cases, we can and do learn from them. That is the first thing.

As I see it, there are two aspects to the relationship, in governance terms, with section 38s and section 39s. One is those organisations themselves and their internal governance, and whether that is appropriate. While we are not an innocent party in that, it is largely a matter for them and their boards. The other piece is the management of our relationship with those section 38 and section 39 organisations, which gets much more difficult when we get to the bigger volumes of section 39s, remembering that we fund more than 2,000 organisations. We recognise that we had a problem and we still have elements we are working on. We have nine community healthcare organisations, CHOs, around the country and have established what we call contract management support units in each of those nine organisations. Most of them are now fully staffed and up and running. Their job is to assist local management to be able to keep on track of that relationship management with the organisations.

Deputy Paul McAuliffe

My concern is that more than €5 billion is going into the sector, admittedly across a whole range of spectrums. For intellectual disabilities in particular, and in the Cork area specifically, it essentially came to a situation where those people in receipt of HSE funding were not able to accommodate children with special needs. The education and training board, ETB, stepped in and opened special schools there. In addition, there is resistance to providing respite care to those children who are no longer registered in section 39 organisations because they are now registered for schooling in the ETB. That is a classic example, from my perspective, of how an organisation that is being funded is taking its own direction rather than direction from the State. Governance is about internal processes but it is also about responding to the direct demand of the State.

Mr. Stephen Mulvany

I agree. That relationship around services for residential provision, education and social care services between ourselves and other Government agencies is a complex one, as the Deputy knows. Progressing disability services is one of the ways we are trying to improve that. Clearly, in the Deputy's example, there may be tensions as to how well or not it is working. We are aware many of our section 39 organisations and, indeed, our own services, have been under pressure to provide sufficient residential capacity, particularly as we had a very positive experience as regards improved regulation over the years. The issue is it has not been possible for the investment to keep up with that and we have lost a level of capacity. We know we have challenges in providing residential accommodation to people. That is an accepted point. I do not know if Mr. McCallion wants to make any comment.

Deputy Paul McAuliffe

There is an increasing demand for the public provision of services. That is very clear when there is a private operator but sometimes, when there is a voluntary operator, that same call is not made. It is a policy issue maybe rather than a matter for Mr. Mulvany. I sometimes feel we do not subject section 39s to the same level of scrutiny regarding value for money. I ask for a note from the representatives to respond to the committee regarding some of the issues raised in that 2016 report about how the HSE is responding to concerns raised.

Mr. Stephen Mulvany

Without being able to comment on the specific issue, and we can certainly give the committee a note, the section 39s will probably disagree with the Deputy. The relationship is one we are working on, and need to work on, but there is a lot of engagement around individual client needs, accommodating additional clients and equality around what is being provided to existing service users. That is an ongoing process between every CHO, every disability service manager and the section 39s they are funding. Whatever about the formulaic, monthly, performance-type meeting, day in, day out our managers and placement co-ordinators are engaging with voluntary providers about the quality of service people are getting, or are trying to get people access to services. It is a collaborative partnership thing. Sometimes, voluntaries do not have the flexibility they used to have in the past - maybe that is a good thing - to provide accommodation or services.

Deputy Paul McAuliffe

Those are very fair comments.

Mr. Damien McCallion

The annual report sets out some of the governance arrangements. Mr. Mulvany talked about a contract unit. On a broader level, a report by Catherine Day was commissioned by the Department some time back on voluntary bodies and how they work with the health sector. The Deputy might recall it. A consultative forum was set up under that, where we have representatives. Apart from contract management and the formal side, that is all about trying to see how we work better together. We will always use voluntary organisations - Mr. Mulvany mentioned a figure of 2,000 - from the big voluntary hospitals through to the small service provider in a remote area, inner city area or wherever, that is providing a vital service. A lot of work is trying to get us in a room together to look at how we actually work better together at a practical level both in terms of the ethos and principles of how we work, apart from on the ground-----

Deputy Paul McAuliffe

I accept interagency is easier said and done. I understand that.

I will turn to the matter of the National Ambulance Service. Can the HSE confirm how many posts are vacant at present?

Mr. Robert Morton

At the moment, we have 282 vacant posts.

Deputy Paul McAuliffe

Some of the anecdotal evidence I am hearing from people is that the potential for staff to be allocated anywhere in the country is one of the major challenges. Parts of the country have persistent vacancies, while in other places demand might be oversubscribed. Has the NAS considered direct recruitment?

Mr. Robert Morton

We have worked very closely with our trade union partners on a number of the issues we feel are affecting retention. One of those is where we allocate new staff and new students. We have changed our policy this year, which has actually helped our recruitment strategy, to allocate all new staff to a base within 45 km, at a maximum, of where they live. For existing staff, we are currently implementing a new staff transfer policy to give people the opportunity to move to a base within 45 km of where they live. We think that will support retention because it has been a big issue that our trade union partners have consistently brought to our attention.

Deputy Paul McAuliffe

The NAS was probably based on a model similar to An Garda Síochána, where members are centrally trained and then distributed around the country, but we are in a very different employment market. On the role of the NAS, there are other private operators it is competing with as a potential employer. That degree of flexibility is very important.

I am jumping around here; I often think we should have a standing committee of public accounts just for the €23 billion the HSE spends, but that might fill the representatives with horror. I will come to the issue of non-compliant procurement. A process was carried out, which was a self-assessment exercise, to determine the level of non-compliant procurement. Within that, I was alarmed that compliance assessments were not completed in respect of 13% of the procurement expenditure, when the scoping exercise was carried out.

That was either because a manager responsible for the expenditure could not be readily identified or the manager failed to respond to the exercise. That is quite alarming when we are looking at a process to establish non-compliant procurement. Would our guests respond to that in the time remaining?

Mr. Stephen Mulvany

Overall, the fact that we are doing this exercise for a second time is progress. We are now moving into quarterly assessment, which is progress. While it is self-assessment, there is also an element of independent sampling as an insurance. Yes, the 13% is a concern. We are following it up although I do not have details as to where we have got to. We do not find it acceptable, as the Deputy does not. We will always have some level of non-completion but that level is higher than we would expect and higher than we want. We have assumed it is all non-compliant. Some of it might actually be compliant but we have had to assume it is non-compliant. We will chase it down.

Deputy Paul McAuliffe

What is the total expenditure in respect of non-compliant procurement?

Mr. Stephen Mulvany

The compliance procurement level within the subset we examined, including during the period of the pandemic, was 91%. That number falls to 84% if one ignores the pandemic. This is only looking at projects of over €20,000, which is approximately €2.2 billion. Another €2 billion-----

Deputy Paul McAuliffe

There is 44% below that figure.

Mr. Stephen Mulvany

Will the Deputy repeat that?

Deputy Paul McAuliffe

Some 44% of the HSE procurement was not within the scope of the assessment, in that it would have been below that €20,000 threshold.

Mr. Stephen Mulvany

We normally look at over €25,000. We would not disagree with the Comptroller and Auditor General's previous statement that the level of compliance is likely to be lower for the lower amounts. We are getting after that.

Deputy Catherine Murphy

Our guests are very welcome. I wish to start with the ambulance service and I thank our guests for the briefing document in that regard. In the document, there is reference to €9.1 million for Dublin Fire Brigade. That represented 15.75% of the breakdown of non-staff costs. Is there a contract in place? Is there a service level agreement in place for the role that Dublin Fire Brigade plays? Are there any penalty clauses if, for example, the service is deemed to be unsatisfactory? It looks as if that equates to almost 16% of the national funding for the ambulance service. Is that correct? From whose budget comes the cost of the replacement fleet? Is it Dublin City Council? Perhaps our guests would start by answering those questions.

Mr. Stephen Mulvany

I will make a couple of comments and will ask my colleague, Mr. Morton, to make comments too. We value the work done by our colleagues in the Dublin Fire Brigade ambulance service. They provide an essential service. As the clinical director said, we will continue to work with our colleagues in the fire brigade about the need to better integrate the call-taking and dispatch element of the service, that control centrepiece.

Deputy Catherine Murphy

I have very little time so I want very short replies.

Mr. Stephen Mulvany

I apologise. Mr. Morton might come directly to the Deputy's questions.

Mr. Robert Morton

There is no service level agreement in place. The current arrangements are grounded in a 1993 review. The fire brigade, through section 25 of the Fire Services Act 1981, deliver fire and ambulance services as a statutory authority in its own right. It does not deliver those services on behalf of the ambulance service or on behalf of the HSE. Arrangements emanated from the 1993 review of ambulance services. As a result of that review, we make a contribution towards the running of the cost of the ambulance service because otherwise we would have to deliver it.

Deputy Catherine Murphy

That is fine. What are the annual running costs, including staff, for an ambulance?

Mr. Robert Morton

That depends on the part of the country but the average cost of an ambulance would probably be in the region of €860,000 to €900,000 per annum. That would be the cost for the National Ambulance Service. I am not sure exactly what the costs are in Dublin Fire Brigade but that is the average cost.

Deputy Catherine Murphy

What about replacement vehicles for the Dublin Fire Brigade? Would that be-----

Mr. Robert Morton

We provide replacement vehicles on the basis that we have economies of scale. We are procuring perhaps 100 vehicles per year so we provide the vehicles for our colleagues in Dublin Fire Brigade.

Deputy Catherine Murphy

An article in a newspaper earlier this year stated that a debt in the amount of €116 million was owed by the HSE to Dublin City Council in respect of the ambulance service. That debt went back over a nine-year period. Is that something that is in dispute? Why would such a debt be outstanding for such a length of time?

Mr. Robert Morton

The Deputy has answered the question. It is in dispute. There is no service level agreement in place. There is no mechanism in place to vary the current financial arrangements. That is something we have engaged on over a number of years but we have not reached a resolution on that point.

Deputy Catherine Murphy

How has the HSE been engaging on that? Is there a legal process involved?

Mr. Robert Morton

No. We talk to Dublin Fire Brigade every day. Usually around June, July or August, during the Estimates time of year, that conversation would take place. A number of groups have been established over the years. There is currently a piece of work ongoing involving both Ministers to establish a governance group.

Deputy Catherine Murphy

Does the HSE accept there is money outstanding?

Mr. Robert Morton

No.

Deputy Catherine Murphy

Okay. I will move to another area. The annual report of the Comptroller and Auditor General includes a chapter in respect of the management of clinical indemnity. Perhaps one of the biggest areas relates to contingent liability. There is somewhere in the region of €4.5 billion involved, and €3.4 billion of claims. The estimated outstanding liability is €3.4 billion. That is decided on a pay-as-you-go basis. I understand the Minister must provide that is done on that basis. Is that something that the HSE seeks or does it come from the Government side?

Mr. Stephen Mulvany

That has been there for a long number of years. I do not know the long-term history of it but it is similar to the provisions around public service pensions.

Deputy Catherine Murphy

We would all accept that where a baby has suffered a brain injury at birth, for example, the number one priority is to ensure that lessons are learned from that and it is not repeated. That should go without saying. We are supposed to be at a point where there is open disclosure when there has been an accident.

Representatives of the State Claims Agency were before the committee and we discussed trying to get a mediated settlement whereby there is acceptance that there was an injury and fault involved. During that engagement with the agency, it was interesting to hear that there appeared to be a change in the practice during the pandemic when the courts were not available to prosecute some of these cases. There was a greater use of mediation. Are there mechanisms in place to ensure that happens? The evidence seems to suggest that settlements are quicker and less costly because there are fewer legal costs. Why did it take a pandemic to make that change? Is that change being maintained?

Mr. Stephen Mulvany

I agree with the Deputy that it is about trying to learn lessons and manage risk. We work closely with the State Claims Agency in that regard and it is helpful to us. The agency provides a service to the Government and Government bodies in respect of managing claims under its own statute. It is not doing that for us. It is doing it because the Oireachtas has asked it to do so. In my experience, the agency does that very well. It always seeks to get to an appropriate resolution. That may not be the experience of individual families. The court process is what the court process is. The Deputy would have to ask the State Claims Agency as to why Covid may have brought about a change. I would say it was a matter of practicality with regard to the courts, even though the courts did operate remotely during the pandemic. As to whether that situation has continued-----

Deputy Catherine Murphy

I would have thought the HSE would be a driver in that regard because we are seeing this as a stated contingent liability. That will include the legal costs. It was the non-availability of the courts that appears to have brought about this change. We need to pursue this matter separately and we may have to look at this chapter in its own right because I am not at all satisfied that this is working in the way it should be.

Obviously, Mr. Mulvany is acting CEO of the HSE. I understand there is a recruitment process under way. On the previous occasion, there was difficulty in filling that role. What is the status of that process?

Mr. Stephen Mulvany

The advertisement is out and it is due to close on 13 October.

I make the point in the context of the State Claims Agency that we have established a team to work with hospitals that have some of those more catastrophic cases. The evidence is that, thankfully, the incidence of those claims, those tragedies for families, is the same in Ireland as it is in other developed countries. The incidence of claims is not necessarily the issue; rather, it is the operation of the courts process and the legal process. We engage with the State Claims Agency in that regard but there is only so much of that we can influence.

As to the value, obviously the State Claims Agency is, in effect, part of the National Treasury Management Agency and the Department of Finance. The fact that it is not on the balance sheet of the HSE does not mean there is not an awareness all the way up to central government of those amounts, and they are very serious amounts.

Deputy Catherine Murphy

It is about changing behaviour in terms of making mediation more available rather than the legal profession deciding that this is the way one deals with it.

Mr. Stephen Mulvany

I understand the State Claims Agency is in favour of that, and would actively support it.

Deputy Catherine Murphy

It was really noticeable when the courts were not available.

With regard to the filling of the position, is Mr. Mulvany, as acting CEO, on the same salary as the outgoing CEO?

Mr. Stephen Mulvany

Yes. There is only one salary for the CEO of the HSE.

Deputy Neasa Hourigan

I am sorry to do this to the witnesses but I wish to return to a matter discussed last week as I want clarity on it. I have received an email that was sent to the committee. Is it okay to deal with this issue now?

Chairman

The Deputy may continue.

Deputy Neasa Hourigan

This session is on a different issue but some of the same people are in the room and I want them to revert to the committee with more information. Last week, we extensively considered capital spending in Cork-Kerry CHO and I was assured that the service users who are in 24-hour assisted living at Owenacurra and Garnish House had been fully communicated with regarding the closure of Garnish House and the move out of there. In the meantime, I have been contacted by families who say that is not the case. I am not sure whether that is just a breakdown in communication but I would like to get more information on this. The witnesses do not have to take my word for it; the Irish Examiner this week published an article on the matter written by Cianan Brennan. Last week, the HSE stated that "staff and clinicians talk directly to service users at Garnish House on a constant basis about their future plans". However, the family of a Garnish House resident stated "The only communication we (my relative and my family) received regarding my relative’s move from Millfield House to Garnish House came on the evening of the move in April 2020 via a short phone call from ... Millfield House". Another communication I received from a family states:

We asked both the Garnish House staff and the clinical team as recently as last week for information. On pointing out that a recent PQ response ... [to a question I tabled] stated that Garnish would be vacated by the HSE in early 2023, the Garnish House staff and clinical team stated that they have not been informed of this. The uncertainty of the past two and a half years has led to a deterioration in our relative’s mental health.

My time is running out and I do not want to use it all on this issue but the clear answer to this issue is to find out exactly what the communication has been.

In the email I received from the chief officer in the CHO he states:

In this context, there is and has been on-going discussion with residents of this high support service, to ensure that they are aware that the service would be moving at some stage, though we would not have a finalised decision on its location. This discussion would be more in the context of keeping service users aware of the temporary nature of the service location rather than in any greater detail and not to detract from their own individual plans of moving forward to a more independent living model suitable to their needs. Once we are clear on the service relocation plan, the clinical team will be engaging with each service user once again in more detail on the specifics.

I am reading this into the record on purpose. The email continues:

The commitment is made that the service will transfer from Garnish House by the end of Q 1 2023. There will be full communication with service users around the details of the service transfer in advance.

I know we discussed the matter last week but these are incredibly vulnerable people. We know that Cork-Kerry CHO's idea of lots of time in advance is, at best, three months, because that is what it did in the context of Owenacurra. These people have been living there for a very long time. I would love for the HSE to come back to me and explain exactly what the communication has been. I do not want to say that what we have been provided with is muddy but there is not a huge amount of detail from the CHO on exactly what the communication with these people was. There should be a log. If a clinician speaks to a family member, he or she makes a note of that, as is best practice. If the families are saying one thing but the HSE is saying another, the way to move forward and get rid of that grey area would be for the HSE to simply set out exactly how it has been informing residents and their families. I acknowledge that the CHO has been careful to state here that it does not wish to discuss individual residents. I am not asking for anyone's name or PPS number or anything like that; I just want to understand how the testimony of the HSE is so at odds with what the families are telling us. That is really important in the context of people being moved from their home of more than a decade. I am not asking for answers to be provided today but I am asking the HSE to take the matter away and see if it can come up with actual information. The information that has been provided so far is fuzzy.

Mr. Stephen Mulvany

I do not wish to add to the disagreement or, let us say, the challenge - and the pain, I am sure - some people have experienced in the context of this issue but I understand that, in addition to the email, the chief officer has issued a note to the committee. If there is any additional information required or queries to be answered,we will seek to deal with them but there is no-----

Deputy Neasa Hourigan

I am looking for a recognition that committee meetings have a value. We need to be able to trust what we are told by witnesses who sit in the room with us and enjoy parliamentary privilege. If they are saying they did communicate, we should be able to follow up and say that is true, they did communicate and the families are happy that is a fair representation of what happened. I am not there yet, however. I am asking the HSE to meet me halfway and ensure that we can have that trust. If we cannot be sure of that, then committees are in a strange place.

Mr. Stephen Mulvany

The Deputy understands the vagaries of communications, human beings and people's perception of matters. We will certainly speak to-----

Deputy Neasa Hourigan

That is a good point. I absolutely agree that the vagaries of interpersonal communications are important here because these are people who have mental health difficulties and are incredibly vulnerable.

Mr. Stephen Mulvany

I totally agree.

Deputy Neasa Hourigan

It could be that somebody at a low level in a service is saying a particular thing might be happening but, in the case of vulnerable persons with mental health difficulties, the issue is whether that is being communicated back to the family properly. Mr. Mulvany is exactly right. I am looking for the HSE to make sure it is doing all its due diligence to ensure that everybody involved in that situation knows what is happening with Garnish House and Owenacurra.

Mr. Stephen Mulvany

I hear what the Deputy is saying. When we come in here, we always seek to make sure we are as straightforward as possible. We will speak to colleagues and see whether there is any further information or assistance we can provide to meet the Deputy on the topic.

Mr. Damien McCallion

There are two pieces. There is the initial move, which was in response to the pandemic. Obviously, that happened at pace because of the concerns at the time with regard to multi-occupancy rooms and so on. The Deputy is raising concerns in terms of both staff and residents with regard to the current process in respect of where the centre is going. We will speak to the chief officer again on that just to confirm and make sure that all the communication happens. I have been to some of those units to visit people. As the Deputy stated, there is significant amount of dialogue between the staff and patients all the time. In many cases, one is trying not to make it a clinical environment in terms of in its entire-----

Deputy Neasa Hourigan

I completely agree. That was why Owenacurra was so great - it was like a home. I take the point made by Mr. McCallion and I thank him for it. He is correct, but it seems that some of the staff were not aware of the plan for Garnish House, so they would not have been able to communicate that on a low level with service users. From what the families are telling us, it seems the staff did not know.

Mr. Damien McCallion

I cannot confirm that.

Deputy Neasa Hourigan

Neither can I, in fairness.

Mr. Damien McCallion

We will take that concern back with us and address it. If there is uncertainty in respect of a potential move, even a temporary move in response to the pandemic as in this case, we still need to make sure that there is good communication with the people who are affected by it. We will take that away.

Deputy Neasa Hourigan

Okay. I will keep my eyes peeled for more communication.

In the two and a half minutes I have remaining, I will ask a quick question for clarity on the debt that is in question. I do not want to say it is owed by the HSE to Dublin City Council, given that the witnesses say it is not owed. As a former member of Dublin City Council, this is something that I did not realise.

There seems to be an acceptance within Dublin City Council, DCC, that this is owed. Obviously, the HSE is at odds with that.

Can I just understand this a bit better? The HSE awards the council €9.19 million per year to run the service. The debt that is outstanding, which is at question here, is now at the figure of €116.8 million. Within that context, the chief executive, Owen Keegan, has also made the point recently that costs have risen steadily, in line with the cost of everything else over the last couple of years. The council suggests that the cost of the Dublin Fire Brigade, DFB, emergency ambulance service is expected to reach approximately €26 million. For my own clarity, are we not accepting that all of that figure of €116 million is a debt that is owed?

Mr. Stephen Mulvany

It is important that I first say that we do value the service that Dublin Fire Brigade provides-----

Deputy Neasa Hourigan

That is brilliant to hear.

Mr. Stephen Mulvany

-----in relation to ambulances. It is really important that we say that because some of the next things I say may not be as positive.

We will also continue to work to address what is a very real issue and what has been identified by HIQA in terms of a much better integration of call taking and dispatch. This is a real issue. We are willing to play our part in addressing any wider resourcing issues, recognising first that it involves the two parent Departments. We have already taken some practical steps, as Mr. Morton has said. We already pay for or fund the ambulances. There is an issue, which has been around since before I joined the public service.

Deputy Neasa Hourigan

I think it has been around since before all of us.

Mr. Stephen Mulvany

Exactly.

Deputy Neasa Hourigan

I am glad to hear Mr. Mulvany say that he values it, because I think that every representative in Dublin values that kind of dual service. For clarity, and my time is running out, is it the entirety of that sum of over €100 million that is at question?

Mr. Stephen Mulvany

We do not want to get into the debate now but I suggest that the real issues are around the integrated call taking and so on, as well as with finding a way with assisting the Departments around settling the ongoing costs. As for the issue of the future of historic deficits, they tend to be part of overall negotiations, let us say, that get resolved.

Deputy Neasa Hourigan

Is the HSE aware that at a recent council meeting, the councillors were discussing taking legal action against the HSE?

Mr. Stephen Mulvany

The HSE is aware of the views about the fire brigade. However, as Mr. Morton said, we would not agree with them and they are not entirely ours to settle. There are policy matters as well.

Mr. Damien McCallion

Very briefly, to close off this topic, there is a discussion at a departmental level on this. Clearly, two public bodies are involved and we all want to resolve that. Much good work has been done in collaboration right through from operations on the ground, to planning and to fleet and through technology to make sure the two services are working hand in glove. This ultimately is what people want in Dublin.

Deputy Neasa Hourigan

That is great.

Mr. Robert Morton

Can I take this opportunity to say that given what we have described in terms of our workforce, planning and deficits, we do not ever foresee a time when the Dublin Fire Brigade is not involved in the delivery of ambulance services. That is important to put on the record.

Deputy Neasa Hourigan

That is great to hear.

Mr. Robert Morton

We envisage them delivering ambulance services indefinitely.

Deputy Neasa Hourigan

Great.

Chairman

In relation to Dublin Fire Brigade, I want to ask Mr. Morton about the figure of 16%. The expenditure was €9 million in 2021 or 16%. The overall budget is in excess of €200 million for ambulances.

Mr. Robert Morton

That is correct.

Chairman

Are the figures of €9 million and 16% in 2021 correct?

Mr. Robert Morton

They should be. The financial figure is definitely correct. It is definitely €765,000 per month.

Chairman

I know it is a valuable service and it compares very well. I know that this is not the main issue with ambulance services, because the main thing is to save lives and to improve people's medical conditions. Does it compare favourably in terms of the cost per ambulance and the cost per response and everything with service across the State?

Mr. Robert Morton

It does indeed. Broadly speaking, that cost would be reflective of the HSE's own costs.

Chairman

It is good to hear that. I thank Mr. Morton. We will break and we will resume in ten minutes sharp.

Sitting suspended at 11.04 a.m. and resumed at 11.18 a.m.

Chairman

The next committee member is Deputy Colm Burke who has ten minutes.

Deputy Colm Burke

I thank all of our guests here for dealing with the queries that have been raised. I want to move onto an issue that I raised in the Dáil yesterday, which is in relation to the level of claims against the HSE and where we are with that issue. The amount paid out for the level of claims in 2021 was €461 million. That was paid out by the State Claims Agency. Not all of that figure related to healthcare but, as I understand it, the bulk of it was. As the figure in the previous year was €372 million, that is an increase of €87 million.

In relation to the estimates, it is my understanding that were everything settled in the morning for all claims against the State, the figure would be approximately €4.2 billion. However, the figure for the healthcare sector is approximately €3.4 billion. We have dealt with the issue of insurance. It is in the context of dealing with the insurance Bill yesterday that I raised this issue. We made major changes to many areas of insurance over the past ten or 15 years but we have not really made any major changes as to how we process and deal with things when incidents do arise. No matter how careful people are within a hospital setting, errors do happen. What we try to do is try to reduce them as much as possible.

Has any analysis been carried out on what can be done to reduce the level of errors and hence the level of claims? Where an error arises, should we be far more proactive in dealing with it than the current system appears to be? Unfortunately, the HSE is getting caught up by post mortems, inquests and so on. I am thinking of the idea of having an overall review of how we can deal with this in future.

Mr. Stephen Mulvany

There are two parts to this. The first, which the Deputy raised and is the most important, is trying to make sure we are managing the risk and reducing it for patients and service users. We are very significantly focused on that. The State Claims Agency, in fairness, has given us great assistance in that. We seek to focus on making sure that we log and report incidents and that we investigate them, seek to learn the lessons and respond. Specifically, in the case of a subset of the incidents that are driving a disproportionately large amount of the annual payment that the State Claims Agency makes and we reimburse - the catastrophic birth cases - we have established under the chief clinical officer a separate central team which works with maternity units when they have these tragic cases to see what can be done differently and what lessons can be learned. That is despite the fact that the incidence of those catastrophic cases, which are individual personal tragedies for the families involved, is in line with international norms for developed western economies. We still would like to reduce it and reduce it further.

The second part is that the State Claims Agency, under its own legislation, is the indemnifier for the State. As well as providing risk management support to us, which is excellent, it also has to seek to progress the claims. We discussed that with Deputy Catherine Murphy. It does not itself control the legal process in which it operates. I understand that there are efforts to streamline elements of that legal process. The evidence to us is that the increasing level of costs appearing in our accounts for reimbursing the State Claims Agency and the increasing noted contingent liability around future costs of claims are not being driven predominantly by the volume of claims increasing or the severity of claims. They are being driven by the legal process and increases in the cost of processing, completing and paying out claims. It is not the piece that we predominately can influence but the piece that relates to the legal process.

Deputy Colm Burke

I apologise. It was €461 million that was reimbursed to the State Claims Agency in 2021, up from €373 million. That is an increase of €86 million in 12 months.

Mr. Stephen Mulvany

While we do not have the figures for this year, we know the budget for this year is north of €400 million and the likely outturn will be closer to €500 million or above, so it is a very substantial resource.

Deputy Colm Burke

Looking at how medical negligence is dealt with in other countries, is there a need to look at a policy change in this area? Can we manage it in a better way while making sure that where errors are made, people are adequately provided for? Is it not time to review the whole process rather than having what we have now where claims can go on for long periods of six, seven or eight years before they are finalised? Do we now need to look at that overall picture?

Mr. Stephen Mulvany

The Deputy is absolutely correct. I am not an expert but as I understand it, there is an interdepartmental group in which the State Claims Agency is involved that is doing just that and looking at the overall operation in this area. It is largely in the courts process or not necessarily the courts but how redress is sought and provided, which is currently predominantly through the courts process, although there are alternatives that may need to be used more. The work the Deputy is talking about is going on. The HSE is involved indirectly through its engagement with the State Claims Agency but it is a matter for the State Claims Agency, a number of Departments and the Courts Service how that operates. I agree with the Deputy that it is something that needs attention.

Deputy Colm Burke

In other countries, an annual payment is made rather than a lump sum, so it is ongoing. It goes back to the issue of children who suffered as a result of thalidomide. While they got compensation, it was in no way adequate in real terms. I have heard of a number of cases where substantial compensation was paid out and within a very short period people passed away unfortunately. There is a huge variation. Is there a need to be proactive in trying to reduce further the level of errors that arise by checking all the systems, whether in smaller hospitals or very large ones, and at the same time, looking at how we can expedite the processing of these claims?

Mr. Stephen Mulvany

Yes, I agree on both fronts. We are and do put significant energy into reducing and minimising the impacts of clinical incidents, acknowledging, as the Deputy said, that they will always arise. They are very difficult for patients and can also be very difficult for staff and we need staff to be supported as well as to be assisted to make improvements, where they can be made. Not every critical incident or adverse incident can be avoided but some certainly can.

Returning to redress, periodic payment orders is the language used to refer to a process where there is not just a single large lump sum paid but payment is made over time. I understand they have been and are in use. There is work on those orders within the overall courts process. I do not know exactly what it is. That is something the State Claims Agency would keep us briefed on periodically. The notion of moving to a different form of redress payment mechanism and hopefully, over time, to less adversarial methods of getting redress are all in that mix, as I understand it.

Deputy Colm Burke

The money paid out to the various section 38 and 39 organisations amounted to €5.7 billion in 2021. That is a huge slice of the HSE budget. There are more than 2,300 of these organisations and it is not physically possible to audit every one of them. They obviously have proper systems in place. In any one year, how many of the 2,300 organisations' accounts would the HSE go and review?

Mr. Stephen Mulvany

A huge amount of money is spread over a large number of organisations. Over 93% or 95% of it is provided to a relatively small number of very large organisations. I would guess it is less than 100. There are a number of ways by which we review and engage those organisations. Our internal audit division will go out, put boots on the ground and visit a certain number of section 38 or section 39 organisations in any given year. It may be between 30 and 50. I may have the figure wrong but I can check it. Separately, depending on size, we get a certain amount of information every year, including annual accounts, although we do not get audited accounts from every one of those organisation. It depends on the size and if they are below 50,000. We get their audited accounts, we have a review process and above a certain size we ask them to provide a summary or precis of that financial information so that we can see and track through the HSE's resource going into the organisation. As we said earlier, we have established across each of our nine CHOs what we call conflict management support units to try to help the local services to deal with that volume of interaction with a greater number of those organisations. We are by no means entirely there yet but a significant amount of effort is going into that and managing our contractual relations with those voluntary organisations. Remember, as Mr. McCallion said, we are also working on the bigger relationship.

Deputy Colm Burke

Let us say the HSE goes into 50 organisations in any one year. In how many of those would it find that not all the checks and balances are in place and not everything is being done by the rules?

Mr. Stephen Mulvany

It will vary. In fairness, audit will find something in a lot of organisations. The issue is the complexity of it, the risk and the proportionate response to it. Ultimately, with a lot these organisations, we are making a contribution to what they are providing so we have to be very focused on making sure the services they are providing are what we have asked for, but their governance is a matter for themselves.

Deputy Colm Burke

A lot of these organisations are in very much the same area. Has any effort been made to have organisations work more closely together and maybe amalgamate them in order to create greater efficiencies?

Mr. Stephen Mulvany

Yes, there are efforts from time to time to do just that and-----

Deputy Colm Burke

Is a proactive approach being taken in encouraging people and organisations to work more closely together in order to deliver a better service more efficiently?

Mr. Stephen Mulvany

The answer is "Yes". Take the area of disability services and progressing disability services. That is all about trying to get organisations to focus on servicing clients. There are other examples, but that is an area where I am sure more can be done. Obviously, we do not control the establishment of these voluntary organisations.

Chairman

May I ask about the pandemic bonus? I know that one of the members referred to it earlier but I would like further clarity. I have had more letters about this again this morning from constituents, from Sharon, Caitríona and so on. Every day come emails, letters and phone calls about people working on the front line, in private nursing homes, in the HSE itself or with agencies. May I clarify if funding for the payment has been transferred into the accounts of private nursing homes or agencies at this point? I would like a brief answer to that because I have other questions. The funding has not been transferred, has it?

Mr. Stephen Mulvany

Not yet. An organisation has been appointed to work through that, but money is not the issue here.

Chairman

I have tabled parliamentary questions about this. It was mentioned that the HSE hopes to have the payment made by the end of the year. Does that include the private nursing homes and agencies?

Mr. Stephen Mulvany

Yes.

Chairman

Okay. It is an issue. The witnesses can understand. I could quote from the letters I have received. Sharon says she has put herself and her family at risk, put her patients' welfare before that of her children, contracted Covid-19 so many times during the course of the pandemic and put her own health in jeopardy. The witnesses can understand-----

Mr. Stephen Mulvany

We totally accept that.

Chairman

I appreciate that. I am just asking that every effort be made.

I will revert to the ambulances. Last year, I think, at a meeting of the committee, I raised with Paul Reid the issue of dynamic deployment and the fact that a number of ambulances were quickly deployed from, for example, County Laois or County Offaly to Wexford or Waterford. When they are three quarters of the way there they are told that an ambulance has arrived on the scene and told to turn back. Not only is time lost, but that also leaves parts of the midlands without a service. I have heard reports of this from different parts of the country. On the second occasion I raised this with Mr. Reid and pressed him on it, he said that the HSE was looking at the geographical situation, that there may be a case for geographical limits and that there were working groups looking into this along with the unions, which I know about. This may be a question for Mr. Morton. What is the current situation? Has the HSE come down on a figure for that?

Mr. Robert Morton

The work we did with the trade unions focused on trying to address much of the staff concern about being sent quite significant distances. That was in response to capacity challenges. We had to balance what we wanted to do against patient safety. Obviously, once a limitation is put in, there is always the possibility of not reaching a patient. However, what we have reached a conclusion on is that we have set a limit of 80 km. That basically balances patient risk against staff well-being. We have been working on that for a considerable period of time and it seems to be working well so far - broadly, anyway.

Chairman

How long has that been in operation?

Mr. Robert Morton

It has been in operation since early in quarter 2 of this year, I think. The working groups concluded their work at the end of quarter 1.

Chairman

There have not been as many complaints in the past few months, either from staff or members of the public.

Mr. Robert Morton

That is correct.

Chairman

I acknowledge that. Mr. Morton is an expert on this matter, whereas I am not. This is his everyday job. It seemed to me, however, that it was becoming a real problem, particularly given that the service is running at about 54% capacity. We have little over half the number of ambulances and staff we need.

I will turn for a moment to the recruitment targets. There are 2,161 staff at the moment. I think it was said that the HSE needs around 850 extra staff to stand still, that we really need to double staff and that to do so would take ten years. I am looking just at the recruitment for this year. How many staff has the HSE recruited into the service this year?

Mr. Robert Morton

In January of this year we recruited only six student paramedics. In September we recruited 90. Then we have a plan to recruit around 90 more. It depends on people passing Garda clearance, but we expect to recruit about 90 in December of this year as well. We have also recruited 60 emergency medical technicians, who work in our intermediate care service and support our ambulances. That is the kind of profile of recruitment we are working to this year.

Chairman

We have 577 ambulances. How many do we need?

Mr. Robert Morton

We have 340 emergency ambulances out of about 577 vehicles. We probably have sufficient vehicles; our challenge is staff.

Chairman

Let us compare Ireland with Scotland, for example. I remember looking at this before and we were a long way behind in comparison. Scotland is a country that is fairly similar to Ireland. There are a lot of similarities. A few large cities and rural-----

Mr. Robert Morton

I am not sure how many emergency ambulances the Scottish Ambulance Service has, but it has more than 5,000 staff, so you are right, Chairman, in the sense that the two countries have very similar demographics and similar activity levels. Scotland has about 5.3 million people and about 33 hospitals compared with our 26, so the two countries have very similar profiles and workloads, but Scotland's staff number more than double ours. Vehicle-wise, I cannot answer the question. I would have to-----

Chairman

I think the figure for vehicles is nearly double our figure. I am open to correction on that.

Mr. Robert Morton

It could be. I would have to check that.

Chairman

Mr. Morton believes, however, that we may not need a large increase in the number of ambulances. That would indicate to me that we have a lot of ambulances not being used.

Mr. Robert Morton

It is not that we have ambulances standing idle. We have a sufficient amount of latent capacity. We would have to grow our fleet in the out years, but right now we probably have one of the better fleet profiles of most of our comparators around the globe. We are in a very good place. The HSE has invested a lot of money consistently over repeated years. The Department has been very supportive of our fleet replacement programme over a number of years. We are therefore in a really good place at the moment, and that has improved immensely since 2011, when our fleet was in a dreadful situation.

Chairman

What is the total number of vacant posts at the moment?

Mr. Robert Morton

There are 282 pre-existing vacancies but, obviously, we have new developments this year which we are filling. We hope to fill all those by the end of the year.

Chairman

Maybe this question is one for Mr. Mulvany. What is the spend on private ambulances? I was not able to find the figure in the briefing notes. It was just over €200 million all together-----

Mr. Stephen Mulvany

Maybe Mr. Morton could help me out.

Mr. Robert Morton

The whole HSE - obviously, not just the National Ambulance Service - will spend just shy of €10 million, there or thereabouts, on private ambulance services. That is across all the hospital groups. That is basically where hospitals contract private ambulance companies to do inter-facility transfer. The figure is somewhere between €9 million and €10 million per annum.

Chairman

Has that figure been increasing much?

Mr. Robert Morton

No. During Covid there was an increase - it went up to about €13 million - but that was not in respect of private ambulances. It was in respect of swabbing services.

Chairman

From a policy point of view, within the HSE, is the emphasis on having HSE ambulance services directly owned? Is that the direction of travel? Is there a move away from the private? I know that on social media there is a lot of rubbish that makes a comparison which is not like for like. Obviously, private services do not deal with critical incidents and so on, so we cannot compare like for like, but is the direction of travel in terms of the service to stay with the publicly owned HSE National Ambulance Service ambulances?

Mr. Robert Morton

It is. HSE policy is to continue to develop our own intermediate care service. Equally, however, one of the valuable lessons we have learned from Covid is that there is always a need to have access to surge capacity. Private ambulance companies and voluntary organisations have ably provided that surge capacity, particularly in supporting patient flow between hospitals. There is a place for the private ambulance sector, but the HSE's policy is basically to develop our own intermediate care service.

Chairman

I acknowledge the work of the service. The staff are more highly trained, maybe, than years gone by. Like a lot of other things, time moves on. The feedback from the public generally is very good, and the workers in the service are very dedicated. Talking to them, the one thing that always comes across, although they might complain about this, that or the other, is their dedication to doing the best for the patients.

I will ask about a more local issue regarding County Laois. County Offaly has three ambulance stations. I have no argument in that regard. There is one beside Ofalia House, one in Birr and one in Tullamore. We have one in the middle of Laois, which is a good location because it is a rounder county; it is not as strung out as Offaly. There has been a significant population increase in the northern part of the county, however. Are there plans to locate an ambulance base there?

Mr. Robert Morton

Parts of County Laois are well supported by neighbouring areas. Graiguecullen in the south east, for example, is well supported by County Carlow. Roscrea supports the south-west to some extent. Certainly, there is a need to look at services in the Portarlington and north Laois area. We are examining that at the moment. We are looking at the area that was the M8 corridor down to Durrow and Cullahill. We are currently working with Kilkenny County Council to procure the old fire station in Urlingford with a view to setting up an emergency dispatch point that would then service what was the old N8 corridor; places like Cullahill across to Castlecomer and Durrow and areas that are not particularly well-served by Portlaoise. It is quite a distance away in the event of an emergency. That is what we are working on at the minute.

Chairman

That area of Johnstown in County Kildare and Ballinakill.

Mr. Robert Morton

Yes.

Chairman

That is good news. Mr. Morton might keep me updated on that.

Mr. Robert Morton

Absolutely.

Chairman

I do not expect Mr. Mulvany to have the answer to this today, but can he send me a note on vacant HSE properties in community healthcare organisation, CHO 8 in counties Laois and Offaly? What properties are vacant at the moment? Some of them might be health centres that are no longer in use, some may be houses that were bought to provide services or some may be facilities that have been owned by the HSE for some time.

Mr. Stephen Mulvany

We will. We have a process around vacant properties to make sure they are offered up to other Government agencies, including as part of the recent efforts to respond to the Ukrainian crisis. We will get the Chairman the list and we might just set out that policy for him. We have made the details of our properties that we were not using available to the various bodies, however.

Chairman

Some health centres have been lying empty for a while. They could not be used as a house tomorrow but they would be suitable for residential accommodation. There is one in Errill, and there are villages like that throughout the country. There are properties that could be used and converted in my own area. Mr. Mulvany might send me a note on that, including properties the HSE has bought but that have not yet been put to use. We are not at 300 ICU beds yet. Is the figure 280?

Mr. Stephen Mulvany

The figure is just under 285 or 290 beds.

Mr. Damien McCallion

We are coming close to 300 at the moment in terms of critical care beds, which just exceeds the quota.

Chairman

Okay. Again, we are a long way away from where we need to be on that. On an EU comparison with many other countries, we were at approximately 50% or just above that. Capacity seems to be the issue. Is the issue the fact that we do not have the consultants?

Mr. Stephen Mulvany

The issue is that at least seven to eight highly-trained nursing staff are needed to run every individual bed. The facilities are needed and so is the space. They are very specialised. Then, a certain number of consultants are needed to run intensive care lists, particularly to run a certain number of beds. It will, therefore, be a combination of those factors. More typically, it is getting the suitable space and particularly the expert nursing staff.

Chairman

At start of and during the pandemic, we were facing a fairly critical situation and no one was sure where it was going to go. I know this is dependent on budgets and on direction from Government but is there a plan to reach 300 or 350 ICU beds by a given time?

Mr. Stephen Mulvany

Mr. McCallion might take that question.

Mr. Damien McCallion

One of the positives to come out of the pandemic is that a piece of work that was under way by the critical care team to set out a clear plan for the country on where beds should be based on demand, and future configuration was accelerated .

Chairman

What is the target for the next five years?

Mr. Damien McCallion

We can come back to the Chairman on that. At the moment, the plan is to be up around 320 beds by the end of this year and there are further developments from there. Some of those are tied to capital and staff. The one advantage we have now is that we know exactly where they should be and how they should be developed. We can forward details of that plan to the Chairman.

Chairman

We will have 320 beds by 1 January.

Mr. Damien McCallion

Yes, that is our plan.

Chairman

That is good to hear because I know ambulance turnaround times are tied up with capacity. We can see that from the ambulance figures. Unfortunately, the situation arises where an ambulance with a patient inside arrives at the door of the emergency department and there are no critical care beds. There are bottlenecks, which I presume this is adding to. It would be welcome if that happened because that would be an increase of nearly 40 beds.

Mr. Damien McCallion

Yes, that is the plan by the year end. The only thing I would say is that some of it is between buildings at the moment. There are a couple of projects but, effectively, that is our aim at the moment.

Chairman

The next question on the 80:20 divide in the consultants' contract is also for Mr. McCallion. Is that working the way it should for consultants who are on those 80:20 contracts, that is, 20% of their work being carried out in the private sector and 80% in the public sector? Is that working, as a rule, throughout our public hospital system?

Mr. Damien McCallion

As the Chairman said, that is the model in general terms. Effectively, each hospital would monitor that locally in terms of what is there. We know from time to time that-----

Chairman

What about nationally, though? I expect Mr. McCallion to have some insight on this.

Mr. Damien McCallion

We look at this regularly but it is managed by hospitals on the ground in terms of working with consultants to make sure that is in place, and, if there are issues, those are addressed locally in the hospital system. There is a clear reporting line now to a clinical director into the CEO in each hospital.

Chairman

What is Mr. McCallion's sense of it nationally?

Mr. Stephen Mulvany

If I could answer, overall, nationally, it is typically slightly under the 20% if we look at private versus public. Therefore, yes, as Mr. McCallion said, nationally, there are many variations and different hospitals-----

Chairman

Are there hospitals in which 20% of the private work has been exceeded?

Mr. Stephen Mulvany

There may be in some cases or individual specialties but-----

Chairman

How far is it going? Is it going to 25%, 30% or 40%?

Mr. Stephen Mulvany

I do not have that detail but overall, it is 20% or actually less nationally.

Chairman

There is a perception, based on feedback from staff in various hospitals, that the people who run the hospitals are the consultants. They control patient flow, waiting lists and all the critical issues in hospitals. How accurate is that? Who actually runs the hospitals? Is it managers or consultants?

Mr. Stephen Mulvany

The managers and CEOs manage the overall hospitals but we have to be very clear that we want consultants and other clinicians to do what they do, which is take a huge role in the day-to-day decisions around individual patients and contribute hugely to general management and strategic development. Therefore, yes, most of the decisions in many of our services come down to clinical staff and, in the hospitals, that comes down to consultants. They are not the only members of the team but they are very important members of the team. The vast majority of them do a really good job. It is in terms of-----

Chairman

Can Mr. Mulvany point to who calls the shots when the big decisions have to be made?

Mr. Stephen Mulvany

What is the question, though?

Chairman

It is in terms of overall management. The consultants are, some would say, the most powerful group within a hospital, and we have a shortage of them. I do not want to be hard on consultants because they do a very difficult job and they are highly skilled. We and our families are all dependent on them. In terms of the important management decisions, however, is it Mr. Mulvany's sense that consultants in this State have a greater influence or greater control over how hospitals are run than they should have? Is that a concern of his?

Mr. Stephen Mulvany

It is not something on which I have a specific view at this stage. The key point is that hospital managers and CEOs have to manage - they are leaders. Leaders need followers, however, so they need to make sure their clinicians, non-clinical employees and all their staff are being brought with them. Therefore, yes, our consultant colleagues have a huge impact. In some cases, that may be problematic and the consultant body itself will tell us that. We are no different from any other part of the world in some of that. There will always be areas where clinicians may in some cases overstep the mark or where managers may not fully be doing what might be expected of them. It would be too simplistic to say it is an overall general concern, in fairness.

Mr. Damien McCallion

I might just add an important point. Each hospital has a chief executive and an executive management team with a clinical director, director of nursing and other associated disciplines. We are trying to promote clinical leadership. There are programmes to encourage clinicians to come forward into those roles because that is how we bring about change. We need to have good executive leadership, as the Chairman said, alongside good clinical leadership, be it nursing, added health professionals, consultants or medical staff.

We are actively trying to encourage more clinicians to come forward into those clinical leadership roles.

Deputy Verona Murphy

In regard to the National Ambulance Service, there has been a huge increase in population in Wexford alone, so I assume the CHO 5 area has had an increase. Can the committee have a note on how the HSE is catering for the increase in population through the NAS?

Currently, in Wexford, 160 people with special needs are awaiting dental treatment under anaesthesia. Pre Covid, there were two sessions a week at Wexford General Hospital but there is only one now. One hundred of those 160 people with special needs are children. Who is responsible for restoring pre-Covid levels of service?

Mr. Damien McCallion

Acute dental work in the hospital would be the responsibility of the hospital but it would work with the CHO in the sense the dentist would come in. I am not familiar with the drop in service, so we will have to come back to the Deputy in regard to the change from two sessions to one.

Deputy Verona Murphy

Will our guests please do so? This is very important. These are very vulnerable people. I am sure that at the level of our salaries, we have never had to wait to see a dentist. I cannot imagine what it is like for these people but they keep coming back with the same problem and I have not been able to get an answer to it.

Mr. Mulvany was the chief financial officer prior to taking up his current role. How does it sit with him that the figure for non-compliant procurement by the HSE is in the range of €2.37 billion, more than half of the procurement budget?

Mr. Stephen Mulvany

On procurement overall, we are making progress but we have more to do.

Deputy Verona Murphy

When Mr. Mulvany says "making progress", when did the HSE start that? According to anything I have read from the Comptroller and Auditor General, it is going the wrong way, not the right way.

Mr. Stephen Mulvany

I do not think that is correct-----

Deputy Verona Murphy

In that case, let me read out what the Comptroller and Auditor General wrote.

Mr. Stephen Mulvany

Can I answer the Deputy's question?

Deputy Verona Murphy

I want an answer to the question I asked. How does it sit with Mr. Mulvany, as the former chief financial officer?

Mr. Stephen Mulvany

I am trying to answer the Deputy's question, if I can be allowed to. First, the Deputy is incorrect in her statement. It is not correct that more than €2 billion is non-compliant-----

Deputy Verona Murphy

In that case, the Comptroller and Auditor General is incorrect, given that is what was written.

Mr. Stephen Mulvany

No, that is not true either.

Chairman

I ask the Deputy to allow Mr. Mulvany to answer.

Deputy Verona Murphy

The note refers to 36,000 invoices and states the estimated total expenditure on invoices over €20,000 is in the order of €2.37 billion. That is 56% of the HSE's procurable spend in 2021.

Mr. Stephen Mulvany

That is correct, but we are not saying the 56% is all non-compliant. We are saying that 91% of that is compliant and that if we exclude the Covid piece, 84% is compliant.

Deputy Verona Murphy

The Comptroller and Auditor General is of the view that the estimated rate of non-compliance may not accurately represent the scale of the underlying problem of non-compliant procurement for a number of reasons, and Mr. Mulvany has agreed those reasons already.

Mr. Stephen Mulvany

As I commented earlier, we do not disagree with the Comptroller and Auditor General's assessment - he can speak for himself - which is that below that €20,000 threshold, that is, the other 44%, it is more likely the lower values would not have as high a level of compliance. We do not disagree with that but I am saying we have made progress. We definitely have more to do and we are focused on doing more. We are, for example, turning that annual self-assessment, which we managed to do for the first time only in the past two years, into a quarterly self-assessment, with the first two quarters of this year to be done by the end of October.

Deputy Verona Murphy

To what extent is the HSE making progress?

Mr. Stephen Mulvany

The level of compliance is improving. Without restating the Covid story, we lost a lot of ground earlier during Covid. When you are trying to get contracts, in what is called spend under management, you are losing ground every month because every contract has an expiry date. Earlier during Covid-----

Deputy Verona Murphy

We will see a significant improvement in the next accounts, therefore.

Mr. Stephen Mulvany

Our aim is to have spend under management at about 69% by the end of this year, which we are on track for, and at 84% within 2024. That means contracts in place.

Deputy Verona Murphy

That brings me to the Covid personal protective equipment, PPE. It was just a disaster but there is one issue I do not understand. Why do we have so much hand sanitiser that is considered useless? Why is it useless? It contains alcohol. Does it go off?

Mr. Stephen Mulvany

First, I cannot allow the Deputy's comment about the PPE issue being a disaster to go uncorrected. It was not a disaster. We are sitting here today feeling comfortable, as I said earlier, behind a wall of vaccines. That is not where we were in March or April 2020.

Deputy Verona Murphy

That is not what I asked Mr. Mulvany.

Mr. Stephen Mulvany

The technical specifications-----

Deputy Verona Murphy

I appreciate Mr. Mulvany's point. My question concerns how much obsolete PPE that we cannot use we are storing and how much it costs.

Mr. Stephen Mulvany

The Deputy's first question related to how alcoholic hand gel could go out of date. It has a technical specification and those specifications are set by standards bodies outside the HSE. If they determine that it goes out of date, it goes out of date.

Deputy Verona Murphy

Why does the HSE know that now but did not know it when it was purchasing the product? Is Mr. Mulvany saying it did not meet the technical specification?

Mr. Stephen Mulvany

No Deputy. I apologise; I might not be making myself clear. We knew what the technical specifications were when we bought it. Everything that is bought has a sell-by date and goes out of date at some point-----

Deputy Verona Murphy

I do not have time for this.

Mr. Stephen Mulvany

The Deputy asked the question. That sell-by date has now been arrived at.

Deputy Verona Murphy

How much is it costing to store all this obsolete equipment?

Mr. Stephen Mulvany

The figure for the obsolete PPE and other equipment is approximately €1.25 million per annum.

Deputy Verona Murphy

Is that to store it?

Mr. Stephen Mulvany

It is to store it until we find an alternative use for it or dispose of it.

Deputy Verona Murphy

When Mr. Mulvany says "alternative use", it is obsolete for us, so what would be the alternative use? Will it, like the ventilators, be sent abroad?

Mr. Stephen Mulvany

I am talking about the entire range of PPE, hand sanitiser, the whole lot. As I said, and I do not wish to be argumentative with the Deputy-----

Deputy Verona Murphy

It is not about being argumentative. This is costing money and it is about-----

Mr. Stephen Mulvany

We agree.

Deputy Verona Murphy

This is reminiscent of the voting machines and how much they cost the country for something that was never worth it in the first instance.

Mr. Stephen Mulvany

Again, go back to why we purchased the stuff and what the situation was then-----

Deputy Verona Murphy

Do not go back. Go forward and tell me when we will make a decision to save that €1.25 million.

Mr. Stephen Mulvany

We already have significantly rationalised the cost of storing the PPE. We have further work to do, there is more clean-up to be done and that includes getting the unusable PPE stock out of storage and either disposing of it or putting it to an alternative use. In some cases, we can extend its shelf life. It is a cost we would prefer we did not have but that is where we are.

Deputy Verona Murphy

The equipment is not obsolete, therefore.

Mr. Stephen Mulvany

That is not what I said.

Deputy Verona Murphy

Mr. Mulvany referred to extending its shelf life.

Mr. Stephen Mulvany

In some cases, the shelf life can be extended, depending on the item, but that involves engaging with the relevant regulatory body. I am not saying it happens a lot but it can be done.

Deputy Verona Murphy

Why can the HSE itself not store it?

Mr. Stephen Mulvany

In some cases, we do. We are storing it ourselves in that we are engaging, in some cases, companies to store it on our behalf. In other cases, we are storing it using our own facilities but it is still the HSE that is storing it.

Deputy Verona Murphy

Was there a tender for the storage? Did it have to go through a tender process?

Mr. Stephen Mulvany

There was a tender process recently to regularise a lot of the storage and to rationalise it. So yes, there has been a tender process. We have reduced the number of storage companies and storage locations and we have got a better overall price per pallet of storage, so that has been attended to.

Chairman

It caught my eye when I was reading my notes for the meeting that the hand sanitiser has a best-before date. I was under the impression alcohol improves with age.

Mr. Stephen Mulvany

I would not recommend drinking it.

Chairman

Some things may not improve but I had thought that drinks, especially those that have a high concentration of alcohol, such as anything above 13% or 14% alcohol by volume, seem to improve.

Mr. Stephen Mulvany

I am looking around the room for a scientist.

Chairman

There remains a high demand for hand sanitiser and so on because Covid is still here and we are still vaccinating people. Apparently, the incidence of the virus is on the rise again, so there is a need for hand sanitiser in workplaces, schools and other buildings. Why would we throw it out or dispose of it? Is there not a question mark over the best-before date? I saw a figure suggesting €38 million had been spent on hand sanitiser.

Mr. Seamus McCarthy

It is €35 million.

Chairman

Can that not be reviewed? I cannot for the life of me understand why we would waste hand sanitiser that has a high concentration of alcohol.

Mr. Stephen Mulvany

I agree with the Chairman; it is difficult to understand why it would go out of date. I will certainly get a note on that for the committee. Personally, I do not know why it is. It is down to the specifications.

Chairman

Hospitals need gallons of it.

Mr. Stephen Mulvany

There is no disputing that one would look for an alternative use if that was practical and no disputing that hand sanitiser is needed.

Chairman

In light of this meeting, will our guests review this and distribute the product to health centres, section 38 organisations and whoever else within the health services needs it, such as hospitals and nursing units?

Mr. Stephen Mulvany

I agree with the general thrust of what the Chairman is saying. If it was as straightforward as that, our teams would have done that. I will go away and find the answer for the Chairman. I understand the question and logic.

Chairman

The question I am asking the team is this: will somebody explain to me how it has gone out of date?

Mr. Stephen Mulvany

We will. I do not have an explanation today but we will.

Chairman

Maybe it does. I am not an expert.

Mr. Stephen Mulvany

Maybe it does. Let us get the Chairman a note.

Chairman

I would be surprised if it goes out of date that quickly. It is only a couple of years since it started.

Mr. Seamus McCarthy

The Oireachtas has supplied these on the desks. This one is 17 April 2022, so it is already out of date.

Chairman

My one is out of date but I am still using it.

Mr. Seamus McCarthy

The Chairman is still using that one. These are good points for the Oireachtas.

Chairman

Mine says 7 April and there is still a strong smell of alcohol from it.

Mr. Stephen Mulvany

Again, we are not recommending that anyone would drink it.

Chairman

Nor am I. I am a very moderate drinker, I can assure Mr. Mulvany. I call Deputy Catherine Murphy.

Deputy Catherine Murphy

I want to come back to the issue of the Ambulance Service. The newspaper article pretty much said that the costs for providing the service have risen steadily and the cost to the Dublin Fire Brigade emergency ambulance service is expected to reach just less than €26 million. As we know, the amount that has been allocated from the HSE is €9.19 million, so there is €16.55 million in running costs for the service. Mr. Owen Keegan said:

Anybody else would have withdrawn the service long before now. But there’s a huge commitment among the staff, and I think it’s important that we will support them. And we’ve done that and the HSE have exploited that to the hilt.

That was the article. Is it costing Dublin City Council more to run its ambulances than it is costing-----

Mr. Stephen Mulvany

It is important that we say a few things. First, we value the service.

Deputy Catherine Murphy

I absolutely value the service as well.

Mr. Stephen Mulvany

Second, we see it continuing, as I said. Third, it is not really appropriate for two public bodies to effectively engage in a kind of dispute by me trying to respond to that. We have already said we would disagree with the CEO, Mr. Keegan, on some of the figures. We believe a resolution is required and we know that does not involve ourselves. As a final point, we actually do not know. We told the committee, and the director of the Ambulance Service has said, that the contribution we are making is broadly in line with what we understand to be our costs. The city council's costs are its own costs and they intermingle to some extent. The service it has, which is a great service, is a fire brigade service with an ambulance component. Again, let us remember that the key thing to be resolved in all of this is the integration of call-taking and dispatch, because that is a quality and safety issue. The rest is money, and the money is important. We do and we will engage with Owen Keegan but I do not think that across the floor of a committee chamber is the way to do it.

Deputy Catherine Murphy

We are the Committee of Public Accounts. If there is a disparity between the cost of running a service in one area as opposed to another, it would be our job to try to understand why that is the case.

Mr. Stephen Mulvany

That is a cost disparity of their service, not ours. We are contributing what it broadly costs us, as I think we said. If the Deputy has questions to ask, it is of the city council as to their costs, not of the HSE as to why-----

Deputy Catherine Murphy

They are not under the remit of the Comptroller and Auditor General so we do not get the opportunity to do that. That is under the local government auditor.

I will move to a different topic, which is the cyber attack. Some €657 million over seven years is the cost of implementing the PwC recommendations. Obviously, some of the things that happened can be rectified reasonably quickly. We were told there was no single person responsible and no documented recovery plan, the patching updates were not effective, there was a single antivirus product, antivirus signatures were not updated and 30,000 machines were on Windows 7. Some of those issues are pretty basic. Have the most immediate aspects been dealt with and how will that plan work out? I presume the HSE has moved away from Windows 7 at this stage. Have some of those more exposed and easily fixable aspects been dealt with at this stage?

Mr. Mulvany might also deal with the number of people who have been identified. Has the HSE identified every one of the people who are likely to have had their information disclosed or accessed during that attack? Many people have yet to be notified. Does Mr. Mulvany have a ballpark figure for that?

Mr. Stephen Mulvany

We are making progress on it. Our board has a committee governing the overall monitoring of the implementations of these recommendations. The low-hanging fruit and the priority stuff is getting that additional focus. The number of Windows 7 licences is down from over 40,000 to less than 10,000. They are only on systems where we are in the process of replacing those systems so we do not rely on Windows 7, but we do have clinical systems that-----

Deputy Catherine Murphy

Are they networked?

Mr. Stephen Mulvany

Most of our systems are.

Deputy Catherine Murphy

So there would be Windows 7 machines in a network.

Mr. Stephen Mulvany

Yes, but I am not technically competent to comment on that. The key point is that-----

Deputy Catherine Murphy

To be honest, I do not think-----

Mr. Stephen Mulvany

We have drastically reduced the volume of Windows 7. Around the rest of it, we have put in protections to make sure we are mitigating that risk, which is key.

Deputy Catherine Murphy

Windows 7 is out of licence. I do not think anyone needs to be technically competent to know that if something is out of licence, there is not the kind of security that is required if it is on a network.

Mr. Damien McCallion

The HSE has a lot of what we would call legacy applications that are crucial to running services, particularly in some of our facilities, and that is the point Mr. Mulvany is making. It is not Windows 7 in itself; it is the fact that the applications are on that. There is a plan to try to migrate that or to replace those as quickly as possible to remove Windows 7, and that is basically where we are at, but there are old applications that our services are entirely dependent on for operation, and that is what we are trying to ramp down as quickly as possible. Good progress has been made on that already because, as the Deputy said, that is one of the risks identified.

Deputy Catherine Murphy

What of the numbers?

Mr. Stephen Mulvany

We are not in a position to give out the number but, as I said earlier-----

Deputy Catherine Murphy

Would Mr. Mulvany estimate that it is, say, ten people, 1,000 people or 10,000 people? Is there a ballpark?

Mr. Stephen Mulvany

It is certainly more than ten but, for obvious reasons, we do not want to go into the numbers. We are engaging closely with the data protection officer, DPO, on this. We will do it properly. We will make sure that people are told directly, as soon as we have finished the assessment. It is a complicated process, although I know I have said that already. We have asked ourselves how quickly we can tell people because we want to tell people so they would know, but we do not want to cause unnecessary angst to people. That is our aim. We are nearing the end of that process but it has been a very long and difficult process, in fairness.

Deputy Catherine Murphy

The HSE has a risk register.

Mr. Stephen Mulvany

Yes.

Deputy Catherine Murphy

Before the attack, would any or all of this have been on the risk register?

Mr. Stephen Mulvany

The overall cyber risks, which are many and varied, have certainly appeared on our risk registers for a number of years. We have invested in some of these areas but, clearly, we were not prepared and we have been very clear on that. We have a whole panoply of legacy systems and a system that grew up as a product of history as opposed to design.

Deputy Catherine Murphy

It is hard to visualise how it would have been identified as a risk without dealing with the most basic of things, such as, for example, updating a password, antivirus signatures or using the same antivirus product. I would have thought some of those things would be fairly basic, and even Windows 7 would have been a fairly basic point on a risk register.

Mr. Stephen Mulvany

On Windows 7, not so much because, as Mr. McCallion said, we have a whole heap of clinical systems relying on that. We have got ourselves away from and out of Windows 7 as quickly as we could, but we cannot risk damage to patient services, so we put in mitigations. We have had policies around all of those basic issues for years and the issue is getting the full implementation of them.

Deputy Catherine Murphy

In terms of confidence, if other things are on the risk register or if the other issues that were identified are pretty basic, I think there is a question mark over the risk register itself and I would have concerns about that.

Chairman

Deputy Hourigan is next.

Deputy Catherine Murphy

This is going to cost an absolute fortune. It is not just about the financial cost as the actual impact on patients cannot be quantified.

Mr. Stephen Mulvany

To reassure the Deputy, the board has directly created a separate committee to give additional oversight and governance around cyber risk. The €700 million over the ten years is an investment that would have been required anyway at some point, or the vast bulk of it. The issue partly was we were not able to put enough investment into this area and partly we would have always tried to focus on providing access to systems to support clinical and operational as well as to invest in the cyber piece. We have all got a very clear message, namely, we need to and needed to invest more and more in the cyber piece, which is what we are doing.

Chairman

I thank Deputy Catherine Murphy.

Deputy Catherine Murphy

I ask that we are given a note on that.

Chairman

Okay, on the cyber-----

Deputy Catherine Murphy

On the €657 million and-----

Mr. Stephen Mulvany

Yes Deputy.

Deputy Catherine Murphy

-----what the staging of that is and what it is for so we can then monitor it in an ongoing way.

Mr. Stephen Mulvany

We can set out a summary of what it is for, absolutely.

Deputy Catherine Murphy

Yes, okay.

Chairman

Deputy Hourigan.

Deputy Neasa Hourigan

I thank the Chairman. I have two quick questions. The first is a question I ask of An Garda Síochána a lot. I am interested in the key performance indicators, KPIs, and understand an ambulance service will always look at its indicators based on how may calls it takes and how quick it is. However, I am interested in whether the service, bearing in mind it is the first point of contact in often quite traumatic situations, is investing in training around diversity, human rights and civil rights. It is something the Garda has taken on board and started to train up staff on. What kind of recognition is there in the service of the need for that? I am aware the service did good work as part of the Covid-19 roll-out and doing mobile sites in the Travelling community. That is the kind of area I am interested in. That is my first question.

I am looking at the annual report and the financial statements from 2021 on the National Ambulance Service and there are a number of areas like the out-of-hospital cardiac arrest strategy and things like the enhancement of alternative care pathways. Will the service give us a general approach to how that aligns with the reforms of Sláintecare?

Mr. Robert Morton

On the first question, we are just finalising a people plan for the National Ambulance Service that is aligned to the overall HSE HR strategy. On the area of equality, diversity and inclusion we are looking to our colleagues in the UK, who have done quite a lot of work on this area. Our head of HR is engaging with that broader network to understand what the sector is doing over there and what lessons we can bring and embed in our workforce thinking as well. That is something we are actively doing.

Deputy Neasa Hourigan

The head of HR is engaing with best practice in the UK and that is fantastic. If I can have a very quick follow-up question on that, are they talking to stakeholders in Ireland, for example the Travelling community, new communities in Dublin or whoever it might be?

Mr. Robert Morton

Yes. Obviously we engage through our broader HSE family network as well and there is a broad range of contacts there but on an ambulance-specific workforce, given we have a highly-moblie workforce that engages with all sorts of vulnerable people from a broad range of backgrounds we also need to look at diversification of our own workforce as well because quite frankly-----

Deputy Neasa Hourigan

Absolutely.

Mr. Robert Morton

-----that is a challenge for us as well. That piece of work is ongoing and as I said it is encapsulated in the people plan.

Deputy Neasa Hourigan

What is the timeline on that?

Mr. Robert Morton

The people plan has just been finalised and it is a three-year plan from 2022 to 2025.

Deputy Neasa Hourigan

Brilliant.

Mr. Robert Morton

We are hoping to adopt that. We have a health psychologist now as part of our education team so we are rolling in that direction, as it were, but our head of HR is very much focused on it this year.

The second question was on the out-of-hospital cardiac arrest strategy and alternative care pathways. The two things we are doing, which the CEO mentioned in his opening statement, is hear and treat and see and treat. We are looking at ways to offer services to patients in the community or at the point of contact. We have developed a clinical hub and I might ask Professor O'Donnell to talk about the clinical aspects of in a moment. The hub tries to provide a meaningful clinical solution for patients at the point of contact, as distinct from having to send an ambulance, which is not necessarily always the right thing to do. An obvious example is when somebody dials 999 with a broken toenail. They may be alternate pathway of care we can offer to that patient in those circumstances. The out-of-hospital cardiac arrest strategy is based on the sudden task force report from 2007 that has been Government policy since then. It says every uniformed responder in Ireland should be contributing to a reduction in out-of-hospital cardiac arrest mortality. That involves the fire services, the Garda, community first response schemes and the Irish Coast Guard. That strategy is focusing on embracing all those organisations and we have 12 organisations around that table that are actively involved in progressing that strategy, which is funded this year to the tune of about €650,000, and all that money will be expended on that. Some of that is around placing automated external defibrillators, AEDs, in the communities.

I ask Professor O'Donnell to touch on the clinical hub aspects.

Professor Cathal O'Donnell

I thank Mr. Morton. The traditional ambulance model where someone rang us and we went out to them in an ambulance with two paramedics and brought them to hospital, unless they told us they did not want to go, is the historical model and not nuanced enough for modern healthcare. We have an aging population and a much more complex healthcare system. What we are currently doing, and what we are going to build on to do in a much wider fashion, is identify patients who have low-acuity healthcare needs and try to address their healthcare needs in the community close to them so they do not have to go to hospital. That is good for the patient first of all, it is good for the hospital given the capacity issues we have in the hospital service and it is good for us because of capacity issues we have.

We have a couple of different threads to that. The one Mr. Morton mentioned is the clinical hub. We have had clinicians, that is, doctors and nurses, in our ambulance control centre for the last couple of years. We plan to increase that very significantly. We recently reached an agreement with Tallaght University Hospital for it to provide us with the clinicians, clinical leadership at consultant level and then nursing staff too.

Deputy Neasa Hourigan

That development sounds very beneficial and progressive - and I know I am out of time - but my question is whether that is impacted in any way by the changes being brought to bear by Sláintecare.

Professor Cathal O'Donnell

It will be improved.

Deputy Neasa Hourigan

Okay.

Professor Cathal O'Donnell

We see it as a good thing because it is all about-----

Deputy Neasa Hourigan

Community.

Professor Cathal O'Donnell

-----being more local and that is the way we want to go as well.

Chairman

I thank the Deputy. Deputy O'Connor has joined us. He has ten minutes.

Deputy James O'Connor

I thank the Chairman and welcome the officials to the committee. It has been referred to very strongly in contributions by other members but the importance the NAS has across every constituency in the country cannot be understated. All I can tell the officials about is what is happening in my own area and unfortunately the reports are not good. Recently, we had an incident in east Cork where a gentlemen who was waiting over 90 minutes for an ambulance died. I have dealt with other consequences for people who have been waiting well in excess of an hour. The consequence of course was the person who was waiting for the ambulance is now deceased. Unfortunately, this seems to be a recurring issue. Our existing ambulance service staff, especially those in the HSE Cork-Kerry region, are working exceptionally hard. I know many of them and they are good people but they will say themselves they are under huge stress.

Something I find completely unacceptable is that when it comes to arriving at the hospital, staff must remain with patients and this effectively disallows them from leaving places like Cork University Hospital and other emergency rooms to go back on the road and get back out there to help people. It is a profoundly flawed system. That is the question I put first and foremost. From a cost perspective, what is the HSE planning to do to allow a quicker turnaround time for ambulance crews who arrive at a hospital with an extremely sick patient and who want to get the patient into the hospital and leave? I am hearing many reports of crews who are being left in the hospital caring for patients, which is something they should not be doing, quite frankly. It is a huge concern because the knock-on impact is that ambulance crew will not get to another patient who needs them.

Mr. Stephen Mulvany

I agree with the Deputy on the importance of the ambulance service. I was lucky enough to visit the Tallaght control centre on my first day and it was great to meet the staff. The atmosphere of caring, quietly efficient teamwork was very impressive. I will get to meet an ambulance-based crew tomorrow. We agree ambulance handover times at hospitals are a significant problem. We are working with hospital staff. It is about changing mindsets. We must remember the hospital staff themselves are under significant capacity pressures, which we are trying to alleviate. It is also about working with them so that we are all thinking of the patient who could be at the side of the road needing the ambulance. It is a complicated problem that is not straightforward to solve but it is about supporting everyone to get to that same place.

Mr. Robert Morton

I thank the Deputy for the question. Absolutely, it is probably the single biggest clinical risk we face at the moment. Working closely with all of our colleagues across the acute hospital sector we collectively realise the implications of offload delays and the clinical risk this presents, which is the patient lying on the ground waiting for an ambulance because it is parked at a hospital somewhere. The solutions are complex. Some of it is down to capacity in the hospitals and in the ambulance service. We are focused on working with our acute hospital colleagues to try to streamline the process of handing over patients, and looking at measures we can take in extremis. Part of that is how we prepare for the forthcoming winter period. For example, Professor O'Donnell is involved in a high-level group along with other clinicians looking at what are some of the process solutions we can put in place. From our perspective, we are looking at measures around improving the local escalation arrangements between local National Ambulance Service, NAS, managers and local hospital managers. We are looking at models such as fit to sit, where we must take a deep look at ourselves and ask ourselves whether every patient who attends an emergency department needs to go in on a stretcher or are some patients clinically suitable to sit in a chair, which would release the ambulance to get out back out to another patient. We are also looking at cohort arrangements whereby we can have one crew looking after more than one patient, to release another ambulance. These are the kind of in extremis measures we need to look at as part of our own contingency planning. It is very high on our radar but the solution will not lie in the acute hospital or the National Ambulance Service looking at it in isolation. We must look at it together.

Deputy James O'Connor

I accept that it is on the HSE's radar but the part that bothers me is that it has been on the HSE's radar for an awfully long time. This issue has not occurred just today or yesterday. It has been going on for a number of years. It is starting to seriously worry me now and, while I do not mean to be parochial, in my area we are seeing a collapse in SouthDoc services. I am getting repeated calls from people telling me that they can get through to SouthDoc. This causes issues and knock-on impacts on whether or not ambulances should be called. Then, when ambulances are called the waiting times are far too long. This is happening as a consequence of the issues outlined, and as I have outlined, in that they are not being released quickly enough from the hospital.

Surely it is not that big of an undertaking for the HSE to put in place a task force to look at this over six months, and to get teams in place at hospitals to receive the patients so that the ambulance crews can get back on the road. That is all it is going to take: a couple of nurses and a couple of doctors. We are all aware of the recruitment shortages in the HSE at the moment, but I do not believe it would have an adverse knock-on impact on the entire national healthcare system to put those staff into the busiest hospitals in the country. It all boils down to the fact that ambulance crews should not be sitting in hospitals caring for patients. They should be out on the road trying to rescue people who are in circumstances where they need the help. It is unacceptable that this is going on in this day and age.

From my knowledge and from what I am hearing in my area it seems to be deteriorating. That is a serious worry. Is the provision of funding for a task force something that the HSE would be willing to undertake or look at, and that we would have period of time to look into this issue, with a time limit to come back with some findings to the Government? Is this on the cards with the HSE? I cannot take anything that the witnesses said to me today at face value. I do not believe there was any commitment in anything they said. Would Mr. Mulvany consider that?

Mr. Damien McCallion

I will come in on that. Mr. Morton mentioned that there is a group already in place focused on this issue between hospitals and the ambulance service. The core of the issue with regard to staffing is that we have put extra funding in for safer staffing in our emergency departments and our hospitals. We also discussed at the committee recently, and the Deputy has mentioned, the challenges around staffing in the context of recruiting nurses and doctors in emergency departments. As Mr. Morton has said, some of the measures that have been set up with the ambulance service are to try to mitigate those pressures that continue on our emergency departments. Part of the winter plan is looking at those measures. It is not just in the ambulance service because, in fairness, the challenge is not just there. It is in the hospital on the one hand as well as trying to grow the capacity in the ambulance service.

We are under pressure. We spoke to the NHS last night and they are equally under huge pressure on this issue of ambulance turnarounds. The causal factors are partially down to the current increased demand going into the winter. This is why that group is in place to look at solutions in the short, medium and longer term, and also looking at crisis solutions, as Mr. Morton has set out. Mr. Morton might want to respond on that. I want to be clear to the Deputy that there is a group focused on this. We see it as a huge issue for our performance, for safety, for the release of ambulances, and for patients. There is a group focused on this for our hospitals and ambulance services. A collective solution needs to be found. It is a challenge in lots of healthcare systems at the moment, unfortunately, coming out of the pandemic where we are seeing a lot of pressures on emergency departments.

I understand the Deputy's concerns and what he has said about getting confidence on it. We can assure the Deputy that every effort is being made to try to find solutions that will address it. It is not a simple fix. I just want to be clear on that. We are trying-----

Deputy James O'Connor

I do not believe that anybody is making that assumption. It is a difficult thing to do. Anything that involves deploying a medical team does not have a simple solution. This must be raised, however, and I will give a recent example. A person in east Cork recently had to wait 90 minutes for an ambulance to come from Carlow. I will not give any further breakdown, but that person is now dead. I will leave it to the experts to make their assumptions but it is my understanding that perhaps the person could have been helped if they had got to the hospital on time. This is extremely worrying. It is just not good enough. It is wholly unacceptable that ambulances are being pulled from the middle of Leinster down to Munster in east Cork, and particularly when we have hospital only 45 minutes up the road. There are most certainly ambulances waiting there to be discharged. There is an enormous urgency around this issue. I would hope that in one years' time when the witnesses are before the committee again that improvements would be made by then. I accept that Covid was exceptionally difficult for everybody but I remind the witnesses that this issue was there before Covid.

All of us here acknowledge the extraordinary work done by the people in the National Ambulance Service. We are very grateful to them. They are under enormous pressure. It is just not good enough from the HSE quite frankly.

Mr. Stephen Mulvany

We agree with the Deputy. It is a huge issue for us. Mr. Morton will confirm that it was the first issue that I as CEO discussed with him as director of ambulance services. The issue is getting a lot of focus and we accept that we need to improve the situation substantially.

Chairman

I will revert to the personal protective equipment, PPE, issue, and hand sanitiser in particular and the best by date. Perhaps the HSE will come back to the committee with the definitive position on that. The figure of €25 million worth is a significant sum of money. Surely there is a use for that across the health sector. That needs to be questioned with the manufacturers.

With regard to PPE. The Comptroller and Auditor General estimates the impairment charges of €374 million, and these are recognised in the 2020 financial statement. In 2021, the HSE incurred further impairment charges of €109 million. That is a total impairment of €483 million. It is a substantial sum of money. I understand, and it has been explained a few times in this committee by the Health Service Executive in relation to why a lot of stuff must be procured quickly, that saving lives was the priority. At the same time, it has turned out that a lot of the PPE purchased was not suitable, fell short of standards, or maybe was more than we needed. In the situation that we were in, obviously people have to play it safe. The figure of €483 million is a substantial sum of money. Perhaps Mr. Mulvany will respond to that.

Mr. Stephen Mulvany

There is no doubt that it is a huge sum of money. Again, going back to conditions that were in place at the time, about which we do not need to remind people, all of those decisions were made largely in March or April on all the orders. On the technical piece of it, the vast bulk of that €483 million over two years, which was the €109 and €374 impairment charges, the vast bulk of that was a price impairment. There is a level that was obsolescence and there is a level that was storage, but the vast bulk of it is price. This means that we had a choice. Back in March and April 2020, we could have said "We will buy less now in the hope that we will be able to buy more later, on which there was no certainty, or that we will get it at a better price". We were just not prepared to do that arbitrage or that gambling.

Chairman

I understand that but-----

Mr. Stephen Mulvany

The technical piece is important. This was a price impairment. We did not buy it to resell it. We bought it to use it. This is simply a technical piece: if it is worth less at the end of the year before one gets to use it, one charges it to the year. It is not an impairment of something that is going to be resold. It is not because it was the wrong size or that it was not fit for purpose. It is none of that. That is now on the record of the House and I just need to correct that. It was not the case. This was price impairment. We balanced the financial risk, which was substantial, against the risk that we would not have enough PPE to keep our staff coming to the service.

Chairman

Am I correct in saying that some of what was imported was not suitable for use?

Mr. Stephen Mulvany

The vast bulk of what was not suitable for use was not equipment the HSE bought. There was a small element of that and a small element of this overall impairment is obsolescence. It was suitable for use when bought but went out of date. I believe I am correct in saying that very little of the impairment has anything to do with not being fit for purpose.

Chairman

What Mr. Mulvany is hearing today from the Committee of Public Accounts and what I am saying as its Chairperson is that we understand that and that decisions had to made quickly. We and all of Europe were caught in this situation. We were at the epicentre of the Covid-19 pandemic and we understand that and the work that was done to counter that. What we are saying to the HSE now, however, is that whatever the main equipment and sanitiser is, that this receives serious attention, in terms of trying to use it. Other services possibly might acquire this equipment, as in the case of India which I have no argument with, because this was a worldwide pandemic and a better use was found for it.

My other question-----

Mr. Stephen Mulvany

Just for the record, Chairman, and I know that he is aware of this but for people consulting this record, none of this impairment material is available for us to try to reuse. That is a separate discussion about the hand sanitiser, which we will do everything to address.

Chairman

I understand that. One of the reasons for this was that it was a sellers’ market at that point in the spring of 2020. One of the reasons, in turn, was that it turned out that we did not have any indigenous sources. Many people have raised with me the question as to how we arrived at a situation, not just in Ireland, but in Europe, and in particular western Europe, where we do not make masks, hand sanitisers, gowns or protective suits. What has been done now because I would not like to see the country caught again? Because of international travel now, the world is a smaller place. I am not an expert on this but the Spanish flu became an epidemic mainly in Europe. It did not travel as far and travelled more slowly. Many of us thought that perhaps Africa would be very badly affected by the Covid-19 pandemic but it turned out that the virus did not reach parts of Africa because, from a development point of view, cars were not as available and people do not move as far. Many localities in Africa, apparently, remain, thank God, fairly Covid-19-free. My point is to ask what is happening now and what is being done now to ensure that we have indigenous supplies of PPE when we need them. Perhaps the Department and Mr. O’Grady might answer my question here.

Mr. Stephen Mulvany

In the first instance I will answer and Mr. O’Grady can come in then. We have bought a substantial amount of masks, in particular, from indigenous suppliers but we had an element of indigenous supply prior to Covid-19. The issue was that the volume of PPE required pre-Covid-19 and post-Covid-19 was incomparable. The Chairman is completely right in that this is one of the lessons to be learned and it is being learned. There is a European-wide agency looking at future preparedness.

Chairman

Have we a greater capacity now than we had before?

Mr. Stephen Mulvany

There is more on-island capacity and we have a strategy of on-island, near-island, that is, Europe and far, which is, for instance, the Asian market. Our significant reliance was predominantly on that far market during the Covid-19 pandemic, .

Chairman

We could have another pandemic like this. Would Mr. O’Grady like to comment further on this?

Mr. John O'Grady

Mr. Mulvany has covered the substantial point. There has been development of indigenous supply. As I understand it, our HSE colleagues have advised that a great deal of current expenditure on replenishing stocks is coming through indigenous suppliers. That has been built up with support from the Department of Health and from other Departments. The Department of Enterprise, Trade and Employment is also involved, so I believe that lessons have been learned. I am not across the detail of this or have it in front of me.

Chairman

Has work been done, for example, with some of the bodies like Enterprise Ireland and has that agency been spoken to about this?

Mr. John O'Grady

I believe so. I do not have the details but we can get a note for the Chairman on this.

Chairman

That would be to reassure people because Aer Lingus and some airline companies did some good work on putting on special flights to China and so forth at the time. It is hard to prepare for every emergency but if one thing emerged from that pandemic, it showed that western Europe was caught out and we need to be more prepared in future.

I have a couple of final questions. On home care, the budget and the number of hours have been increased, all of which are welcome. We want to try to keep more people at home. There are problems arising in the nursing home sector which clearly point to this. The demographic trend is that people are living longer and they want to stay at home. Some 99 out of 100 elderly people will say that they would prefer to be kept in their own home for as long as possible.

I understand there are problems with recruitment. The service is provided directly by HSE staff, by what used to be termed home helps and by agency staff. As an observation, based on my own contemporaries, the agencies have a job in retaining staff and perhaps the HSE does too. On the issue of costs, and in answer to parliamentary questions I have submitted over the years to which I have often had difficulty in getting a direct answer, where it might take a couple of parliamentary questions, these replies confirm that agency staff cost more to the HSE than directly-employed HSE staff. This was contained in the answers I received on three occasions over the past 12 years. On that issue, how much effort is being put into recruiting directly-employed HSE staff for home care?

Mr. Stephen Mulvany

We provide just over half of the overall home support and the balance is either voluntary or private. There is a policy position which we have been advised of, which is to try to maintain if not increase that balance.

Chairman

Mr. Mulvany mentioned a policy position. Can he clarify that for me, please?

Mr. Stephen Mulvany

Yes, it is to maintain if not increase that balance of direct public provision versus private.

Chairman

The policy position is to increase that public provision then.

Mr. Stephen Mulvany

It is to maintain or increase the public-funded home care. In parts of the country, such as the east, this care is predominantly voluntary or private whereas the rest of the country has more direct provision, so this would be to rebalance it. That said, we always will need to work with both voluntary and private partners around this.

Chairman

Is the HSE active at the moment? I see letters to people informing them that they been granted home help hours but staff may not be available in some parts of the country. Is the HSE actively recruiting in those areas?

Mr. Stephen Mulvany

We are very active. If we were appearing before the committee three years ago, members would have been correct in informing us that they had seen letters where people were waiting because of funding. That has now been substantially eliminated. Now we have people waiting, unfortunately, because we need to get caring staff to go out and care for them. This is just as big a problem if one is waiting, but is one we are seeking to recruit for.

Chairman

On the issue of dental services, I raised this last week and I am trying to understand what is happening. On the breakdown of funds, the HSE had €23 billion for the coming year and just under €22 billion for this year. What is the budget for HSE dental services in the State this year?

Mr. Stephen Mulvany

We are probably in the process of responding to the Chairman's queries but I do not have it with me today. We are working on getting a detailed response for the Chairman, as he asked us this question in our previous meeting.

Chairman

Can Mr. Mulvany ensure that I get the breakdown, as always, for Laois-Offaly? I understand that there are three different types of services. First, there is a public one, which is the PRSI service, whereby some people get cover if they have a certain class of PRSI and are entitled to certain treatments. The second is the dental treatment services scheme, DTSS, which is the medical card scheme. The third one is the school service. I am trying to understand what is happening in the three of those. I am saying here today that the school service is not available in the part of the planet I inhabit; it is not available in Laois. Every time HSE representatives appear before the committee, I will say the same thing to them because this has to be fixed. There is no primary school dental service in County Laois and it is patchy in County Offaly as well. Children who have gone right through that system, are almost at the end of the secondary school system and are 17 years of age, have never seen a school dentist or public dentist.

I am saying directly to our witnesses that on its budget, the Committee of Public Accounts and I want to know that if the Department of Health takes up a significant amount of money for the budget over at the Miesian Plaza - I would argue for as much money as possible going there because running the health service is expensive - that we will see a service at the other end. What is happening in between? If we are relying on private providers, why are we not offering a career path here to train, recruit, encourage and educate people into these positions?

This must be sorted. The DTSS has collapsed also. It is non-existent. There is no DTSS. The HSE is negotiating with hundreds of businesses.

Mr. Stephen Mulvany

If I could make a comment on the DTSS, there are challenges there.

Chairman

There are more than challenges.

Mr. Stephen Mulvany

The Government has invested-----

Chairman

It has collapsed.

Mr. Stephen Mulvany

I would not use that characterisation. There is an additional €20 million in a full year going into the DTSS.

Chairman

How much?

Mr. Stephen Mulvany

It is €10 million, with a full-year cost of €20 million. That was announced last year. We will come back specifically to the children's service in County Laois. That is as likely as anything to be a recruitment rather than a base-funding problem. We will determine that.

Chairman

But that is going on for years. In my time as a Deputy, over the past 12 years, the service has deteriorated. It has fallen off a cliff. The service has collapsed. Here we are in a rich country with another big budget passed for health. I heard no one in the Government or in the Opposition arguing about that. No one has said to the Minister for Health or to the Minister for Finance that they are putting too much money into it. I know these issues are hard to fix, but a start must be made somewhere. Could Mr. Mulvany say what the funding is on a national level for dental services? Could he tell me what it is per CHO? I do not want to be parochial, but I am trying to get my head around what is happening. Could Mr. Mulvany give me a breakdown of what the funding is in CHO 8 in terms of the DTSS, the public scheme and the school scheme? Am I correct in saying they are the three schemes?

Mr. Stephen Mulvany

Yes. We will come back to you, Chair.

Chairman

Could Mr. Mulvany give me the figures for Laois and Offaly as well, so that I can see what is happening?

Mr. Stephen Mulvany

Yes. We will do that.

Chairman

The public ask me these questions and I cannot answer them.

Mr. Stephen Mulvany

We will come back to you, Chair.

Chairman

I am not trying to finish on a bad note, but it is an issue I cannot let go of.

Mr. Stephen Mulvany

In fairness, you did raise it last week, Chairman, and we are working on getting the answer.

Chairman

Okay. I thank the witnesses from the Department, the National Ambulance Service and HSE senior management for joining us here today and for preparing for the meeting. I thank the support staff for their work and supplying the documentation. From the Comptroller and Auditor General's office, I thank Mr. McCarthy and Mr. Crean for attending and their support staff for assisting the committee.

Is it agreed that the clerk will seek follow-up information and carry out any agreed actions arising from the meeting? Agreed. Is it also agreed that we note and publish the opening statements and briefings for today's meeting? Agreed. The committee will resume in private session at 1.30 p.m. before moving into public session soon after that to deal with correspondence and other committee business.

Sitting suspended at 12.43 p.m. and resumed at 2 p.m.