COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 5 Oct 2023

Health Service Executive: Financial Statements 2023

Mr. Bernard Gloster (Chief Executive Officer, HSE) called and examined.

An Cathaoirleach

We have received apologies from Deputy Munster. The witnesses are very welcome. I remind those in attendance to ensure their mobile phones are switched off or in silent mode.

Before we start, I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards reference that 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 the Constitution and statute, by absolute privilege. This means they have an absolute defence against any defamation action for anything they say at the meeting. However, they are expected not to abuse this privilege and it is my duty, as Cathaoirleach, to ensure it is not abused. Therefore, if a witness's statements are potentially defamatory in relation to an identifiable person or entity, he or she will be directed to discontinue their remarks. It is imperative that witnesses comply with any such direction.

Witnesses are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of a person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, witnesses will be directed to discontinue and it is imperative that they comply.

Members are reminded of the provisions within 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 to the effect that they should not comment on, criticise or make charges against 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, is a permanent witness to the committee. He is accompanied this morning by Ms Olivia Somers, deputy director at the Office of the Comptroller and Auditor General.

This morning the committee will engage with the Health Service Executive to examine its financial statements for 2022. We are joined this morning by the following representatives of the HSE: Mr. Bernard Gloster, CEO; Mr. Stephen Mulvany, chief financial officer; Dr. Colm Henry, chief clinical officer; Ms Anne Marie Hoey, national director of human resources; and Mr. David Walsh, national director of community operations. We are also joined by Ms Louise McGirr, assistant secretary at the Department of Health. They are very welcome.

I call the Comptroller and Auditor General, Mr. Seamus McCarthy, to make his opening statement.

Mr. Seamus McCarthy

The Health Service Executive's financial statements for 2022 record total expenditure of €24.5 billion. This comprises capital spending of €1.2 billion and non-capital or recurrent spending of €23.3 billion. Operating expenditure in 2022 exceeded income by €185 million and this deficit was carried forward to be met from the funding provided from the health Vote in 2023.

On the capital side, there was a surplus of €47 million. It is a matter for the Minister to direct whether the HSE retains the surplus or returns it to the Exchequer.

The revenue, income and expenditure account analyses expenditure by spending type. Pay and pensions cost a total of €7.8 billion in 2022. Grant funding transfers to section 38 and section 39 agencies amounted to €6.3 billion. Spending on primary care and medical card schemes, including drug refunds, amounted to €4.2 billion. The bulk of the HSE's funding comes from the health Vote, amounting to a total of €23.3 billion in 2022, including funding for capital projects. Other much smaller sources of income for the HSE were retained employee pension contributions deducted from HSE and section 338 agency staff salaries, which amounted to approximately €384 million in 2022, and receipts of €370 million in respect of patient charges for hospital treatment or long-term residential care.

I issued a clear audit opinion in respect of the financial statements. However, in my report, I drew attention to a number of matters disclosed by the HSE. In 2022, Covid-19 vaccines that had been acquired at a cost of €94.4 million were written off. Vaccines to the value of €33.7 million had not been used before the manufacturers' expiry date.

Vaccines that cost €60.7 million were written off because they were expected to reach their expiry date before they could be used.

Separately, the HSE incurred storage costs amounting to €1.7 million in 2022 in respect of stocks of obsolete personal protective equipment, PPE, and hand gel. The costs of the obsolete stock were written off in 2020 and 2021.

Once again, my audit report for 2022 draws attention to non-compliant procurement. A self-assessment exercise carried out by the HSE on individual invoices costing above €25,000 estimated that non-compliant procurement in 2022 was around €128 million, representing 7% of the value tested. I concluded for technical reasons that this estimate rate of non-compliance with procurement rules may not accurately reflect the scale of the underlying problem but I am satisfied that non-compliant procurement remains a significant issue for the HSE.

Voluntary and community sector agencies, referred to as section 38 bodies, provide health and personal social services on behalf of the HSE and are considered part of the public health system. Section 39 agencies provide services similar or ancillary to those provided by the HSE. As mentioned previously, HSE grant funding to the agencies amounted to €6.3 billion in respect of their recurrent operations. A further €532 million was provided to the agencies in respect of capital investments, which included €340 million transferred to the national paediatric hospital development board. An appendix to the HSE’s financial statements lists the transfers in 2022.

In the statement on internal control, the HSE outlines its system for oversight and monitoring of those grants, including the arrangements for agreeing on what is to be delivered for the funding provided and for reporting on the outcomes. There appears to be a downward trend in the proportion of annual funding covered by timely formal contract agreements. As a result, even by the end of 2022, only 83% of the funding issued to section 38 and 39 agencies was covered by a completed funding agreement of the appropriate type. This compares with 96% in 2017.

Finally, note No. 7 to the financial statements analyses the HSE’s direct payroll costs into bands. This indicates that eight staff members each received remuneration in excess of €500,000, with the highest remunerated staff member receiving €974,000. All of these staff were medical consultants and almost all the payments related to their service and entitlements in respect of 2022. An HSE internal audit report identified some potential internal control gaps around payments to highly-remunerated staff under local working pattern arrangements.

Mr. Bernard Gloster

I thank the committee for the invitation to attend today to discuss the HSE financial statements for 2022. I am joined by my colleague, Mr. Stephen Mulvany,CFO, Dr. Colm Henry, chief clinical officer, Ms Anne Marie Hoey, national director of human resources, and Mr. David Walsh, national director of community operations. I am supported by Mr. Ray Mitchell from parliamentary affairs and Ms Sara Maxwell from my office.

In the context of addressing the financial statements for 2022, I am aware the committee has indicated particular interest in losses related to obsolescence of Covid-19 vaccines and PPE as well as high remuneration payments to certain employees.

I wish to take this opportunity to acknowledge the recently highlighted difficulties for children with spina bifida and scoliosis and their families. The outcomes from two Children’s Health Ireland, CHI, reports – an internal report and a Boston report – are concerning at the higher end of the scale. The additional revelations regarding the use of unauthorised springs as internal devices are most concerning and have seriously damaged confidence in this most sensitive area of our healthcare system. To the parents, advocate groups and, most importantly, the children, I apologise and give my assurance as CEO that these matters will be fully examined and responded to as part of the independent expert review commissioned by the HSE, to be led by UK-based orthopaedic surgeon, Mr. Nayagam.

Addressing the committee agenda for today, I direct attention to the briefing paper provided in advance of the meeting. The briefing details are instructive on the evolving financial position of HSE building from 2019, the impact of the pandemic and once-off supplementary allocations. The resulting pressures for 2023 are evident.

The current challenges in closing out 2023 are best described under three headings: non-pay, increased demand and control environment. Regarding non-pay, inflation is typically higher in a health context and non-pay is also driven by higher volume spend associated with higher volume activity. Increased demand for health and social care services is higher than expected, with both post-Covid pent-up demand, increased morbidity and complexity within parts of that demand and also demographic pressures, resulting in unprecedented levels of people requiring services. The third component is the control environment. There is no doubt that as we move past the Covid years, the control environment requires improvement. Significant attention is being paid to this at the close of 2023 and will be required throughout 2024.

The briefing submitted to the committee details the historical challenges with existing level of service, ELS, funding and outlines the requirement for full funding of ELS prior to any additional or new developments in 2024.

Covid-19 vaccine obsolescence for 2022 was circa €33 million for out-of-date and €60 million worth of vaccine with no further utility due to change in health guidance and the related excess of supply over demand. PPE write-offs were in years predating 2022 and have previously been the subject of detailed hearings of the committee. However, continued storage costs of obsolescent PPE were recorded in 2022 at €1.7 million. The briefing sets out the options and challenges for disposal. I am committed to a resolution of this cost, subject to the result of various assessments regarding safe and cost-effective disposal.

Currently, an HSE employee is defined as a high earner if they are earning above €300,000. This is likely to require adjustment as the new consultant contract will mean that a significant number of employees will be above that figure when all dimensions of the contract are factored in. That noted, there are improvements required regarding the control environment and inconsistency of approach that results in some of the high earnings recorded. Despite contractual entitlement and legally correct application of terms, I do not accept that we can continue at a position where eight staff earn more than €500,000 - in one case, more than €700,000 and the highest more than €900,000. Based on the internal audit reports and the resulting action plans, we are working to address this issue.

In parallel with the financial context, 2022 saw the HSE return to increased normal operational business across all services. The outturn for 2023 in service terms will show one the of highest rates of activity ever across many services. The main focus for the remainder of this year is on the waiting list action plan and the management of unscheduled emergency care, in both of which we continue to make improvements.

Deputy John Brady

I will pick up first where Mr. Gloster finished, which is the high-end earners within the HSE. He said they are working to address the issue. He cited a number of grossly overpaid staff in the HSE. My first concern is that the number of high-end earners seems to be increasing rather than what he said, which is that they are working to address the issue. Looking at the financial statements for 2021, the number of staff earning more than €450,000 was eight and, for 2022, it was 14. In 2021, there was no one earning in excess of €970,000 and, in 2022, there was one. The numbers are increasing rather than decreasing.

What does working to address the issue actually mean? I have a number of specific questions in that regard. In respect of the highest earners, without identifying any individuals - I am not here to establish that - are we talking about additional payments to certain consultants? It is safe to say that all these high-end earners are consultants. Would I be right in saying that first and foremost?

Mr. Bernard Gloster

Taking into account what I said about the €300,000 on the higher end, yes, they would be consultants with specific specialties. With regard to the volume of payment, particularly with regard to the highest earners, it is associated with the terms that can be specifically provided for in a consultant contract with regard to on-call-----

Deputy John Brady

Okay. Was it for additional work above and beyond?

Mr. Bernard Gloster

It is a range of issues covered in the contract but predominantly to do with call-outs.

Deputy John Brady

I beg your pardon.

Mr. Bernard Gloster

It is predominantly to do with call-outs.

Deputy John Brady

Would that involve double time or triple time?

Mr. Bernard Gloster

No, there is a specific rate in the contract. The chief financial officer or director of HR may wish to address the technical aspect, but in the consultant contract it is not overtime per se.

Mr. Stephen Mulvany

It just depends on the rota they are on. The less people on a rota, the more there is a requirement for 24-hour coverage and the more on-call a consultant will experience and, therefore, the more they are called out or have to be available for call-out, the more they will attract additional payments. That is one of the reasons, certainly, for the top eight who are in the numbers.

Deputy John Brady

On average, how many hours per week would those high-end earners be working? Would Mr. Mulvany have those figures?

Mr. Stephen Mulvany

Dr. Henry may have those figures.

Dr. Colm Henry

For the large part, these earners need to continue on scheduled care cover 24-7, particularly in a number of hospitals where it has proven difficult to recruit additional consultants to create a more sustainable rota. In surgery, for example, there is a need for 24-7 cover. If we cannot recruit a general surgeon to a particular hospital, or an emergency department consultant or, indeed, a radiologist, that does not take away the need to provide continuous 24-7 cover.

Deputy John Brady

Absolutely, I understand that. On average, how many hours per week would the consultants be working - these high-end earners about whom we are talking?

Dr. Colm Henry

It depends on the frequency of the rota. If they are covering for other unrecruited posts then they may be on a one-in-three or one-in-two rota, which means that in addition-----

Deputy John Brady

They would, therefore, be working more than 40 hours per week.

Dr. Colm Henry

Way in excess. It is not just the core hours but the availability out of hours that demands their availability 24-7 and sometimes, as I said, due to our inability to recruit other consultants for that particular rota.

Deputy John Brady

These individuals would be carrying out operations and life-saving procedures. Who oversees the number of hours to ensure the hours being worked are safe? If we look at, for example, truck drivers, there is a very robust system in place called the tacograph system to ensure that they operate within safe working hours and times. What procedures are in place to govern consultants who carry out lifesaving operations?

Dr. Colm Henry

They report to clinical directors within their own individual hospitals and, of course, through those to the general managers and chief executives of hospitals and hospital groups. In those situations, of course, as the Deputy said, it is not in anybody's interest, most of all the patient, that they are being cared for by somebody who is working excessive hours, be it the core hours of availability during the week or excessive on-call availability. Our thrust in many of these cases is to create more sustainable rotas. For example, in maternity networks over the past few years, we have placed a minimum of six doctors for each of the 19 maternity hospitals, including some of the 19 maternity units, rather than relying on traditional models of two or three consultants providing continuous cover. We are working in a very competitive environment recruitment-wise to recruit consultants for more sustainable rosters rather than one-in-two and one-in-three rotas, which result not just in excessive payments but excessive hours worked by consultants in those cases.

Deputy John Brady

The Comptroller and Auditor General clearly identified concerns regarding internal control gaps. What control gaps in respect of additional hours have been identified by the HSE?

Mr. Stephen Mulvany

The core issue here, as the chief clinical officer said, is that balance between maintaining a service at all and trying to maintain a safe service. In terms of some of the controls and some of what we have done to address those control issues, it is not our job to try to second guess our local service managers who are trying to make those judgments. What we have done is put in place a series of local registers of the individual situations that are causing excessive payments and excessive hours. Some of the excessive payments are because of compensatory rest days, for example. Some of them are related to retirement-related payments. In the main, however, it is about overall hours. We have put in place a series of registers of those and, obviously, for our hospital groups. Centrally, the issue now is monitoring those registers and trying to remove as much as possible the conditions that lead to those choices having to be made so people are on more sustainable rosters.

Mr. Bernard Gloster

With regard to the improvement question, which is fundamentally where the Deputy is going although I would not assume that, the new public-only consultant contract provides for a very different banding structure of how consultants' hours are rostered and deployed. We had at the last count 622 signed up to that contract. As we increase the capability to deploy differently, we will reduce the type of incident we have here. With the type of incident we have here, there are parts of the country where there are one or two specialties that are just impossible to fill. They have to be there. As the chief financial officer said, it is that constant tension and balance. That said, I personally believe that in management terms there can still be better controls about the number of call-ins and how they are managed and monitored.

Deputy John Brady

Okay. I thank everyone for that. I want to move on to a completely different area, which is the dental treatment services scheme. When the witnesses appeared before the Committee of Public Accounts previously, I raised serious concerns I had in terms of the failure to address the serious shortcomings regarding that scheme. I gave figures relating to my own county where 70% of dentists who had signed up to that scheme have now withdrawn. It is down to 16 dentists now in County Wicklow providing that cover. It is proving virtually impossible for people and medical card holders to access a dentist. How much is budgeted annually for the dental treatment services scheme?

Mr. Bernard Gloster

I will ask the director of community operations to address that. I am conscious that it was raised the last time we were here and I am anxious to address it.

Mr. David Walsh

I will give the Deputy some idea of expenditure over the years on the dental treatment services scheme and how it has ebbed and flowed. It was-----

Deputy John Brady

I am conscious of the time. Mr. Walsh might perhaps just give us the most recent. How much has been-----

Mr. David Walsh

That is where I am going. In 2022, it was just under €50 million, so, €49.5 million. In 2023 to the end of August, it is €43 million. For January to August last year, it was approximately €29 million. It is, therefore, up significantly this year based on the enhanced reimbursement rates that were introduced last year. The number of dentists within the scheme continues to fall slightly. The Deputy mentioned County Wicklow. I am also conscious that in County Laois, Chair, there are 12 dentists within the scheme currently. They are two of the lowest in the country. That is still a significant issue. There are better payments available.

Deputy John Brady

On those figures, in 2023, it was €43 million. In 2022, €50 million had been allocated for the provision of the scheme over the course of the year. What was the total amount?

Mr. David Walsh

They were the claims.

Deputy John Brady

They were the claims.

Mr. David Walsh

They were the claims. This year to date, the claims are €43 million. Our expectation is that the outturn for 2023 will be significantly higher than last year's. Up to the end of August, it was running approximately €13.5 million ahead of last year. We would expect that to continue to the year end.

Deputy John Brady

Okay, so, the claims figure is going up-----

Mr. David Walsh

Correct.

Deputy John Brady

-----but the number of dentists continues to go down.

Mr. David Walsh

Yes, the rate of decline has slowed but it is still going down.

Deputy John Brady

We are probably close to rock bottom. There are not too many left to jump out of the scheme. The counterargument would be that we are at rock bottom and the impact on my constituents and constituents right across the State is they can not get a dentist for love nor money. That is the crux of the issue. Where are we in the negotiations with dentists and representative organisations to address the serious issue in terms of what they have identified?

Mr. David Walsh

I am not too sure. I believe the Department is engaging with the Irish Dental Association but I do not have details of that. The measures taken last year were seen as interim measures to increase the reimbursement rates for the various treatments. It is also worth noting that the HSE's public dental service continues to try to assist people to locate dentists where they have trouble locating dentists who are participating in the dental treatment service scheme, DTSS. An increasing amount of the public dental service's resources are going to emergency work. It now accounts for well over 50% of the total work done.

Deputy John Brady

It is not working. What is happening is that ordinary people, who do not have the means or resources, are having to pay out considerable amounts of money to private practitioners to address-----

Mr. Bernard Gloster

I think the issue is the volume available as opposed to the amount of claims. Some €68 million was provided for this year to be available to the dental profession to enter and draw down from the DTSS. That is a 20% increase on last year. That would seem to suggest that it is not just what we are offering to pay. There are obviously other factors informing people's choices to operate and participate in these schemes.

Deputy John Brady

There clearly are serious failures there that need to be immediately addressed.

I want to move on to another area for the last few minutes, namely, the portfolio of properties held by the HSE across the State. We know there is a considerable portfolio of over 4,000 properties across the State, but I want to focus on derelict and vacant properties held by the HSE. How many properties in the database are vacant? Do we have those figures?

Mr. Stephen Mulvany

There are over 2,000 properties, property being everything from a small house to a very large campus or a number of-----

Deputy John Brady

Are they vacant?

Mr. Stephen Mulvany

No. On the overall database there are over 2,000 properties, but the number vacant just below 400.

Deputy John Brady

About 400.

Mr. Stephen Mulvany

They are spread around the country and are of all different shapes and sizes.

Deputy John Brady

Is the database listing those vacant properties publicly accessible?

Mr. Stephen Mulvany

We provide information from it in response to parliamentary questions, representations and when people want information.

Deputy John Brady

I ask that the committee is furnished with an itemised breakdown of where those properties are in each county across the State, and how long those properties have been vacant.

Mr. Stephen Mulvany

We will certainly look at that. We have an active process of disposing of properties and exchanging properties with other public bodies, as we are required to do under overall public service requirements. Other public bodies, including the OPW, are aware of our vacant properties and of our willingess to transfer sale and sometimes donate those to the State or other public bodies.

Deputy John Brady

I know a fairly lengthy process is involved. Looking at my own constituency, there are a number of properties there. I am very conscious that there are over 12,600 homeless people in the State and that up to 400 State-owned properties that are lying vacant. Is there a value on the portfolio of vacant properties?

Mr. Stephen Mulvany

I do not have the value currently. The HSE is part of the task force centrally which is looking at the use of public property for homeless-----

Deputy John Brady

Okay, so there is no value on the assets that are vacant.

Mr. Stephen Mulvany

There is a value, but I just to not have the figure with me. We can certainly provide it.

Deputy John Brady

Can that be furnished to the committee?

Mr. Stephen Mulvany

Absolutely. I should also say that we are actively participating in identifying with colleagues in other Departments whether any of those properties are suitable for accommodation, including for homeless people.

Deputy John Brady

Can we also get details on the square footage or area in square metres of the assets that are vacant? Can that information be provided to the committee?

Mr. Bernard Gloster

We can certainly check the depth of the data that is available nationally on all the local properties. We are talking about a lot of cottage health centres, as they used to be termed, in small villages and add-ons to community centres and so on. We will certainly do our best to provide everything we can. As Mr. Mulvaney said, apart from properties we are also engaging with-----

Deputy John Brady

The HSE is trying its best. Mr. Mulvany said it is linked in with the OPW in a process. Surely that information is centrally held. I referenced the figure of 12,691 people who are homeless in the State. There are people who have come to this country for international protection who are living in tents, and there are 400 properties that are held by the HSE in a derelict or vacant state.

Mr. Bernard Gloster

I can assure the Deputy that if any part of the State, whether that is the Housing Authority or the Department of Children, Equality, Disability, Integration and Youth, wants to avail of any property that is available, free and we are not using, we are not hiding it from anybody.

An Cathaoirleach

I will let the Deputy back in for a second round.

Deputy John Brady

Just one last question.

An Cathaoirleach

No, the Deputy has gone over time.

Deputy John Brady

I have one last question on the information that the HSE is going to furnish to the committee. I also ask that details are provided of the cost in terms of how much it is for the upkeep of those vacant properties, including security provided, to keep them.

Mr. Bernard Gloster

I absolutely assure the Deputy that we will do everything we can to provide the committee with that information. Given the scale of the detail, it may just take a bit of time.

An Cathaoirleach

Thank you. Deputy Dillon has ten minutes.

Deputy Alan Dillon

I welcome our guests. I want to go back to the issue of the eight highest earning staff members within the HSE. They are receiving remuneration in excess of €500,000, with the highest earning staff member receiving up to €974,000. They are all medical consultants. Are the taxpayers getting value for money with such high consultancy payments?

Mr. Bernard Gloster

I would say the necessity that the chief clinical officer has outlined is the genuine imperative for us in trying to manage it. Contractually and legally, we are advised that it is correct. I would say where the margin of difference might be is to the benefit of the taxpayer. The Comptroller and Auditor General had pointed to it and I have accepted it. I think there might be some better control of the utilisation of the individual call-out that attracts an individual payment in a small handful of the cases. To answer the Deputy's question, I think we can do better. I do not accept that the €900,000+ earning or the €700,000+ earning, even given the need outlined by the chief clinical officer, is a fully essential payment.

Deputy Alan Dillon

In essence, Mr. Gloster is saying the HSE cannot justify the exorbitant earnings.

Mr. Bernard Gloster

We cannot justify the scale of it.

Deputy Alan Dillon

Members of this committee would say that it is unethical for consultants to earn such vast sums of money, especially in the healthcare crisis that we face.

In relation to the measures the HSE is putting in place to prevent the potential abuse in the payment system, according to the briefing note submitted to the committee, there are internal gaps. Can Mr. Gloster provide us with an understanding of the measures that are being put in place?

Mr. Bernard Gloster

There is an attempt to translate anything that the internal auditor identifies into a practical and pragmatic implementation plan, both nationally and locally.

Deputy Alan Dillon

What measures are being taken?

Mr. Bernard Gloster

Let us face it, in the case of the handful of individuals the Deputy is talking about, it is about engaging with the clinical directors and the individual hospital managers and recognising the pressures that they are under that require a higher level and standard of management of the call-out system that results in the payments.

Deputy Alan Dillon

Are there plans to cap or limit these high payments in the future?

Mr. Bernard Gloster

Because they are contractually and legally sound, if we ask a doctor to be available in a particular rota or format, we cannot then, as managers, determine when it is clinically appropriate for them to decide to come in or not come in on a particular call. There are challenges to it. It is not as simple as saying we are capping them to coming in on a certain number of days. If there are only 1 or 1.5 doctors in a particular specialty, the priority is the public interest and safety.

Deputy Alan Dillon

Is Mr. Gloster is saying that in 2023, this practice can continue within the HSE?

Mr. Bernard Gloster

I am saying-----

Deputy Alan Dillon

When the Comptroller and Auditor General reviews the 2023 financial accounts-----

Mr. Bernard Gloster

I think the 2023 financial accounts will show that one or two of those high earners will still be in the same category. I think for the closing period of 2023 and as we enter 2024, we will start to see an improvement and a downward trend. There certainly will not be a shortage of focus on it.

Deputy Alan Dillon

The preliminary financial outlook for 2023 indicates that there will be a deficit in the region of €1.5 billion. What level of deficit is attributed to the Covid-19 pandemic? What are the other factors leading to this deficit?

Mr. Bernard Gloster

As I said in my opening statement, the deficit is characterised under three headings. Approximately half of the deficit is in the non-pay space. That is predominantly health inflation. Inflation for us is different from inflation in the general economy. This affects a number of the purchases we make. Another part of the non-pay space is that we are spending more because we are treating more people. That is the first portion.

Deputy Alan Dillon

Does Mr. Gloster have a breakdown of the areas to which costs were attributed?

Mr. Bernard Gloster

We have some. The chief financial officer can address that in a second but I will just note that the second portion of the headline deficit relates to increased demand. This year, we were funded to take a certain number of people off of our waiting lists. We have taken 68,000 more off than we were funded for. That is just one area of demand. There is obviously a lot in social care and so on.

The third area, which I accepted on the record before the Deputy's colleagues on the Joint Committee on Health last week, makes up approximately a quarter of the deficit. There is a challenge for management to address in the control environment. The control environment issue is not just about people spending money loosely. There are necessary controls. I will give the Deputy an example. This year, we funded 1,400 additional new jobs in management and administration grades to add to the already high number recruited between 2019 and 2022. We exceeded that 1,400 by a long shot. We have no money for that and cannot afford it. I introduced a control on that grade sequentially from the summer and, yesterday, I had to introduce full control on that grade such that there will be no additionality between now and the end of the year. Tomorrow at 9 a.m., the representative organisation for that grade will commence industrial action. That is what the control environment is. Issues in that area comprise in the order of a quarter of the deficit.

Deputy Alan Dillon

I thank Mr. Gloster. Could Mr. Mulvany give us a breakdown of the costs related to the deficit of €1.5 billion for the previous six months of this year?

Mr. Stephen Mulvany

Of the figure of €1.5 billion the Deputy mentioned, Covid-related costs make up approximately €120 million. Approximately 25% relates to pay. That is mostly for agency staff and overtime but some of it relates to the removal of what are known as the Haddington Road hours and things like the FEMPI pay award. Approximately €113 million relates to the removal of acute hospital private income, which is partly driven by policy and partly driven by insurers. More than €200 million relates to non-pay inflation, as the CEO has indicated. State Claims Agency and pension demands represent another €200 million or €300 million.

Deputy Alan Dillon

Will Mr. Gloster deal with the impact of the estimated €100 million year-end deficit with regard to community disability services? How will that impact be seen on the ground as regards this vital and needed service? Will there be a drawback of services as a result?

Mr. Bernard Gloster

There are two things to say in that regard. Like all of our services that are essential on the ground, disability as a function has transferred from the Department of Health to the Department of Children, Equality, Disability, Integration and Youth. I met with the Minister, Deputy O'Gorman, and the Minister of State, Deputy Rabbitte, last week. We are not planning on taking any measures during the remainder of this year that would impact the service delivery system for people with a disability. There may be challenges in the management and administration piece. I referenced a moment ago what I introduced yesterday. Vacancies that arise in management and administration grades in the disability area will be filled through internal redeployment or expression of interest, as is the case for all other parts of the health service that are seen as critical to front-line services. I do not envisage any immediate impact there. The budget position for 2024 will determine the level of service we can afford to provide. It has certainly been made clear to me since I came into office that, coming into 2024, I can only spend what I have. The Deputy will have seen that in the public domain over the last two weeks.

Deputy Alan Dillon

The Comptroller and Auditor General has drawn attention to issues in community disability services and section 39 organisations, which are voluntary and really important. What concrete steps are being taken to improve efficiency and the timelines for funding these critical section 38 and section 39 organisations? Strikes are pending on 17 October. It is really important that these services are supported. What discussions is the HSE having on the ground and with the Department to seek fairness, pay parity and increased contracts and funding in these areas?

Mr. Bernard Gloster

It is a matter of public record that I have said for quite a long time that service providers that are section 39 agencies are critical to our service delivery platform. There is a fundamental issue for a number of them that had been paying staff according to public sector pay scales for a long time and which were funded by us to do so. On the introduction of FEMPI, that system was retracted and, when others had their conditions restored, these staff did not because they were not technically public servants. That is what the strike is based on. There is an offer of 5% on the table which also includes 3% retrospective to last April. That has been rejected. Obviously, talks will continue to be active between the Departments and the unions representing these staff. We are not the employer so we cannot negotiate directly on pay but we are doing everything to work with them to ensure the best continuity we can and we do give these agencies quite a lot of additional support to keep them sustainable.

Deputy Alan Dillon

Will Ms McGirr of the Department comment on the timeline for resolving the pay parity issue and ensuring fairness for section 39 workers? Where is that now in terms of the current dispute and the unions' rejection of the 5% offer? Where do we go from here? Ultimately, the HSE cannot deliver that service so it goes back to the Department of Health.

Ms Louise McGirr

It is a matter for the Department of Health and the Department of Children, Equality, Disability, Integration and Youth. Obviously, a significant number of the bodies involved are disability bodies. We have been engaging with the unions representing the section 39 employees on an ongoing basis. There are multiple unions involved. As the CEO said, we made an offer of 5%. That offer is comparable to the 5% offered and accepted in other similar bodies across the public service.

Deputy Alan Dillon

It is not like for like, however. We understand that.

Ms Louise McGirr

Different groups argue different things. Those working in community services, social protection, housing agencies and educational bodies will all agree their services are critical.

Deputy Alan Dillon

Has the Department done a comprehensive review of pay and conditions for section 39 employees?

Ms Louise McGirr

We are not the direct employer so we do not have access to that information. The pay scales and so on of individual employees are confidential information so we have not done that. There was a previous Workplace Relations Commission provision - I believe it was in 2018 - whereby section 39 agencies could apply for funding for additional pay to bring salaries back up post FEMPI. That was available to 300 to 350 organisations, not all of which applied. We had hoped the unions representing section 39 workers would put the offer to their members. They have not done that and have rejected it without putting it to their members. In other sectors, unions rejected the offer but members accepted it when it was put to them. We do not have visibility of members' direct response to that 5% offer.

Deputy Alan Dillon

Their counterparts are in section 38 organisations.

Ms Louise McGirr

No, they are not. There are equivalents across Government and they all have different numbers. They come under the Department of Housing, Local Government and Heritage, the Department of Justice and the Department of Further and Higher Education, Research, Innovation and Science. There are lots of different bodies that were set up over many years and which are the main providers of Government services. These organisations are not covered by public sector pay agreements and are not bound by modernisation measures. We do not know what has happened to the pay. We can assume the bodies have not been able to fund pay increases but we do not know for sure.

Deputy Alan Dillon

Are the businesses plans submitted by these voluntary community disability services and their requests for additional funding necessary because of the inadequate funding provided through grants processed by the Department?

Ms Louise McGirr

No, they go in through the HSE. The HSE has service level agreements with them.

Deputy Alan Dillon

How many of them have been processed in the last six months?

Mr. Bernard Gloster

What does the Deputy mean by "processed"?

Deputy Alan Dillon

I mean getting approved.

Mr. Bernard Gloster

What happens is that every year, regarding all of the section 38 and section 39 agencies, we have a target to conclude the signing or entering into a service-level or grant-aid agreement with them, usually by the end of February. This is due to matters well-rehearsed in this committee ten years ago. That is what we aim to do. It is through that process that we negotiate with them what we are able to give them and what the best level of support we can give them is. What we are not allowed do is determine public pay policy and specifically say that this is now the pay grade for the sector. That is not within our gift.

Deputy Catherine Murphy

I want to touch very briefly on the resumed industrial action on foot of the announcement that there is an embargo on particular grades. What does Mr. Gloster think the impact is likely to be and what plans has he got to deal with that? Not covering the industrial action relates to not covering, for example, vacant posts. Embargoes can be a very blunt instrument. One could have a number of vacancies in one particular section and none in another. How is that going to be managed or impacted?

Mr. Bernard Gloster

The first thing is that I only got the notice this morning, and to be fair to Fórsa it is a recommencement, so we are aware of the context. The simple reality is that the amount by which we have breached the funded target of that part of the workforce, along with it being the highest percentage growth part of the workforce for the last four years, means that I cannot afford to hire any more external-----

Deputy Catherine Murphy

I am specifically asking about impact. It is an industrial relations issue.

Mr. Bernard Gloster

The impact of a work-to-rule is that it can be highly disruptive at the management end, for example, providing data for us to be able to understand what is happening in the services every day, co-operating with the completion of parliamentary questions, co-operating with change or the implementation of the new regional health areas, and so on. It will be disruptive both at the business management end and the change end more so than at the front-line service end. We have not just the right within contract but - in fairness to unions - in the agreement with unions, to ensure that in these types of measures the public is not directly affected.

Deputy Catherine Murphy

Okay, I want to go on to a number of other questions. I was looking at Mr. Gloster's briefing document, and the high earners by specialty. Radiology marginally increased to become the highest discipline, from 24 to 25. Psychiatry has gone from ten to 18, which is a very sizeable jump. Surgery has gone from eight to 17. Is that to do with really plugging gaps where there is a recruitment issue?

Mr. Bernard Gloster

In psychiatry, for example, we went into an international recruitment campaign in recent months. The director of human resources, HR, can talk the Deputy through more of it. We went in with 75 vacancies in that specialty, and it is increasing, and that is what drives it.

Deputy Catherine Murphy

Okay. I want to touch on the way funding is allocated. It is probably more to do with Mr. Walsh on the community services side, and Mr. Mulvany. Say there is an increase in the various community healthcare organisation, CHO, areas, how is that distributed? Say there is a 5% increase - I am just picking a figure off the top of my head - how is that distributed? Is it equally across the board?

Mr. David Walsh

Does the Deputy mean based on demand or-----

Deputy Catherine Murphy

How is that assessed?

Mr. David Walsh

Let us take an example of, say, home support.

Deputy Catherine Murphy

No, I am talking about among the CHO areas. What analysis is done in each of the nine CHO areas? Is there a 5% increase across the board? Are there differences, depending on demographic changes or whatever? How is that assessed?

Mr. David Walsh

If one looks at it by care group and then how we build up a picture, we would have heads of operations covering mental health, disability, primary care and older persons, who would work throughout the year with the local CHOs to build up-----

Deputy Catherine Murphy

I will tell Mr. Walsh what I am trying to get at. We have a postcode lottery for services. It is very unequal in some services between one part of the country and another. I had a look at the HSE website in advance of the witnesses coming here, and I looked at the populations of each of the CHO areas, which are vastly different. When I looked at the numbers, it was the 2011 census that was used. Does the HSE update that to the 2016 and 2022 censuses when making decisions? For example, there has not been an equal increase in population across the country. Services that were poor to begin with and were stretched are stretched even more if there is a bigger increase in population. Where does that play into?

Mr. Stephen Mulvany

I will answer that. It depends on what the increase is for. If it is an increase for pay awards, obviously we will look at the individual staff and what each staff has. When we are planning, we do look at up-to-date censuses. More and more one will find individual increases across different care groups are seeking to take account of the historical differences in demographics. Where we are moving to in the medium to long term is a more population-based resource allocation, so that we try over time, as we add extra resource into the system for developments, to even out those regional disparities across different care groups and across different counties.

One will find that some parts of the country are higher than others in one care group, and lower in another because they may have, in the past, prioritised certain types of service. As much as possible, we will be asking the local areas, and in particular each of the new regions, to resolve those issues internally across their region. They are big enough, at six, to do that. Over time, Government, the Department and the HSE will seek to level the playing pitch with additional new money.

Deputy Catherine Murphy

Are we going to see less of this postcode lottery?

Mr. Stephen Mulvany

Yes but it will take a substantial amount of time to change. The entire budget gets increased in service development terms by 1% to 3% every year so it will take time to even it out. That is the path. That is what Sláintecare says and what the regions are partly designed to enable.

Deputy Catherine Murphy

I want to go back to the vacant properties. What are retained assets? Can Mr. Mulvany give me a description of that? Some are under review. What is the evaluation process for properties that are under review, and are there plans to bring any of the vacant units back into use? Mr. Mulvany might also deal with the kind of costs there are. If there are vacant units, are they being heated? Vacant units can deteriorate if they are not looked after. Mr. Mulvany might give us a bit of an overview on that.

Mr. Stephen Mulvany

It really depends. There is something like 400 of those vacant units, some of which are derelict. To be very clear, we participate in a number of cross-governmental task forces to try to make sure-----

Deputy Catherine Murphy

We have been told that already. What is being spent on heating, for example?

Mr. Stephen Mulvany

Where they are derelict, and derelict for a long time, it is unlikely that we would be heating them. Generally, we only heat them if there is a value to maintain with regard to the fabric of the building. Some of the building fabric is no longer worth maintaining. It depends on each individual building, and as the CEO said, there are all sorts of different shapes and sizes. The notion that any of them are actually directly usable for accommodation is something that the relevant accommodation public bodies will have to decide. They all have the information as to what is available per county. They have specific lists of our properties and we are actively engaged with either bringing them back into use for ourselves, donating them to voluntary bodies where that makes sense for voluntary bodies doing things in our sphere, or to other bodies, including local authorities, where we will often swap or give away properties at nominal values.

Deputy Catherine Murphy

Are these on a risk register, or would they feature?

Mr. Stephen Mulvany

We have them on a property register.

Deputy Catherine Murphy

Are there aspects that feature on the risk register with regard to the HSE's property portfolio?

Mr. Stephen Mulvany

There may be but most of them would be low-risk, if one thinks about it. Generally, there is security on them and they are not in active use. The risk related to them, and certainly the risk to services, is very low. They are on a property register and they are reviewed by our local and central estates management teams. Periodically, we will transfer them into the ownership of public bodies.

Deputy Catherine Murphy

We have a big problem with dereliction in this country. A lot of the HSE's properties are likely to be in village or town centres. The idea that a State agency would be contributing to that dereliction is becoming an even bigger issue. Will the HSE come back to us with that? We will need some detailed information on the condition of those buildings as much as anything else.

Mr. Stephen Mulvany

Our estates team does everything it can to make sure our properties are not adding to that aesthetic often associated with long-derelict buildings. We try to keep the grounds reasonably maintained etc.

Deputy Catherine Murphy

Okay.

Finally, the HSE carried a deficit from 2005 when it took over from the health boards. In reality, the shape of the boards was still there. How does the accumulated deficit now feature in the HSE's management system?

Mr. Stephen Mulvany

The HSE inherited from the former health boards an incoming deficit of more than €800 million.

Deputy Catherine Murphy

That has increased.

Mr. Stephen Mulvany

It has increased in the 18 years since to about €1.2 billion. It is accounted for every year in the accounts of the HSE.

Deputy Catherine Murphy

How would that have increased? Will Mr. Mulvany describe how that increased?

Mr. Stephen Mulvany

The last increase over the past four years was about €200 million. This was partly because over those four years from 2019 to 2022, the HSE delivered something like a €73 million surplus, but because we were not enabled to retain those surpluses - a €200 million surplus one year - because, according to the legislation, keeping a surplus requires the approval of the Minister for Health.

Deputy Catherine Murphy

How can the HSE ever get rid of the accumulated deficit?

Mr. Stephen Mulvany

The only way to get rid of it is to generate sufficient surpluses over the years, which is an issue in itself for a public health body, and if the policy decisions under legislation allow the health service to retain that. That is why over the past 18 years the deficit has increased. It does not have any material impact on the day-to-day provision of services, although it is an important accounting issue.

Deputy Marc Ó Cathasaigh

I thank the witnesses for appearing before the committee and for their opening statements and briefing documents attached.

I will begin on a very generalised issue. It is a gargantuan budget and it always seems to be spiralling. We know we are heading to a €1.2 billion overrun again this year. From the point of view of the body within the Oireachtas that is supposed to have oversight of public funding, it is well acknowledged that between HSE service plans and financial statements, Vote 38, and all these different spending classifications, it is very difficult for anybody outside the organisation - and I suspect within the organisation - to have a clear grip on the funding, budgeting and the control of spending in an organisation that is one of the largest spenders of public money in the State; probably the largest. Does Mr. Mulvany have any active and specific plans to streamline how that reporting process happens so that bodies like the Committee of Public Accounts and the Comptroller and Auditor General can have a clearer view of the spending that is happening with in the Department?

Mr. Stephen Mulvany

One of the recent reports, which probably goes to the heart of the Deputy's question, is from the Parliamentary Budget Office, PBO, which notes that while the HSE under legislation is required to report on an accruals basis, the Oireachtas naturally deals in cash and Vote accounting. Currently, our capacity to report on cash and Vote is largely limited to those former health board areas. However, the new integrated financial management system, IFMS, which went live in July in the east of the country, will give us the capacity to report in cash terms by what we call profit centres; in other words at whatever level the Departments of Health and Public Expenditure, National Development Plan Delivery and Reform, agree they want. Regardless of whether this is by care group or by location, we will be able to report both in INE and in cash terms, and cash is very close to both. That will make it much more straightforward to address the point the PBO raised, which is when one body is by legislation dealing in INE terms, but is being funded in cash terms, it is difficult to do, for example, cash-based programmatic budgeting. We do programmatic budgeting on an INE basis but we cannot do that because of the systems on a cash Vote basis. In the coming months, we will be able to turn that on in the part of the country where we have gone live with IFMS. By the end of 2025, when all the HSE statutory part is on that system, we will be able to do that for the full statutory system. Seeing how money flowing from the Oireachtas is getting spent is one thing that will make it more straightforward.

Mr. Bernard Gloster

There is a fundamental challenge to this. There might be a view abroad that we started this year with a flat budget adequate for what we needed and we overspent that by €1.5 billion. That is not the case. We started the year with an inadequate level of existing service funding. I am sure members have heard the Minister's comments in the last fortnight. To be fair to him and to the cabinet committee on health which I attended two weeks ago, there is a real effort and commitment to try to sort out the existing level of service cost in real terms and to put in the proper controls to not breach that once we have it in certain parts of the organisation, and to do that before we start adding more new developments that will give us more existing level of service, ELS, problems next year and the year after.

Deputy Marc Ó Cathasaigh

To try to translate that into layman's terms, Mr. Gloster is saying that different languages are being spoken and that the HSE is attempting to translate into the language it would be more comfortable in. If the Comptroller and Auditor General and the PBO are telling me they find it difficult to get a handle on the spending, that means it is not readily understandable to the lay person. One of the issues with that and with the narrative around overruns is that it occludes the fact that we have very good health outcomes for people who get access to the services. It changes and alters the narrative when we discuss the health system in Ireland when we are not communicating in two languages that are mutually compatible and when bodies such as ourselves do not have adequate insight into the spending.

Mr. Stephen Mulvany

The last question about reporting is what I answered. To be clear, internally in the HSE where we use the accrual-based accounting that is specified in legislation by the Minister, there is full clarity down to cost centre and activity type as to what the costs and the budget are, what is cost against budget, and the variance. I am responding to the fact that the PBO has rightly said that if you are sitting here trying to track money from the State in cash through the HSE and back out again, that is difficult. That is an entirely separate matter. It is not a cause or a causal effect of what the CEO described, which is the fact that a big chunk of this year's overrun was brought in from last year because the ELS was not funded. They are two entirely separate things.

Deputy Marc Ó Cathasaigh

I understand that. My counterpoint to that is that when it becomes difficult to understand in that way, people who are within this House are going to the people trying to explain why there is a budget overrun. When you do not have clarity in that communication between the HSE, the Department and the Members of the Oireachtas, that creates difficulties.

Mr. Bernard Gloster

It is a fair point regarding the large elements of confusion about it. I hope what we have attempted to do, certainly in the last two to three weeks during which I have been publicly commenting on this, is to try to reduce it to very simple terms: what we are overspent by, why we are overspent, and what we are trying to do about it.

Deputy Marc Ó Cathasaigh

I will move on to the issue of non-compliant procurement. It is a very substantial amount. The exercise that was carried out indicates about 7%. Only about half of the procurement spent was analysed and it came up with this 7% figure. I do not know whether that adequately captures the non-compliant procurement.

Is there any local aspect to this? Are there places where that level of non-compliant procurement is worse than in others? I know we are inheriting a regional health board model. Are we seeing that translating into non-compliant spending?

Mr. Stephen Mulvany

There is no direct correlation between the regional health areas, RHAs, that are being introduced and non-compliant procurement. We would not disagree with the CEO and the Comptroller and Auditor General's assessment in this regard. It is a requirement that we look at payments over €25,000, which is what we have done. We have not looked at payments below that, but there will be non-compliance in that as well. As the Comptroller and Auditor General rightly says, it is not a full picture but it is a picture which we could not provide a number of years ago. Now we can and we do it quarterly. There is local variation. We have put additional procurement compliance officers out into our hospitals and our CHOs with central co-ordination.

Deputy Marc Ó Cathasaigh

The next logical question is where are we finding higher levels of non-compliance, geographically.

Mr. Stephen Mulvany

It will vary by service and by which particular suppliers people are using. I do not have the specifics for the local CHOs but certainly we have all that data. The vast bulk of the 12% that came back as non-compliant is in a process to get it tendered and to compliance. There is only about 3% where we are chasing down the relevant service to get it into that type of process. It is on track-----

Deputy Marc Ó Cathasaigh

The eye-watering scale of the money we are talking about means that even when it is reduced down to 3%, it is still a significant chunk of change. Are there sanctions within the organisation if a manager is consistently procuring goods in a non-compliant manner? Is there some way of oversight or of identifying somebody who is not adhering to these procurement procedures?

Has there been any instance of someone being hauled over the coals for that?

Mr. Stephen Mulvany

Not yet. We start with making sure that people can, and understand how to, comply. We then help them to comply. Ultimately, it will become a performance issue if someone is repeatedly not complying after being given all the tools to do so. We do not find that to be the issue. Once we provide the contracts that people can comply with and provide them with some analysis and support, people generally want to, and will, do the right thing. However, if we reach a point where there are individuals who fail continually when they have no good reason to, that will become a performance issue and they can and will be sanctioned.

Deputy Marc Ó Cathasaigh

A follow-on issue is particularly germane, given the scandal in scoliosis operations. At a local level, how does the HSE ensure that products or devices that go through a procurement process are adequate and comply with the relevant standards? Are there controls? We have seen a failure of controls in this high-profile instance. Will the witnesses outline what controls are in place?

Mr. Bernard Gloster

To be fair, I would not say that there is a correlation solely between procurement and the use of the springs in the hospital. There were much bigger breakdowns than just in procurement. One of the complaints we get from the section 38 or 39 agencies that we fund is that our service-level agreement documentation is too cumbersome for them. We are clear, in that we expect them to comply with the same legislative standards with which we have to comply. As Mr. Mulvany stated, we try to help and enable them to comply. Ultimately, we have to call them out when that does not happen.

Deputy Colm Burke

I thank the witnesses for attending, presenting and going through the figures.

I wish to ask about the figure of €7.8 billion for pay and pensions. Is there a breakdown of the agency and locum costs that were paid out because staff were not available?

The HSE spends a great deal of time training people up and down the line, be they care assistants, nurses, administrative staff or doctors. We are now reliant on doctors and nurses from abroad. Are we conducting comprehensive exit surveys when people leave? I have asked this question before. I have also spoken to quite a number of people who left the HSE for various reasons over recent months. Not one of them had been asked to fill out an exit survey. If the HSE wants to keep people, let us at least find out why they are leaving. We are spending a great deal of money on training, yet we are losing good people.

Mr. Bernard Gloster

Regarding the agency-overtime cost line globally, we anticipate that we will spend approximately €1 billion this year. Mr. Mulvany can speak to the detail of that. It is far in excess of what we budgeted for.

The director of HR will answer the question on people exiting. We try to capture people’s views, although they do not always give them to us.

Deputy Colm Burke

Not one of those I spoke to had been asked.

An Cathaoirleach

We have the HR director, Ms Hoey, with us. She may wish to respond.

Ms Anne Marie Hoey

We have exit interviews in some services, but they are not widespread across all services. We completed a staff survey for 2023 across all HSE and section 38 services earlier this year. It asked many dozens of questions that gave us rich feedback from our staff about various aspects of their employment. We undertake such a survey every two years. The results of the 2023 survey demonstrated increases across a number of metrics on which staff reported back. We also examine staff turnover figures-----

Deputy Colm Burke

That is not giving me any information about the reasons people are leaving. We are losing some good people and the HSE, the taxpayer and I need to find out why. We are spending a great deal of money on attracting people from abroad to fill vacancies. Why can we not identify why good people are leaving the service?

Ms Anne Marie Hoey

There are a number of reasons people-----

Deputy Colm Burke

But we have not identified any of them.

Ms Anne Marie Hoey

-----leave and so on. Our survey gives us a good indication of the reasons people stay with us. It also gives us an indication of areas that we need to improve upon to retain people. Our staff turnover figures give us an indication of the turnover within the health service. We can compare them to other organisations. The staff turnover figure for the year to date is approximately 4.2%, which is slightly down on last year’s figure. These figures and the staff survey give us rich data on why people work in the HSE and what we need to do to improve our staff retention.

Deputy Colm Burke

Regarding the €1 billion paid out for agency staff and so forth, can that figure be reduced for the coming year and further on?

Mr. Stephen Mulvany

Yes.

Deputy Colm Burke

My understanding is that there are more than 350 medical locums. Can that number be reduced? How can we fast-track the reduction so that we can have people in posts permanently? Locums are costing us a great deal of money.

Mr. Stephen Mulvany

The new public consultant contract is a key policy initiative in trying to provide an attractive contract. We also have an international advertising campaign. There is a great deal of focus on trying to provide more attractive terms and conditions so that we can get people into as many of those vacant posts as possible. As the Deputy mentioned, a good chunk of our €750 million of agency costs is spent in the medical space, including consultants. Some of those posts are in hard-to-fill areas where there may still be challenges, but there is a focus on trying to fill as many of those vacancies with permanent consultants as possible.

Mr. Bernard Gloster

I have heard commentary in recent days about how there are 900 vacancies at consultant level. There are not.

Deputy Colm Burke

How many are there?

Mr. Bernard Gloster

There are approximately 400 actual vacancies, including new development posts that, in some cases, had not been filled previously. There are approximately 450 posts filled in either a temporary or locum capacity, which we hope to deal with through recruitment.

Deputy Colm Burke

Do the witnesses accept that, in many cases, and especially in smaller hospitals, there is a difficulty in recruiting people to fill posts and it is taking much longer?

Mr. Bernard Gloster

Yes.

Deputy Colm Burke

Have questions been asked as to how the HSE can improve this situation? In some of our smaller hospitals, up to 80% of the medical staff did not go through the Irish university or training systems.

Mr. Stephen Mulvany

The evidence is that, since the introduction of the new public-only contract, the average number of applicants per post has increased. That is a positive sign.

Dr. Colm Henry

There is a clear differential between what we call model 3 hospitals, which were previously county hospitals, and model 4 hospitals, which are the big hospitals. We know from surveys of those in training at the moment – we are expanding the number of trainees – that their general preference is to work in larger centres dealing with, for example, cancer, surgery, cardiology and other specialties. We have to design our training programmes to ensure we incentivise and condition trainees to do the generalist-type of work that we need to provide in model 3 hospitals. That is part of what we are doing in expanding the scope of trainee posts.

Deputy Colm Burke

I will move on to section 38 and 39 organisations. Last year, €6.3 billion was paid out. My understanding is that there are approximately 2,500 organisations. Some of them are large, for example, the voluntary hospitals, but some are quite small. Is any effort being made to see how we can get better on this front? In fairness, the organisations are doing a great deal of very good work and delivering services that otherwise would not be delivered. Can efficiencies be created in respect of them? They account for 25% of the budget and we are dependent on them to provide a service that, technically speaking, the HSE should be providing.

Mr. Bernard Gloster

There are three parts to the headline answer on that. It is difficult to expect the smaller organisations to do more, stretch further or change because their origins are often found in a local individual who started work on a particular cause or campaign of altruism. We have to respect that. There have been examples of where we tried to rationalise some of those organisations and the reaction from their communities was not positive.

That is the first thing. The second thing I would say is that in the bigger funded agencies, we certainly look for them to join us in different efficiency measures. To be fair, the CFO has repeatedly pointed out that efficiencies in our type of work are often much more about being able to do more work with the same resource, for example, responding to more people on waiting lists rather than necessarily saving money. Where I do think there is a requirement for an examination, which is certainly within my sights to examine in the context of establishing the six RHAs, is the very big section 38 agencies and the voluntary hospitals. The examination would look at their resource, processes and efficiencies, do a control comparison to some of our own, and see how best the resource is being utilised to serve the population of that region. I hope there may be something in that.

Deputy Colm Burke

Moving on from that, my understanding is the number of beds in public nursing homes has reduced in real terms but the costs continue to go up. Can efficiencies be created in that area? For instance, some of the public nursing homes got an increase of more than 12% under the National Treatment Purchase Fund, NTPF, whereas some of the private nursing homes got an increase of 1.5%. That raises a huge question about efficiencies and improvements on that.

Mr. Bernard Gloster

Every time I come to the committee, in fairness to the Deputy, he advocates that position. Part of that is understandable. A share of private homes got an increase of 6% this year. They have also reduced contract negotiation time. Whereas previously they were predominantly two or three years, they are now one-year options. In a public nursing home where a bed complement might reduce because of regulatory compliance or other things, the cost will often stay the same because of the volume of staff and the conditions they have. I made the point to the Deputy at a meeting of the Joint Committee on Health two weeks ago that one of the fundamental differences - and I am not saying it justifies all of the cost difference to be fair to private providers - is that we are, and continue to be, the provider of last resort. In the past three weeks, we have had to step in with-----

Deputy Colm Burke

I accept that but, for instance, the owners of one nursing home came to me. It is tied by section 38 regulations regarding salaries and everything else but it got an increase of 1.5%. They are now talking about cutting back, reducing the number of beds they are going to provide because they cannot keep going. They are now in a loss-making situation. I acknowledge the NTPF is not under Mr. Gloster's jurisdiction but there is a problem with it. We have already lost 41 nursing homes in the past four years, and 1,200 beds. The population has increased resulting in increased demand and then there is also pressure in the sense that it is difficult to find people to provide home care. There are a number of challenges, yet it seems those challenges are not being responded to adequately.

Mr. Bernard Gloster

We are certainly attempting to increase community beds, and how we use the private sector, not just for long-term care but for transition care, which is very high volume, and for various types of models of step-down care. We are flexing everything we have to use both. Part of the challenge arises out of the historical level of growth of dependency on the private sector. We are 80% dependent on it, so that in itself presents part of the challenge. A lot of the private operators, whether the smaller ones or the very big ones, have very different approaches to their business models, and so on. It is not an easy challenge for us to resolve but the one thing we cannot do is deal with the pricing model for the private sector. That is for the NTPF to deal with.

An Cathaoirleach

We will take a short break for ten minutes and resume at 11.05 a.m. sharp.

Sitting suspended at 10.54 a.m. and resumed at 11.06 a.m.

An Cathaoirleach

I call Deputy McAuliffe.

Deputy Paul McAuliffe

I thank Mr. Gloster and all the witnesses for being with us. As Deputies, we have seen a significant increase in the budget allocated to the HSE in recent years, in part because of initial spending in response to Covid-19. In many cases, however, much spending has been embedded. We are now at a point where we are spending more than €23 billion. As the body responsible for managing public accounts, it would be remiss of this committee not to ask questions about why we are in a position where there is a very high likelihood that a Supplementary Estimate will again be needed. I want to give Mr. Gloster the opportunity to outline to us why that is happening. I would be even more interested in hearing what we are going to do now to ensure the same issue does not arise again next year. This issue came long before Mr. Gloster arrived. There has been a roughly 39% increase in spending since 2019. It would be hard to overspend having got 40% more of your household budget and yet the HSE, because of increased activity admittedly, are in that space. There is considerable concern among the members of this committee that it has happened.

Mr. Bernard Gloster

That concern is legitimate and shared. I will make three or four brief headline points. I know the Deputy has just joined the session. Earlier, I broke down the deficit into three categories. Non-pay inflation and increased demand driving non-pay account for about half of the problem. A quarter of the problem is increased demand. A quarter of the problem is for us to manage our budgets and processes in an improved way. I take responsibility for that part.

The €1.5 billion we are indicating as this year's problem did not all happen this year. There has been a succession of once-off supplementaries that are not repeated the following year. In simple terms, if there is a deficit this year of €1.5 billion on our balance sheet and the existing level of service, plus the incremental cost, is not funded going into next year, there will be a deficit at the same time next year. Even when I introduce efficiencies and controls, it will only deal with a portion of the issue. I do not know what level of funding we are going to get.

We all need, want and like new developments, initiatives and services. When they come into the budget profile, they come in at part-year funding. In the following year, if they are not fully funded, they add to the deficit. There is an incremental piece to this. That is just the way annual budget cycling has worked.

Deputy Paul McAuliffe

As the Accounting Officer, it is Mr. Gloster's job to see it all goes well.

Mr. Bernard Gloster

It is.

Obviously, the Secretary General is the Accounting Officer. I am the accountable officer, so I do not want to fudge, but it is absolutely the case that it is my job to control what I have and to spend what I have. I gave one of Deputy McAuliffe's colleagues a brief example earlier. Members will see it in the headlines this morning. Between 2019 and 2022, the highest percentage growth among staff grades in the HSE was in management-administration. I do not want to be in any way disparaging towards those grades - I come from them - but that was the area of highest growth. This year, an additional 1,400 jobs were given to those grades, We have already exceeded that 1,400 by a couple of hundred, which we cannot afford. We also have management-administration staff in on an agency basis. I put a control on that. I put a final control on it yesterday for the remainder of the year. The response to that - and I respect the rights of trade unions and, again, I do not want to be in any way disparaging of anybody - is that I face industrial action at 9 o'clock tomorrow morning. It is my job to say "No", but I have to manage the processes by means of which I interact.

Deputy Paul McAuliffe

Mr. Gloster outlined a number of areas which have resulted in the increase. The Comptroller and Auditor General also highlighted the area of section 38 and 39 organisations - the overall oversight. I should not mix up billions, but it is €6 billion-odd.

Mr. Bernard Gloster

Yes, €6.8 billion.

Deputy Paul McAuliffe

Yes, and that represents a huge percentage of the overall €23 billion budget, yet that sector would say to us that, because of the pay disparity issues, there are very significant challenges in terms of service delivery. Is the model of using section 38 and 39 organisations fit for purpose? Along with the challenges those organisations have financially, the disparity between grades and, therefore, the recruitment challenge and the pull towards non-section 38 and 39 organisations, often it can be difficult for us as public representatives dealing those organisations in terms of service provision. I am not saying that as a blanket criticism across the board, but some services are less accountable to us as public representatives and for the services they provide to their patients. Where do we go with section 38 and section 39 organisations? They account for a huge proportion of the budget. We do not seem to have the same oversight and governance. That has been highlighted in the Comptroller and Auditor General's report in terms of the broader picture, and we are experiencing service delivery issues as well.

Mr. Bernard Gloster

Section 38 organisations are a necessary part of the service footprint. You could not flick a switch tomorrow and change that. Some of them are very big organisations, both in the disability space and in the voluntary hospitals. I believe there is room for how we look at how we use that resource and how we better get the full benefit of it. To be fair to them, however, I would say that the same applies to ourselves. That is the first thing.

The origin and history the section 39 agencies are very different. Some of them are very small organisations that started with goodwill by a parent of maybe somebody with a disability and they have grown into being service providers. They are a serious part of our service footprint. I know they are in the middle of an industrial action process at the moment, so, in fairness, I do not want to precipitate that, but there is a 5% offer on the table with a retrospection back to last April of a smaller percentage. My preference would be that the section 39 agencies that are service providers would be able to arrive at a place where they could have sustainability. I see Deputy Verona Murphy. I spent a day in Wexford with two outstanding section 39 agencies. If their sustainability becomes compromised, my service falls.

Deputy Paul McAuliffe

Absolutely.

Mr. Bernard Gloster

That is it. I might not be the most popular for saying that in some places, but we have to fix that issue for once and for all. It is not in my gift to fix it.

Deputy Paul McAuliffe

No, but there is a governance and financial element to that, and-----

Mr. Bernard Gloster

There is, and the governance is mine, and we have service level agreements. Do we interact and get the best value for those service level agreements? Do we flex the State's right to get the best value for the public interest? We could always do better on that. It is difficult to do, but I am certainly up for that.

Deputy Paul McAuliffe

Disability services is an area we need to get right. I could spend the full ten minutes talking to Mr. Gloster about disability services for treatments and therapies, particularly for children on the spectrum. I used my time the last time with him on that. I have not seen a significant improvement in that space but, again, I do not have time to go into that.

Mr. Bernard Gloster

Again - and I am conscious I am on the public record - we do a lot of good work in disabilities. Our staff and the staff of agencies do a huge amount of good work. However, I have to look at the work we are not doing. The work we are not doing is resulting in significant pressure for families. It is probably, outside of our acute hospital system, the most pressured area of our service profile, and we have a lot of work to do.

Deputy Paul McAuliffe

And it puts the parent in a position of having to advocate for a service at the same time as having to educate themselves about a new diagnosis, and then-----

Mr. Bernard Gloster

Completely, and sometimes in very distressing-----

Deputy Paul McAuliffe

Absolutely. I will let Mr. Gloster put saying "No" into practice.

There are three projects locally that I will raise. I appreciate he will not have the time to discuss them, but he might come back to me one to one. I compliment Mr. Colm Henry on the support he has given to the sepsis awareness programme. Both Deputy Devlin and I support Lil Red's Legacy. They are some of the many people campaigning in that space. I acknowledge the work being done on that. It is embedding in the system, and I acknowledge that.

The second project is An Síol in Santry, which is an emerging service. A site has been identified in the hope that we could attract funding to build a permanent centre rather than it being in the rented accommodation it is in. Mr. Gloster might come back to me-----

Mr. Bernard Gloster

What is the type of service?

Deputy Paul McAuliffe

It is for people who have had a catastrophic brain injury. Like Mr. Gloster said, it was a small section 39 dealing with one or two patients and it has managed to expand the service.

The final point I will raise, which is a persistent frustration around delivery, is the Finglas primary care centre. It is rattling on. When I came into my term here in 2020, we were so close to signing an agreement between three different landowners. We are still not out of the woods on the legals on that. I ask if we can get as much urgency on that issue as possible.

Mr. Bernard Gloster

I will certainly come back to the Deputy on those three and the Finglas piece. On the positive side of the Finglas piece, up the road from Finglas there is a new approach to organising GPs by a not-for-profit body called GP Care for All. I went out and met them. What they are doing is outstanding, and we have been able to fund them to expand that model into Finglas.

Deputy Paul McAuliffe

Yes, but they would say their model needs reform because we give the medical contract to their staff-----

Mr. Bernard Gloster

I understand, and there are withholding tax and other Revenue considerations.

Deputy Paul McAuliffe

It is not only that we give it to their staff members; if they have an industrial relations issue with a staff member, the staff member gets up and walks out the door with the greatest asset. There are challenges there.

Mr. Bernard Gloster

There are.

Deputy Paul McAuliffe

I know that Austin O'Carroll is doing great work, and Mr. Gloster is right to mention that. I appreciate the support they have been given.

An Cathaoirleach

I call Deputy Verona Murphy.

Deputy Verona Murphy

I would like to mention the fact that Mr. Gloster came to Wexford and visited those facilities. This coming funding has been announced as granted this morning, and I refer in particular to the school leavers programme for Cumas New Ross, which should keep people out of the day service and move them on to a brighter future.

To follow on from what my colleague said, the reason I asked Mr. Gloster to come to Wexford was to plan for the future of the service users of section 39 organisations but, equally, for the families. He would have seen the demographic. We also have Reachability and St. Aidan's, also in great need. The demographic of many of the service users in both those facilities is parents in the upper echelons of 75 to 85 years of age. The plan we spoke about the last time Mr. Gloster was here was for residential beds. I am afraid that is where the future for many of the service users is, and we do not have those beds. Equally, I have two constituents in Wexford who are in need of in-house residential services due to brain injuries. There is no possibility of that in Wexford, and I do not think there is any possibility because of their age group. One is 27 years of age and the other is 55 but does not want to go into a nursing home setting. She is currently residing with her sister, who is working full-time within the HSE. She has a home care support package that they are now removing from her because her sister will not go into a nursing home and because they expected that, when they granted it, she would get somewhat better. I do have the full facts but I do not know how that happened. She is not getting better.

Removing the supports she currently has at home means that her sister's job is in jeopardy because she cannot do the night shift and work all day. The sister is her primary carer and is not in receipt of a carer's allowance. She has a full-time job with the HSE. We have to support these people. When Mr. Gloster says to me the governance in certain areas is the HSE governance, is he in effect operating with one hand behind his back?

Mr. Bernard Gloster

Is that one hand behind my back in the sense of the agency's independence?

Deputy Verona Murphy

Mr. Gloster knows how important section 39 organisations are. He knows the nature of what they do-----

Mr. Bernard Gloster

Does the Deputy mean in terms of their funding?

Deputy Verona Murphy

Not just their funding but equally the pressures around the care at home for somebody with a brain injury. The cost of having them in a facility is exponential in comparison but the truth is that if we supported the individual to stay at home it is half the price. We are, however, not getting that type of assistance. It is not forthcoming.

Mr. Bernard Gloster

There are two or three points there. I would not stand over any service area withdrawing a home care package because somebody would not go to a nursing home, and David Walsh is here with me. To be fair to the service area I have not heard from them but it may be the case that what they are giving is not enough to keep the person at home. Can they give more? I do not know but I am happy to take the case from the Deputy.

The Deputy is right on the issue of planning. I met the Minister, Deputy O'Gorman, and the Minister of State, Deputy Rabbitte, just last week. The issue we have faced for the last number of years is that we get an allocation for emergency placements. That is when the family unit either breaks down or the parents are elderly and become ill or they die. It becomes an emergency placement and we buy a placement either from a section 39 organisation or a private provider. Increasingly now an individual placement runs to several hundred thousand euro. I had a very long discussion with them both on the capital side and on the future potential revenue side of how we move from emergency to planned placements for those people. I met a group of parents from Cork of adults with very severe to profound autism and the only question those parents asked me - and rightly so - is what happens when they die. Despite all of the good work and all of the placements we do fund, and I want to recognise that, we have a long way to go to plan because the demographic tide is against us.

Deputy Verona Murphy

I am conscious of the clock but I can come back in on it. I appreciate Mr. Gloster's point and that is where I am coming from. I live in the area in the county with greatest concentration of section 39 organisations. I understand the age group we are talking about and particularly the parents of those individual service users. Again it comes back to services. During the summer an 11-year-old child was taken into care because the services were not provided. For nine months I sat in different meetings supporting the parent through dealing with the HSE but ultimately the supports that were promised were not given. It is now costing €37,000 a month to have that child in residential care. To be honest it probably need never have come to that if the supports had been put in place. I was really aghast. The section 12 order was issued with An Garda Síochána. The child was brought to the hospital and spent three days in hospital under 24-hour supervision. The HSE was able to put in round-the-clock care for the child just like that in an emergency situation. I do not want to be faced with emergency situations for anybody. It opened my eyes as to how it should have worked and how it ended up.

We can save money. I am very concerned that at the moment the budget of the HSE is heading for €25 billion - let us call a spade a spade - but there is another €25 billion to be spent if everything was done right. Looking at orthodontics and at the dental treatment scheme, none of those things are operating. There are 364 people in Wexford waiting for the home care support scheme. I am not laying this at Mr. Gloster's door. I will sit through the budget next Tuesday and the fanfare around the announcement will be unreal. Everybody will think they are getting something. It is something for everybody in the audience until it comes to delivery. The Minister of State, Deputy Rabbitte, or whichever Minister it will be - it could be the Minister for Health, Deputy Donnelly - will announce that millions of euro will be spent providing hours for the home care support scheme. These millions are never spent. If I have 364 people waiting on it who cannot get it what is the point in telling them they are eligible? We are doing nothing to cure it. It keeps going and keeps going. Those figures were there last year and are there this year.

The situation with orthodontics is particularly cruel for children who are of an age. I will just relay the experience from one such constituent of mine, as this is very important. Before I do, I must tell the witnesses that a serious number of children - 161 - are waiting over 60 months in Wexford alone. One example is an inexcusable delay. The constituent was deemed to need orthognathic treatment, which was to be followed by approximately 24 months of orthodontic treatment. He has been on the waiting list for orthodontic treatment since 3 August 2016, which is seven years. A treatment plan was discussed for this young chap a full year ago. It was this time last year when he was referred to a joint clinic. This month, through further representation in the offices of the HSE the patient was told that he had a further minimum of 12 months to wait. It is cruel. I need an answer as to why this is happening. What is the problem? Children with disabilities are waiting on anaesthetic treatment that can only be provided in the hospital: 60 children are under the age of 16; 94 are regarded as adults who are over the age of 16; and 101 who are just waiting for extractions under anaesthetic. This is collapsible level. I do not understand. If we have that much money in the system where has this gone wrong? This is not to mention the fact that we have no dentist in Wexford in the dental treatment scheme. I particularly want somebody to take up this discussion and meet the Irish Dental Association, IDA. it It is never going to get any better if there is no engagement. There must be engagement with the IDA. What is the answer to this?

Mr. Bernard Gloster

With regard to engagement, to be fair to the Department and to everybody else, it is certainly not a one-sided argument. The available funding this year for the dental treatment service scheme was increased by 20% from last year. Increased rates were offered. A lot of steps have been made to-----

Deputy Verona Murphy

Can I just clarify that it is 20% and we are still at a deficit of €20 million from what it was back 12 years ago? It was €80 million and we are only at €60 million now. Is that correct?

Mr. Bernard Gloster

We are at €60 million-----

Deputy Verona Murphy

So it was increased by 20%, which means the deficit is less but we are still €20 million short of where it was ten years ago.

Mr. Bernard Gloster

That is fair enough-----

Deputy Verona Murphy

This is the same argument whereby barristers are on strike who are working off rates they were getting in 2009. Dentists cannot do it either.

Mr. Bernard Gloster

The point I am making is that they did get an increase this year, apart from the available funding. It seems to us that the availability of dentists is not just about the money, and certainly on the orthodontic side. It is about the availability of orthodontists and in special needs dentistry. It is certainly not a shortage of money. The number of special needs dentists and access to theatre is a problem. With the dental treatment services scheme I do not know what the next answer to it is bar-----

Deputy Verona Murphy

It must be about engagement. It has to be engagement. There is a solution. I understand that the system needs to change. The HSE wants to bring in schoolchildren to it-----

Mr. Bernard Gloster

Yes.

Deputy Verona Murphy

-----but there has to be negotiation and mediation. Mr. Gloster is the CEO, and he is a bit Drew Harris here for me. It is up to Mr. Gloster to get that engagement going. I will not make any disparaging comments about who is paid what but I lay this at Mr. Gloster's door. It is his job to get that engagement going. I do not know what the figures will be for next year but I do not want the same answer.

An Cathaoirleach

Before we go to the next speaker perhaps Mr. Gloster could clarify the figure regarding the cost of keeping somebody in care. Did I hear a figure of €700,000?

Mr. Bernard Gloster

No. In a disability placement that one would procure today for somebody, given the nature and type of new placements I do not have the exact average but it is in the range of €300,000 per person per year for the rest of their life.

An Cathaoirleach

Up to?

Mr. Bernard Gloster

If it is highly specialised and requires a 2-to-1 staffing ratio it could be heading up to €600,000 per year.

An Cathaoirleach

Is that with a section 38 organisation?

Mr. Bernard Gloster

It could be with a private provider or with a section 38 or section 39 organisation. To be fair, it depends on the level of dependency of the person. On average, it would be €300,000 per year.

An Cathaoirleach

That is great, thank you.

Deputy Cormac Devlin

I thank the witnesses for attending. For the disability sector, how many residential or respite care properties are awaiting allocation of staff currently across the State or awaiting HSE funding for staffing levels for residential or respite care homes?

Mr. Bernard Gloster

I do not have the number that are waiting for funding. We have a number of approved and funded respite beds that we are waiting to get staffed but the providers cannot get them, with Cork being a particular flashpoint that has been in the media. Despite that, respite nights have increased over the past two years. Mr. Walsh may wish to comment.

Mr. David Walsh

Respite nights went up from 131,000 overnights and 28,000 day-only sessions in 2022 to nearly 77,000 overnights and 21,000 day-only sessions in quarter 2 of 2023 alone. They are increasing. The Deputy may want to make a point on decongregation. There are delays in getting people into those homes and we are behind this year on where we want to get to. Our target for the year was 73 people and while we should be at about 50 now, we are currently at 40. That is due to a range of issues, including recruitment of staff, but principally the properties themselves and getting them ready.

Deputy Cormac Devlin

Does that involve planning and everything else?

Mr. David Walsh

Part of it relates to the complexity of using the capital assistance scheme, CAS, to actually get those services up and running and part of it is recruitment timing.

Deputy Cormac Devlin

I thank Mr. Walsh for that. He might send on a note to the committee on the breakdown of those figures, which would be helpful.

I turn to the Comptroller and Auditor General's opening statement with regard to the Covid-19 vaccines. The HSE acquired €94.4 million worth of vaccines which were written off. I understand vaccines to the value of €33.7 million had not been used before the manufacturer's expiry date, which raises the question of the lifespan of those vaccines when purchased, and a further €60.7 million worth was written off because they were expected to reach their expiry date before they could be used. It is a sizeable amount of money, while not forgetting the backdrop of the space in which we were operating at that time. Does Mr. Gloster wish to elaborate on how that happened?

Mr. Bernard Gloster

It is a sizeable amount of money. Normal vaccination or immunisation programmes would be more predictable, so the backdrop is important in terms of the approximately €30 million worth that went out of date. I would make one slight addition to the Comptroller and Auditor General’s observation on the balance that was due to go out of date. My information is that they were either due to go out of date or the clinical guidance had changed in terms of the evolution of the vaccine. Maybe the chief clinical officer could explain that better than I can.

Dr. Colm Henry

It is not akin to a normal vaccination programme, which is predictably seasonal and we deal with a set type of mutations of a virus. In this case, we are dealing with a virus that we are still getting used to and it is getting used to us, and it mutates somewhat unpredictably. What we found is that many vaccines went beyond their expiry dates but what is probably more important is that they were no longer fit for purpose for the type of variants that were circulating. The updated guidance from the national immunisation advisory committee, NIAC, in November 2022, for example, pointed towards a new type of bivalent vaccine which would be more effective.

Deputy Cormac Devlin

Separating that out, for some the guidance had changed and it was not possible to use some of the vaccines, which is fair enough. However, in terms of the time at which they were purchased, was the shelf life of those vaccines extremely short and is that why so many were lost? What was the other reason that so much was written off and not used?

Dr. Colm Henry

The most prominent reason is that they were no longer effective against the circulating variants. While the shelf life is important for any vaccine and we have those in any set vaccination programmes, the other set vaccination programmes deal with steady-state viruses that behave in a relatively predictable way. With this one, as I said, we are still getting used to it. It is becoming more seasonal and we also know, of course, that the effectiveness of the vaccine begins to wear off after a number of months, which makes it different.

Deputy Cormac Devlin

Were any lost because of poor storage of the vaccines?

Dr. Colm Henry

Not to my knowledge.

Deputy Cormac Devlin

I want to turn to the incurred costs of approximately €1.7 million in 2022 in respect of obsolete personal protective equipment, PPE, and hand gel. What was the rationale there?

Mr. Stephen Mulvany

There will be a need to dispose of both the hand gel and PPE. We are talking about thousands of pallets of this and the average cost of storing a pallet is about €3 per week - I have the numbers here somewhere. This cannot just be tipped. We have gone to the market for soundings on the PPE. Three companies came back but €9.5 million was the only firm figure for end-to-end disposal, so we are looking at the options and we will have to go to tender. Obviously, our preference is not to just landfill it and would be to either recycle or recover energy, where that is possible. Hand gels are more complicated, given the alcohol content, so that has gone out to a specialist company that we have on contract to see whether the level of alcohol in them allows them to be properly incinerated so the energy can be recovered. As the CEO said in his opening statement, we want to dispose of that safely as soon as possible. It will cost money to dispose of it and as soon as we can make a decision on that, we will.

Deputy Cormac Devlin

That €1.7 million for 2022 is obviously replicated for 2023 and is an ongoing cost.

Mr. Stephen Mulvany

It is ongoing until we dispose of it.

Deputy Cormac Devlin

Is Mr. Mulvany effectively saying that the cost for storage and, ultimately, disposal could be in excess of €10 million?

Mr. Stephen Mulvany

Yes, depending on what the actual cost of disposal is and how long we store it until then.

Deputy Cormac Devlin

We will need to come back to that. I know we have engaged on this before.

Mr. Bernard Gloster

As I indicated in my opening statement, what I am anxious to do is to get to a decision quickly on the safe disposal so the cost of storage, when we get to disposal, has not gone to the level the Deputy is talking about.

Deputy Cormac Devlin

In comparison to that, for the necessary retention of stock in the event of a similar pandemic evolving again, what is the HSE spending annually on the storage of PPE? I presume it is keeping a valid operating stock each year. Does this include that figure or is it a separate figure?

Mr. Stephen Mulvany

That is the figure for obsolete stock. We have done a lot of work to try to make sure we have identified the slow-moving stock and we are using that quicker so we reduce the risk of further obsolescence, although we will never eliminate it. We have also lowered the cost of storage by moving more in-house and out of outsourced storage provision. As I said, it costs about €3 per pallet per week if it is external storage.

Deputy Cormac Devlin

A note on that would be helpful because that is an ongoing cost and these are very large figures.

I will turn to the risk management report from the HSE annual report of 2022, specifically page 111, which deals with the digital environment and cyber failure. In the context of the hack of May 2021, Mr. Mulvany and others have engaged previously with me about IT capability within the HSE for software and hardware alike. As I recall, there were quite a number of devices across the organisation that were still not up to scratch. Where are we at present in terms of safeguarding devices, information and, indeed, staff?

Mr. Bernard Gloster

In regard to cybersecurity, we had an external updated rating done recently in terms of what is referred to as our maturity rating. That has increased in accordance with the action plan since the cyberattack and it has increased to what would be considered a satisfactory rate of increase. We have a seven-year plan agreed with the Department for the totality of that investment and, to be fair, the Department has not been found wanting in supporting that. On the security side, there is certainly significant improvement but I would never be complacent. The best IT systems in the world have been hit in the last 24 months. With regard to the hardware, again, there has been very substantial investment and significant improvement.

I do not have the exact figures on the devices but they are quite significant.

On use of digital in healthcare, I confirmed recently that I think we will be able to deliver three applications next year. Specifically, that will assist us in delivering care or the public accessing aspects of health information. I am not talking about pilots but more widespread. I do not think we can wait forever for the end of digital transformation. I have recruited a new chief technology and transformation officer. They are due to start on 1 January. That will bring solidity, bringing all the different component parts of the house and the plans together. Finally, the Department is due to publish an updated digital health strategy shortly. This will guide what we do. We have given it a corresponding implementation plan. There is no doubt it is a pressured area. Available skill set is a challenge but we are certainly making very significant progress. There has been exponential growth in moving people off local domains onto what we call healthIRL this year. We have gone up to over 50,000 of a target. Some 80,000 users have moved already. There is really strong activity and projections on that.

An Cathaoirleach

I will let the Deputy in again in the second round of questioning.

Deputy Cormac Devlin

Very briefly. I completely agree with what Deputy McAuliffe said about sepsis. I am also the chair of the diabetes committee in the Oireachtas. I know great work has been done between Dr. Henry and Professor O’Keeffe. The ten-year strategy is something we are really keen on. The continuous glucose monitoring, CGM, approval is very important as well as the diabetes register. Recruitment is involved in that but there was a commitment prior to the embargo.

An Cathaoirleach

Returning to dental treatment services scheme. The budget is €62 million or €63 million for this year. Is that correct?

Mr. David Walsh

It is €63 million.

An Cathaoirleach

When HSE pitches for the budget, is a target set in terms of service delivery? I am interested in the budget and the delivery of services with fillings, extractions, treatments, etc. Briefly. I do not want to rush Mr. Walsh.

Mr. David Walsh

In reality what is paid is what comes through the door. The budget position for this year was fixed on the basis of the increase in rates for certain procedures and, based on that, an assumption in relation to the increased demand that would drive.

An Cathaoirleach

Have we got a rough figure for the number of extractions and fillings, for example? I would not expect Mr. Walsh to have it down to the last one but across the State.

Mr. David Walsh

I have a figure for the number of attendances this year versus last year. So far this year, 26,000 more people have had access to a dental treatment service scheme, DTSS, dentist.

An Cathaoirleach

Have they attended?

Mr. David Walsh

Yes.

An Cathaoirleach

What was the final figure for last year?

Mr. David Walsh

I can give the Chair a full note.

An Cathaoirleach

Please.

Mr. David Walsh

Absolutely.

An Cathaoirleach

Mr. Walsh mentioned Laois earlier. My heart warmed when he said there are 12 dentists in the scheme but there is not. My secretary spent some time ringing around different dental practices. We got lists from the HSE. Right enough, there would have been 12 dentists in the scheme at one stage but it is down to one and that dentist will not take on new patients. I am open to correction on this but up to a couple of months ago, and we need to do it again, there was no one – absolutely no dentist – who would take on a DTSS patient. For somebody with a medical card who wanted dental treatment, there was nowhere to go. We are advising them to go to the HSE. For the local HSE centre, the only option locally is Tullamore. That is the situation for emergency care, or to beg, borrow or steal to go privately. The system has collapsed in the county. When I say collapsed, I am being truthful. If there has been a huge improvement, then I welcome it. If the scheme is collapsing, and the HSE has had protracted negotiations with the Irish Dental Association, is there an option to beef up the public provision for the DTSS? The HSE supplied me with figures for CHO 8 in response to a parliamentary question, or it might have been here. I cannot remember which. Is there an option of trying to employ a salaried dentist to fill the gap and pick up the emergency care? Is that being actively pursued?

Mr. David Walsh

CHO 8 is down several on its existing complement of senior dental surgeons.

An Cathaoirleach

In the public system.

Mr. David Walsh

That is correct. They have advertised those posts three times in the last year.

An Cathaoirleach

I know it is a challenge.

Mr. David Walsh

Yes. It has managed to fill one special needs post but it has not filled the other posts. Laois or the midlands has the highest percentage where HSE-provided care is now emergency care.

An Cathaoirleach

That is because DTSS has collapsed.

Mr. David Walsh

Correct. The Cathaoirleach said his own local survey showed only one dentist in the scheme. On the primary care reimbursement service, PCRS, books, there are currently 12 so that is something I need to follow up on. Similarly, Deputy Verona Murphy said there is not a single dentist in Wexford. I think there are 17 on the PCRS list -----

An Cathaoirleach

We contacted them.

Deputy Verona Murphy

Sorry. There are no dentists operating the dental treatment scheme in Wexford.

An Cathaoirleach

When we phone them or a constituent contacts them, they will not take them. They are refusing to take them.

Mr. David Walsh

Okay.

An Cathaoirleach

The negotiations have concluded.

Mr. David Walsh

The negotiations are not concluded.

Deputy Verona Murphy

When did you last meet them?

An Cathaoirleach

What is the budget for CHO 8 for the DTSS?

Mr. David Walsh

There is no specific budget for CHO 8 for the DTSS. Any participating dentists can claim against a national budget.

Mr. Bernard Gloster

If it might assist the Chair, from January to August 2022 the claim in CHO 8 was €60,500. In 2023, it has gone up to €83,100.

An Cathaoirleach

That is still a relatively small budget. What I hear is that we do not have a budget and projected outcomes. The system would seem to be a patchwork. There is a budget if people can get a service. However, what we are finding is that people cannot get the service because the private dentists are not doing it. The private dentists are providing a fairly good service. I am not knocking them; they have a role. The problem arises with the DTSS ones.

I want to raise the school dental scheme, which I have raised consistently over the years in the Chamber and here. I will raise it with the HSE here again. Will the HSE please come back to me and tell me in what class children are being seen? They are supposed to be seen in third and fourth classes, so that is eight and nine years old, but it is more like 18 and 19 years now. They are certainly 16 years before they are seen. That is a real problem. They are being seen in third and fourth year of secondary, not in third and fourth class in primary. It is a catastrophe if we are allowing children’s health to deteriorate. Never mind the effect on oral health and general health but also on the public purse. Inevitably the problems for this will come down the line. It is a huge problem. That scheme is not working. It has fallen apart. I check these things with parents and in Laois and Offaly, the children are not being seen. They are being seen six or seven years late. Some escape from secondary school and they finish without being seen. It is an awful situation. When I was coming through primary school, the dentists might not have been as skilled as now but we were seen in third and fourth classes. Our children and grandchildren are not being seen until they have left school and it is too late. Will Mr. Walsh come back to me with figures, if he does not have them today, on what class children are being seen in and at what age in counties Laois and Offaly?

Mr. David Walsh

Generally, across most of the country it is sixth class only. I accept that in some cases, it is not.

An Cathaoirleach

Not in Laois. There is a real problem with public dental health in counties Laois and Offaly.

County Laois is on the floor. I do not say that to be parochial. I have to reflect what constituents tell me. The information I pick up from schools and parents is that it is not happening. Regarding the dental treatment service scheme, DTSS, scheme, I understand that there is a challenge. The HSE sent me a reply to a parliamentary question and other replies which show the efforts the HSE is making to recruit dentists. I also know that some people coming out of dental training do not want to run a business, they want a job, particularly women. It is good that more women are going into the profession and I hope it continues to increase. For obvious reasons, a lot of younger people, men as well, want to be employed. There is some mismatch in terms of training people into that service and encouraging them but showing them that there is a career path in it. Are they being offered short-term contracts? Is that the problem?

Mr. David Walsh

We will offer anything up to and including permanent contracts at this stage. Our desire is to get people in. There are a couple of components to it. One is to fill our vacancies and keep trying to do so. The second is implementation of the national oral health strategy and the third is to encourage and continue to engage with the Irish Dental Association, IDA, through the Department in relation to the full DTSS scheme.

An Cathaoirleach

It is fair to say, as Mr. Gloster said, the extra 20% is there. The number of extra ones being treated needs to be looked at. Some figures have been given for that but the facts are that the DTSS scheme and the schools scheme will have to have a large public element as we move into Sláintecare. It is not working. I say to the management team here that they have to accept that this is not working. It is just not happening. Children are coming out of school without ever having seen a dentist or not seeing one until it is too late. Orthodontics has been dealt with; I will not go back there. The witnesses know the picture in that area. I have heard of numerous cases in the past ten or 12 years in which children come out at 18 - some people think they are waiting for them to hit 18 because then they are out of the system - having not got he orthodontic treatment. We are not even able to get the basic one right, the primary school dental scheme, nor the DTSS scheme for emergencies - it is emergency work. That is not acceptable, given the budget available. Will the witness come back to me with accurate figures, not in relation to the numbers who say they are in the scheme but the numbers who will take a patient? That is the picture, unless it has changed in the past 14 or 15 weeks. I am open to correction. Regarding the school situation, will the witnesses provide accurate figures regarding what classes children are being seen in?

To be a little parochial, I wish to mention to Mr. Gloster Abbeyleix nursing unit and the step-down facilities. I raised it with him on his last visit to the committee and we have spoken about it since. He honoured the commitment to visit the site, which I welcome. One can imagine, 12 years ago it was nearly being closed - a 4.5-acre site in the middle of the town. Mr. Gloster saw it for himself. I think I mentioned to him that I hoped he would see the potential in it when he went; I think he has. In relation to that, is it the HSE's plan to increase the number of public nursing home beds? The 80:20 was mentioned - 80% in private - which has a role. In terms of public, is it the HSE's plan to continue reducing that and to just use those facilities for respite?

Mr. Bernard Gloster

There is a plan to raise capital behind the plan to increase the number of public community beds. On top of that, we have to move away from the traditional model of just thinking about long-term care beds. We need rehabilitation, respite, step-down and hospital avoidance beds; there are lots of different requirements. We need dementia-specific beds within our units. That is the profile on which I want to develop. We have good commitment from the Minister behind that.

Regarding Abbeyleix, I spent a couple of hours there. I was seriously impressed with what is being done in terms of a blended mix of use of community beds. It is quite outstanding. I do not want to overstate that; there is lots of good work elsewhere. There is only one long-term patient remaining there. She is a lovely person and I had the pleasure of spending some time with her. I gave them a challenge to step up to the mark on the model that is there and, in return, my view is that we could get into next year's capital plan and modular build a day centre on that site, rather than moving it off-site, because it is interconnected. That would free up the space to increase it by another five or six beds. Along with the primary care service - the GP there is a fantastic practitioner - it is a site that could explode into positive contribution in the future.

An Cathaoirleach

There is plenty of space for development-----

Mr. Bernard Gloster

And for very small money.

An Cathaoirleach

Along with moving the day care and the expansion that is taking up space at the moment for five or six beds, I have no argument with that in the short term because officials were looking at moving to other locations and greenfield sites-----

Mr. Bernard Gloster

I would not agree with that.

An Cathaoirleach

-----brownfield sites and converting buildings.

Mr. Bernard Gloster

I do not agree with that.

An Cathaoirleach

Monasterevin closed and is still closed. I said on the day it closed nine years ago that it would stay closed. The problem is that when you take away a facility, it is hard to get it back there. Along with the day care centre and the six beds that would be generated by accommodation works, is there potential to increase the actual number of beds on the site?

Mr. Bernard Gloster

I think there is, yes.

An Cathaoirleach

Is it part of-----

Mr. Bernard Gloster

The fastest way to do that though-----

An Cathaoirleach

Modular.

Mr. Bernard Gloster

-----is to modularise the day centre, take the space there for the five or six extra beds and have a capital plan to see if one could go beyond that on the site without overcrowding it. It is a beautiful site and one would not want to overpopulate it either to be fair to the people using it. Given that most of it is short stay, there is a good opportunity there.

An Cathaoirleach

Will Mr. Gloster give some commitment in relation to primary care? While it is a good service, the facilities are reduced and limited.

Mr. Bernard Gloster

Yes, they are pretty poor, which is the reality. I hope within the overall plan for the site, we could do something. I do not think it is a primary care centre site, to be fair. I do not think there is the scale in the town for that. We can certainly improve on what is there.

An Cathaoirleach

It serves the hospital and people come to the day care facility as well.

Mr. Bernard Gloster

I understand that. I could say we will put out for expression of interest for a primary care centre there. I would be long gone from office by the time that would come to fruition. I would rather see what I can do because the service the general practitioner and public health nurse provide is pretty outstanding.

An Cathaoirleach

Can we hope to see something in the capital plan for next year for the site?

Mr. Bernard Gloster

It is at the discretion of the Minister. I made the point to him and, to be fair, he has a lot of asks. He is very positively disposed towards that type of model.

An Cathaoirleach

HSE management-----

Mr. Bernard Gloster

I spoke to him earlier this week specifically about going down to see the model. The step-down beds led by a doctor from Midland Regional Hospital Portlaoise are outstanding. I want Dr. Henry to see it as well because it is the perfect blend of medical care extended beyond an acute site for the right people who can get home.

An Cathaoirleach

I acknowledge that. I thank Mr. Gloster.

I will let members in for a second round. They will have five minutes each.

Deputy Verona Murphy

We could probably go further than five minutes Chair. It is only 12 noon.

An Cathaoirleach

It depends on how many are joining online. One member is online.

Deputy Verona Murphy

If we try eight minutes each.

An Cathaoirleach

Seven minutes each. One person is online; someone else could join online.

Deputy Verona Murphy

When did Mr. Walsh last meet in a proper stakeholder engagement with the dentists, the IDA?

Mr. David Walsh

I have not met the IDA.

Deputy Verona Murphy

Who does?

Mr. David Walsh

It is the Department of Health.

Deputy Verona Murphy

Then it comes back to the HSE?

Mr. David Walsh

Correct.

Deputy Verona Murphy

Will Mr. Walsh find that out or do we need to write-----

Mr. David Walsh

Absolutely.

Deputy Verona Murphy

Will Mr. Walsh come back to the committee with that information? That would be great.

Mr. David Walsh

Yes.

Deputy Verona Murphy

Is Mr. Mulvany over the capital infrastructure?

Mr. Stephen Mulvany

I am not but I will try to answer the Deputy's questions.

Deputy Verona Murphy

I am wondering about the 97-bed unit for Wexford that has been spun out of existence for ten years. Are we anywhere near getting the budget for it?

Mr. Stephen Mulvany

I do not have any information on that.

Deputy Verona Murphy

Nobody.

Mr. Stephen Mulvany

We can come back to the Deputy on that matter.

Deputy Verona Murphy

Please. I would like an update on it.

Deputy Verona Murphy

To go back to dentists, I said earlier that the amount of spending in health is a serious concern. Mr. Mulvany has been in that chair for a long time. In case I made an error earlier, I wish to make a correction in relation to dental maxillofacial surgery. I said there were 161 children waiting for 60 months. There are actually 618 children waiting. I do not know how much it costs but if we put a figure of €15,000 per child on it, that would be €1 million at least.

I am sure it is well in excess of that. If there are so many people on that waiting list and another couple of hundred on the other one, has the HSE made any savings anywhere or must we keep putting money into what is perceived to be a black hole? The output does not seem to be there in many of these sectors.

Mr. Stephen Mulvany

In the child dental service, which is obviously different from the adult dental service-----

Deputy Verona Murphy

This is the HSE, the orthodontic service and all of that.

Mr. Stephen Mulvany

I agree with the Deputy. The capacity to get sufficient dental and support staff is the biggest constraint in that service.

Deputy Verona Murphy

That is like saying we do not have a mechanic to fix a new car. What will we do, just leave it there? We talk about retention and recruitment every year. For many of these children there is no other way of doing this. It is not affordable unless they go through the National Treatment Purchase Fund, NTPF. How long does someone have to wait before being able to access the NTPF for these services? Does anyone know?

Mr. Stephen Mulvany

My colleague Mr. Walsh may know.

Mr. David Walsh

I cannot answer that but I do know that 1,596 children from the back end of the national orthodontic waiting list were sent to private providers so far this year.

Deputy Verona Murphy

How long had they been waiting before that happened?

Mr. David Walsh

I would say for several years, based on-----

Deputy Verona Murphy

Mr. Walsh is saying 1,500. There are 618 children waiting in Wexford alone.

Mr. David Walsh

Correct.

Deputy Verona Murphy

There have been 161 waiting for 60 months; 113 have been waiting for between 48 and 60 months; and 82 have been waiting between 36 and 48 months. This is cruel and if we do eventually sign up to the applicable section of the UN charter when it comes to children's rights, we will be sued left, right and centre for this type of delay. Is the HSE writing to any of these children? In the case of the 161 who have been waiting for more than 60 months, I have to engage and initiate the correspondence. That cannot be right.

Mr. David Walsh

I have asked for a breakdown of the numbers by area who have come off the list.

Deputy Verona Murphy

Will Mr. Walsh come back and tell me how long these children have to wait before they can access the NTPF and how long they have to wait before they are sent to a private provider? It does not make much sense to me that, on the one hand, we are unable to get dentists into the dental treatment service scheme, DTSS, while, on the other hand, we are going to private providers for orthodontics and maxillary surgery. None of this makes sense and it does not bode well for where the future budget of the HSE will go. I do not know who should be joining the dots. I asked Mr. Mulvany whether the HSE had made any savings.

Mr. Stephen Mulvany

Is that in terms of dental services?

Deputy Verona Murphy

It is in terms of everything in the HSE. In terms of the €25 billion annually, is money being saved anywhere?

Mr. Stephen Mulvany

Yes. In actual price reductions, our procurement staff have avoided significant cost increases over many years. For example, regarding energy prices, we held firm with contracts until March of this year so we avoided a high level of cost increase. They are savings. In terms of the consultancy costs we are seeking to reduce consultancy costs by 30% in quarter 4 versus quarter 1.

Deputy Verona Murphy

Will that just end up like the case of dentists with consultants no longer working for the HSE and going somewhere else?

Mr. Stephen Mulvany

We have to separate the things. The Deputy asked about savings. Yes, we make savings. We make savings when we switch to biosimilar drugs and increase penetration of generic drugs over brand drugs. We make savings - although we do not seek them - when we cannot recruit enough staff. To the extent that this cost does not become an agency cost, where we try to fill the place with agency staff or through overtime, we make savings there. We make a substantial amount of savings across the system.

Deputy Verona Murphy

I am not sure the agency staff could be regarded as making savings. As Mr. Mulvany stated, it is more like the HSE did not spend the money.

Mr. Stephen Mulvany

I agree.

Deputy Verona Murphy

On warehousing, for how long has the HSE known that it must get rid of these goods?

Mr. Stephen Mulvany

Is the Deputy referring to the obsolete PPE and hand gel?

Deputy Verona Murphy

Yes.

Mr. Stephen Mulvany

For too long, in effect.

Deputy Verona Murphy

It has been too long, yes. I worked in logistics for years. If someone sends an email asking a question, they will get an answer. How long does it take the HSE to make a decision?

Mr. Stephen Mulvany

With the volume we have and the nature of the goods, particularly the hand gel, it takes a significant amount of time to get a safe and efficient means of disposal. We are very clear, as the CEO has stated, that it is costing the HSE €1.7 million per year.

Deputy Verona Murphy

That is a significant amount of money.

Mr. Stephen Mulvany

I agree.

Deputy Verona Murphy

If it was diverted into any of the services I have spoken about, it would probably solve some of the problems being experienced by 600-odd children. How long-----

Mr. Stephen Mulvany

A lot of problems the Deputy spoke about in the dental service, for example, are not money-related. The residential disability problems-----

Deputy Verona Murphy

Everything is money-related. If the HSE cannot recruit staff, it is not paying them enough. Do not be ridiculous. That is something that riles me. Everything is money-related.

Mr. Stephen Mulvany

What I am saying is-----

Deputy Verona Murphy

If we are not recruiting staff, we are obviously not offering the terms and conditions we should. In the same vein, it is money-related for the family who cannot afford to do it any other way. I want to ask one further question-----

Mr. Stephen Mulvany

I would like to respond first.

Deputy Verona Murphy

-----about the hacking.

An Cathaoirleach

We will let Mr. Mulvany respond.

Mr. Stephen Mulvany

I agree with the Deputy that everything is money-related. What I am trying to say is that money is not the cause of all the problems. In some of the areas the Deputy mentioned, such as the home-care waiting list which is a significant problem, the issue is that a couple of years ago we did not have the money and we had people waiting for funding. Now, we have the money but we simply cannot attract enough home-care workers. What I am saying is that money does not solve all of the problems. More is not the answer to everything.

Deputy Verona Murphy

That is because when people are not paid enough and they leave the service it is very difficult to get them back.

I have one important question about the HSE hack. Were the people whose details were hacked identified and notified?

Mr. Stephen Mulvany

Yes.

Deputy Verona Murphy

All of them? Will there be any legal repercussions?

Mr. Stephen Mulvany

I would be surprised if there was not some litigation.

Deputy Verona Murphy

If there is some, can the committee have a note on it and what the prospective outlay will be?

Mr. Stephen Mulvany

Yes.

Deputy Verona Murphy

I thank Mr. Mulvany.

Deputy Alan Dillon

I want to focus on the specific steps and actions the HSE is taking regarding rural GP services. We are having a major issue in my area where a single GP practice has been subsumed into a larger practice without any forward planning or workforce planning. I am trying to gauge and understand what the policy position is or what steps the HSE is taking to avoid this. There is fear, anxiety and major concerns in the community in which a void has been left and there is no GP in place. I ask Mr. Gloster to comments.

Mr. Bernard Gloster

In straightforward terms, we will be challenged in both deprived urban areas and rural parts of the country for some time to come. It would be wrong of me to say differently. On the correction side - the policy side to try to correct that curve, as it were - the Department has had very successful negotiations with the Irish Medical Organisation, IMO, around the various costs of care initiatives for the public, including GP visit cards, contraception and so on. That was successfully concluded again recently to great effect. That is on the access side and it includes terms and conditions for GPs who into the General Medical Services, GMS, contract.

On the supply side, there are approximately 285 trainees in the year of training. We aim to get to 350 by next July in the first year of training. After four years, there would therefore be 1,200 and 1,400 in training. Finally, and this is important, this year we took the step, with the support of the Irish College of General Practitioners, ICGP, and others, to recruit doctors who trained abroad, particularly in South Africa where doctors are very well trained, to come to Ireland and work with us. I think between 50 and 75 have arrived and there is a target of 100 for this year. We are deploying those doctors to the areas where we are most challenged. They can register as GPs and take up contracts after being under two years of supervision.

Deputy Alan Dillon

I appreciate all the good work that has been done on the graduate training programmes and recruitment internationally but I am asking about the here and now and replacing GPs who are moving from one healthcare practice, bringing a GMS panel with them, and that practice being subsumed into a larger practice. Does Mr. Gloster feel there is something fundamentally wrong with not having a backstop for the community, for example, the inclusion of a locum until another GP is recruited? The three-month notice period is fundamentally flawed.

Mr. Bernard Gloster

Okay.

Deputy Alan Dillon

The HSE is standing back and saying it is advertising the post and will readvertise it, without any further consultation with the community.

The community has a right to know what is happening here.

Mr. Bernard Gloster

In fairness to the Deputy, I am not sure I fully understand the situation the Deputy is describing. If a GP is contracted and is operating a GMS list in an area-----

Deputy Alan Dillon

Yes, with 1,100 patients on a GMS panel.

Mr. Bernard Gloster

And if that GP in some way merges into a group of GPs, or whatever-----

Deputy Alan Dillon

He actually accepted a post which was advertised in another healthcare centre.

Mr. Bernard Gloster

Okay, so he went to a new list.

Deputy Alan Dillon

Yes.

Mr. Bernard Gloster

So his list is left behind.

Deputy Alan Dillon

Well, in this case, it is not. CHO 2 has decided that he will bring the list with him and will subsume it into the larger panel. Does Mr Gloster believe that that is fundamentally right?

Mr. Bernard Gloster

If he brings the list with him, he is obliged to service that list in the same way in which he had previously serviced it.

Deputy Alan Dillon

Yes, but not in the same healthcare centre. The healthcare centre is 20-----

Mr. Bernard Gloster

I do not know what the distance is.

Deputy Alan Dillon

I am just giving Mr. Gloster the distance-----

Mr. Bernard Gloster

To be fair to the CHO, if it is in a flashpoint area where, if the GP did not take that list with him and the CHO knew from previous recruitment campaigns that it would not have a hope of getting anyone, it is better if that one doctor is carrying the list than no doctor. To be fair to the Deputy, I am happy if the Deputy talks to me privately about the distance because if the doctor has moved a substantial geographic distance, my expectation under the contract is that he would still retain a presence accessible to his original list and it is unfair if that does not happen.

Deputy Alan Dillon

I will follow up on that afterwards.

My second question is on the tender process for the national private ambulance service. Can our guests provide an update to the committee on that, please?

Mr. Stephen Mulvany

The tender process for the use of private ambulances is completed. There is a dynamic framework in place and a number of suppliers are-----

Deputy Alan Dillon

When was it completed?

Mr. Stephen Mulvany

I am pretty sure it went to the board. It has either just gone to the board or it is just about to. It is either completely finalised or almost there and I can certainly give the Deputy a note on that because the work is done on it.

Deputy Alan Dillon

What is the overall budget which the HSE has set aside for the national private ambulance service?

Mr. Stephen Mulvany

We will come back to the Deputy. It is in the contract approval.

Mr. Bernard Gloster

I have been more focused in the past two weeks on the private hospital piece.

Deputy Alan Dillon

In the last remaining minute of my speaking time, a present which continually lands on my doorstep is the emergency department at Mayo University Hospital. Again, the Taoiseach visited the hospital last July with regard to it. There are delays in the submission of the planning application and the design. On the building and estates division within the HSE, has Mr Gloster strengthened that in the western region?

Mr. Bernard Gloster

I have strengthened it further and I have just issued a new draft design for the HSE centre to replace the current structure at the top of the HSE from the way it is. Specifically included in that is a new dedicated position reporting directly to me for a national directorate of major capital and infrastructure, to bring together all of the resources we need to do exactly what the Deputy is talking about in a faster time.

Our estates people are exceptionally good and hard-working professional people. One, we do not have enough of them and two, we have piled too much work onto them in recent years. We need to upskill them with regard to modern methods of building and so on. We are very heavily focused on that and I have to say, to be fair to my colleagues in the Department of Health, that they have been absolutely shoulder to shoulder with us on that. I spoke with the head of estates in the west only last weekend about some of the pressures and how we might be able to help there.

Deputy Alan Dillon

Okay. I thank Mr. Gloster.

Deputy Catherine Murphy

I have a number of short questions. First, I want to ask the Comptroller and Auditor General about how, in his financial statements, he identified that the Digital Hub Development Agency had incurred an expenditure of €250,000 with regard to the vacant sites levy. Does that levy apply to HSE buildings as well?

Mr. Seamus McCarthy

I am not aware of it but it is for local authorities to identify sites which are within that legislation. Certainly, there have been payments on the Digital Hub site going back to 2018 so I cannot really say anything further.

Deputy Catherine Murphy

Okay. I will follow that up by way of a parliamentary question.

On vaccines, is the HSE doing an assessment on the uptake given the storage costs? Is there an assessment of what the take-up might be? Anecdotally, I am hearing that people are probably feeling less at risk than they did. One will find people in risk categories where there definitely is a different attitude. How does the HSE make that assessment to avoid the oversupply because, obviously, we all understand a little bit more about how these viruses mutate and how they go out of date?

Dr. Colm Henry

I thank the Deputy and that is a good question. It is a dynamic assessment because the pandemic has changed and this is a post-pandemic situation now and the nature of the virus has changed. The primary vaccination programme saw an extraordinary uptake, perhaps the highest in the developed world, with a figure of upwards of 94% to 95% among eligible adults. Each successive booster campaign saw a dropping off to 78% for booster one through to 30% to 40%.

Other factors contributed to this such as people having natural immunity from infections which made them ineligible for a vaccine. A theme now emerging from the NIAC advice this year, where we had two booster campaigns, is there is a focus on older and vulnerable people. The campaign, for example, which is becoming more narrow, is focusing on those aged 50 or more and those younger than 50 with particular conditions or weaknesses of the immune system. That will inform, in turn, the number of vaccines we purchase.

To emphasise again, in answer to a question from a Deputy previously, the vaccine type is changing all the time because the vaccine has to adapt as the virus changes. The latest type was approved by the European Medicines Agency, EMA, at the end of August in response to the growing number of the XBB subtype of viruses, which was causing the most havoc and for which we needed an effective vaccine.

Deputy Catherine Murphy

I thank Dr. Henry. I want to return to the issue of the high earners. Looking at the briefing given to us by the HSE, one related to a settlement in retirement which reflected rest days arrears from previous years. How many previous years are we talking about?

Mr. Stephen Mulvany

I do not have the actual number on this.

Mr. Bernard Gloster

I do not have the actual number for the Deputy. I am very happy to give it to the Deputy but I just do not have it to hand and I will certainly-----

Deputy Catherine Murphy

Could the HSE come back to us with that, please? There are a couple of other things which stand out. Mention was made of additional payments for cross-cover to other service area. The other service area had two consultant posts, one was vacant and one was on sick leave. Obviously, one does not want an area not to be covered so presumably that has an impact on the area, in that I assume there is not spare capacity in the first area. How does that impact on the quality of care? The payment is one thing but there are only so many hours in a day for a person and there could be geographic distances and things like that, I imagine, as well. How does that impact?

Mr. Bernard Gloster

My understanding is that is possibly in the speciality in psychiatry. There is absolutely no doubt but that it impacts and one cannot, in fairness, divide a consultant in two and not expect an impact. It is down then to clinical prioritisation, access and trying to strengthen the consultant, potentially, with registrar support and additional support to minimise the disruption. Perhaps Dr. Henry may wish to add to these comments.

Dr. Colm Henry

Obviously, the focus today is on financial aspects which have been raised in previous questions and how sustainable this is with regard to safety for the practitioner and for the services. That would clearly concern us as much if not more that we are relying on people to work additional hours, additional out of cover, and, sometimes, out of their core area in order to sustain what is an essential need for 24-7 services.

Deputy Catherine Murphy

We define value for money in a much broader sense than just pure financial considerations and the HSE must find that definition itself. It is also about the quality of what one gets for the money one spends. That is why it is logical to tie the two together.

Finally, on this group of issues, in table 3, No. 7 on “Emergency Medicine”, where “overtime to cover vacancy levels” is mentioned. It states that there are “3.5 consultants currently in post with approval to increase to 10.” Are all those positions advertised?

Dr. Colm Henry

They are typically advertised with an additional complement of emergency department, ED, consultants for 50 positions, of which I believe we have recruited 35, and which are included in that.

I will come back and confirm that.

Deputy Catherine Murphy

What is the budget for the unified financial management system? What is the estimated outturn? Is it on target timewise?

Mr. Stephen Mulvany

The budget for the programme is €82 million. The current contract, which is to roll out for all of the HSE, will consume €40 million of that. We have spent €17 or €18 million already. At the moment, it is well within the contract's funding value. As I have said here previously, before we get the completed system for the HSE and the voluntaries, we will have to go back to Government to increase that €82 million because the original estimates for the cost were done in 2014 or 2015. On the timeline-----

Deputy Catherine Murphy

Can Mr. Mulvany expand on that? Has he an estimate of how much more the HSE will require?

Mr. Stephen Mulvany

We do not have an estimate yet. It will be a number of years before we get to that. As I said, the original estimates were based on 2014 and 2015 data. We will have rolled out to all the HSE and a good chunk of the voluntary sector before we get to the top of that €82 million capital budget. On time, the roll-out in the east took place on schedule, on 3 July. However, we are having significant post-implementation difficulties. I expect the second roll-out, which is to the west, will not take place until four months later than originally planned. The overall completion of the HSE part, which is 100% of us but 80% of total healthcare centres, will move from the middle of 2025 closer to November 2025.

Deputy Catherine Murphy

What kind of problems has Mr. Mulvany identifies post implementation on the first roll-out?

Mr. Stephen Mulvany

Along with the usual kind of issues, the fundamental single biggest thing is the level of change required. Despite the fact that we anticipated a significant change and put much effort into change, ultimately, we have underestimated the scale of the change involved. That is causing us difficulties. In fairness to our staff, contractors and suppliers, whom it is impacting, they have been patient and we are getting on top of it. By the year end, we should be in a steady state across all those-----

Deputy Catherine Murphy

Has the HSE documented those issues at this stage?

Mr. Stephen Mulvany

Lessons learned are being documented currently. Before we go to the next site, we will actually ensure-----

Deputy Catherine Murphy

Can we have a note on that, please?

Mr. Stephen Mulvany

Absolutely. We are happy to provide an update on this with a note to the committee.

Deputy Catherine Murphy

Just so we have a sense of what we are looking at.

An Cathaoirleach

What is the total number of agency staff in the HSE at present?

Mr. Bernard Gloster

Ms Hoey might have the conversion figure. We take the amount we spend and convert that with an average. It will take me a minute to get it but I will get it. Between agency and overtime, we budgeted a profile of approximately €330 million and we will spend €1 billion.

An Cathaoirleach

The HSE is going to spend €1 billion. That is a huge gap.

Mr. Bernard Gloster

It is.

An Cathaoirleach

That is an overrun of a couple of hundred per cent. Could Mr. Gloster give us a figure on that in a few moments? What is the longest term that the HSE has agency staff filling a post for?

Ms Anne Marie Hoey

Agency staff should only be a short-term filling of a post pending-----

An Cathaoirleach

What would Ms Hoey describe as short term?

Ms Anne Marie Hoey

It could be a number of months. It is generally used to fill in the period while recruitment is under way for the substantive filling of the post.

An Cathaoirleach

I have witnessed agency staff filling in for three years. There is one person who is in their seventh year in position in admin. I would need to check with them again. Certainly, last year was the person's sixth year in the same position, which has never been advertised as far as I know. Somebody who applied to panels when they come up is still on the agency system. If people's work is deficient, they presumably would not be there after six or seven years, but this person is still there in the same position. I will talk to the witnesses about it afterwards. I do not want to identify a person.

Mr. Bernard Gloster

The number the Chair was looking forward is approximate because we measure it on volume price. Approximately 11,000 or 12,000 people are agency workers across the health service. In the management administration position, that was running at about 1,200 during the summer. It has pared back a little bit. It could probably be 900 or 950. I would love to know where there is an agency worker in administration for seven years. I will offer them a permanent job tomorrow because I will save 20% of the cost.

An Cathaoirleach

That is one of the reasons I am asking Mr. Gloster that, because it is more expensive. We know that.

Mr. Bernard Gloster

When we convert, we save 20%. People do not always want to convert.

An Cathaoirleach

She wants to convert. She will be happy to convert in this case anyway.

Mr. Bernard Gloster

We are looking next year at that €1 billion profile, at a substantial cut in that expenditure and also converting.

An Cathaoirleach

Mr. Gloster is not able to give me a figure for the longest-serving agency staff member. It needs to be looked at in the HSE. A number of people come in as "attendants". That is the word that used to be used for it. There is another term now.

Mr. Bernard Gloster

Multi-task attendants.

An Cathaoirleach

Multi-task attendants. I thank Mr. Gloster. There are a number of those. A friend of mine was in such a position in mental health services for just over three years before the position was brought into the HSE. That person was happy in both positions but it seemed long term.

Ms Anne Marie Hoey

It is certainly not the practice that somebody would be in a post that should be filled on a permanent basis for that period. There are other reasons we would have short-term agency staff to backfill need that arises at short notice.

An Cathaoirleach

In some cases, people in the HSE will say there is a reason for this and it is not a reason in the HSE or public's interest. Does the HSE do checks on whether there are connections between the people who own and run the agencies and middle management in the HSE? Can this consistently be manipulated so that people are deliberately left in agency positions for long periods because it is in someone's financial interest to have this happen? Does the HSE do checks on that?

Mr. Bernard Gloster

Our procurement practices have very clear probity requirements. I am not aware and have never heard that allegation or assertion. If there was any allegation or assertion of that type, I assure the Cathaoirleach that it would be investigated appropriately.

An Cathaoirleach

Sometimes it is raised. I am not in a position to say yes or no. It is raised from time to time. Is it being manipulated a bit?

Mr. Bernard Gloster

I certainly hope that no manager working in the Irish health service would be engaged in any type of mutually beneficial practice to anyone for friendship reasons or otherwise. I would not stand over it.

An Cathaoirleach

I think it is an area that needs to be watched because obviously there is a big spend on this.

Mr. Bernard Gloster

The agency staff whom we approve for use are through a procurement framework of a number of agency firms specialising in healthcare assistants, multi-task attendants, nurses and doctors but when an area cannot get someone in the framework, it will go off the framework and then many smaller agencies are involved. I do not approve of it.

An Cathaoirleach

On homecare or home help as it used to be referred to, I understand that the HSE sometimes has to use agencies to fill gaps, but there is a problem with recruitment.

Mr. Bernard Gloster

There is.

An Cathaoirleach

The agencies are having a huge difficulty. Homecare positions are not being filled. Middle management in CHO 8 told us last year that they were trying to increase the number of advertised posts. Again, it is costing more to employ them through the agencies because I know the figures we received last year. Is work being done to try to bring in a larger cohort of directly employed homecare staff?

Mr. Bernard Gloster

Yes.

An Cathaoirleach

What is the target? I think it is a 40:60 ratio, with about 40% being HSE.

Mr. Bernard Gloster

The private not-for-profit dependency is about 60% of the home support profile and because of the challenges it had in recruiting people, the contract was fundamentally altered this year.

An Cathaoirleach

That is with the not-for-profit ones?

Mr. Bernard Gloster

Not for profit and for profit.

An Cathaoirleach

Some of them do good work.

Mr. Bernard Gloster

To be fair to the Minister and Department, there was a substantial increase this year to bring them up to a pretty credible level of funding so that they could pay rates that would be attractive. That is the first part.

An Cathaoirleach

That is not what happened. It has not always translated into higher pay.

Mr. Bernard Gloster

I know. I cannot legally contract a supplier to do something and then stipulate what it pays. On the HSE, I do not think there is any impediment to recruitment.

Mr. David Walsh

No, there is active encouragement and, under Ms Hoey's department, we have two pilots currently, one in CHO 5 and the other in CHO 7, working with the education and training boards, ETBs, to try to channel new groups of people into that work. We definitely want to increase the proportion of HSE-provided services.

An Cathaoirleach

It is about 40% HSE provided and 20% voluntary. Is that correct?

Mr. David Walsh

No, it is about 40% HSE provided and 60% is a combination of for-profit and voluntary.

An Cathaoirleach

What is the breakdown of for-profit and voluntary?

Mr. David Walsh

I would have to analyse that but it is-----

An Cathaoirleach

Would it be about two thirds to one third?

Mr. David Walsh

I would say it is at least two thirds private at this stage. There are 112 different suppliers of home support across the country.

An Cathaoirleach

Can that work with the ETBs be accelerated? If we are going to help more elderly people stay within their own home, which is more cost effective and is generally what people want, there is no other way of doing this. We simply have to increase the number of people who have a level of training as home care workers to cater for people and provide that service. It is absolutely vital. The private ones have a role, but we are overly dependent on them and it is not happening. They are not able to recruit and they are having great difficulty retaining staff. A number of issues are involved. When you talk to people working for private ones, they will tell you that, as will some of the people running them. I ask that active work be done on that.

Deputy James O'Connor

The SouthDoc service in my area spans the five Dáil constituencies of County Cork and the whole administrative area of County Kerry. We have seen significant challenges with SouthDoc services and they have come down to doctor shortages. Whistleblowers in SouthDoc have described problems relating to doctors not wanting to take shifts over weekends that may be in some way awkward. There has been a reduction in the availability of the car service and bases are being impacted as well. In Fermoy, there has been significant discussion and dialogue on the future of the SouthDoc base and concerns are also now erupting in Midleton, County Cork. Previously, this happened in Blackpool, Cork city, and there was much discussion about it at that stage.

It has been deeply concerning, as a public representative, to see these services not being provided despite millions of euro in Exchequer funding through the witnesses' organisation. We discussed earlier the billions of euro that are being provided to agency workers, staff and organisations by the HSE, but the service SouthDoc is providing and what it is being funded for is in no way reflective of the sums it receives. I have heard many cases, without going into detail, of people who have been left out on a limb, unable to access a GP service when it was most critically needed, often resulting in them having to go to Cork University Hospital, CUH, which is a deep concern.

Is the service SouthDoc is providing something the HSE can commit to looking at? I know out-of-hour GP services nationwide are having challenges but, as a Deputy for Cork East but more so for the entire region for which SouthDoc has responsibility, what is going on at the moment is deeply unacceptable. It smacks of trying to close bases, which, unfortunately, will have a huge impact on our area, and it is a service people throughout County Cork have cherished for good reason. I will start with that question before I move on.

Mr. Bernard Gloster

The Deputy is quite right. I know that when Fermoy became a point in question earlier in the summer, there was a lot of engagement and effort to try to improve that situation and stabilise it. Most of the co-operatives around the country are owned by GPs themselves, but we do fund them and it is in our interest to have them - believe me. For every time we do not have a doctor available out of hours, we have somebody attending an emergency department who does not necessarily need to be there, so there is no question for us of the value. General practitioners themselves will generally say they are happy to run the co-operatives and out-of-hour centres if they are able to hire enough doctors to cover the shifts, because they simply cannot cover them themselves off the back of their working day in surgery, so the pressures are somewhere in the middle. I know the chief medical officer in the Deputy's area is working hard on that with the national primary care service.

There are also many good things about SouthDoc in the area. I want to be clear about that and do not want to be pejorative. Nevertheless, given what I have heard recently about SouthDoc, it is my intention to meet the doctors myself, with the leadership in Cork, to see if there is anything we can do to stabilise the type of concern the Deputy is talking about. In the mid-west, particularly in rural areas such as west Clare or County Limerick, there are the same challenges, with reductions in the number of cells. The co-operatives are not able to maintain the numbers of bases or cells they previously were able to.

Deputy James O'Connor

I come from a family of healthcare workers. My siblings are involved in healthcare and pharmacy and one is studying medicine at the moment. I am very aware, therefore, of the importance of community-based healthcare and how critical it is for people. In the past eight years, we have seen a very steep decline in GP services in my local community. It started to erupt post 2016, when stories emerged of people moving into our region of east Cork were unable to get their family onto the books of a GP. Obviously, such cases are where SouthDoc becomes a critical component, not least if somebody develops a sudden illness. I have heard of people on certain occasions waiting outside SouthDoc in Midleton unable to get in, which is totally unacceptable. It is a fabulous facility with a huge base. Very significant money has been put into the facility. As I said, when it was working at its prime, the people of east Cork found it invaluable. I have used it myself on occasion when it was needed. I have a huge concern for people in the area.

Moreover, Fermoy is just that distance farther from the healthcare infrastructure in Cork, not least the based services. They serve Mitchelstown and into the areas around the Knockmealdown Mountains and the Comeragh Mountains, along the borders of County Waterford and south Tipperary. That is a long way to go if you need to get down to Cork city and are in trouble.

Mr. Bernard Gloster

I absolutely accept the concern and the point the Deputy is making. We have made and continue to make strident efforts to increase the supply of GPs coming into practice by significant numbers-----

Deputy James O'Connor

I might just make one further point, which I also made to the Secretary General of the Department of Health. It relates to the recruitment of GPs. We understand, from previous meetings of the Committee of Public Accounts and questions I put to Mr. Watt, that there was a 1,000-GP deficit in Ireland, and that the rate of retirement just about fell underneath the rate of recruitment at the time the question was put to him. That deficit is not being dealt with. The coming changes, relating to charges to GPs and medical card reforms, will cause a further erosion of their income and a bigger problem when it comes to recruiting people. Obviously, there is a lifestyle aspect of people wanting to live in urban areas such as Dublin, Cork, Limerick and so on, but if we want to attract people to go into rural communities, similarly to what was done with the recruitment of South African doctors on work permits in Cork, which was a great initiative, how are we supposed to get people in if the executive is planning to implement reforms that will cut practices' income, one way or another?

Mr. Bernard Gloster

I addressed this earlier before the Deputy got here. There are three parts. First, there are the South African doctors, who, after two years under supervision, can take over GP lists and become general practitioners. Second, the number of trainees will go up to 350 next July in the first year, and by the fourth year, there will be 1,400 in training. There is already a tilt more positively towards the number coming in versus the number going out, but still, per head of population it is way off, so I do not dispute that whatsoever-----

Deputy James O'Connor

The average age is in the late 50s at present. Is that correct?

Mr. Bernard Gloster

Yes.

Deputy James O'Connor

That is extremely alarming.

Mr. Bernard Gloster

It is, and we want to get more people in to address that.

On the question about GPs' income, to be fair to the balance side of that, we recently with the Department concluded the latest agreement with the Irish Medical Organisation, IMO, on the change to eligibility for six- and seven-year-olds and also certain families on the median income.

My understanding is that GPs, by and large, are happy with the arrangements made in that deal in terms of managing their income. There are now additional supports for specific line items like contraception and so on. There is quite a lot of investment in practice. However, there is a lot more to do if we are to have the health service we aspire to in the future.

Deputy James O'Connor

Finally, I have been very despondent about the pace at which the HSE is delivering capital infrastructure. Mr. Gloster made reference to primary care settings. Youghal, County Cork, is a town of almost 10,000 people. Its catchment area increases that significantly but it has no primary care centre. We have repeatedly seen plans that have changed continuously. There was a HSE-led plan to redevelop St. Raphael's, the former psychiatric facility in Youghal. There is a older building there that is now disused, and has been for some time. There has been brilliant investment put into new de-congregated and hub facilities. They are state-of-the-art, with great care and fantastic staff. However, the older building at St. Raphael's has seen plans change in a concerning way several times. I think the original model was that the HSE was going to put in a 64-bed acute hospital facility as a replacement for the community hospital. Subsequent to that, all of these plans seem to have been shelved on grounds of cost. They are now looking at a private model. We have gone from a State-led public model to now involving private developers.

Mr. Bernard Gloster

Does the Deputy mean for the primary care centre or for beds?

Deputy James O'Connor

Correct. This would have been on the national development plan projects in healthcare. All of a sudden it switched from public to private. How does that happen?

Mr. Bernard Gloster

In the primary care centres, we are still working through the completion of the list from previous Government times. We had a spurt of growth across the country. The lease model has slowed down, where developers develop the primary care centre and we lease it back over 25 years. That has become harder to achieve in the past two years with construction inflation. Developers would say the model does not work for them as easily. That has slowed it down. There was a public private partnership model that delivered 14 primary care centres across the country. There were also some direct HSE builds. I will have to come back to the Deputy about St. Raphael's campus. However, in fairness to the Minister, I know he is looking at the primary care centre model. We are challenged to get people to develop centres to the same scale as we did for the past five or six years.

Deputy James O'Connor

I would appreciate if Mr. Gloster would come back to me on it.

Mr. Bernard Gloster

I assure the Deputy that I will come back to him.

An Cathaoirleach

What was the budget for ambulance services in 2022?

Mr. Stephen Mulvany

It was €219 million, and €228 million is the budget for this year.

An Cathaoirleach

What is the expected spend on private ambulances in 2023, or what was it last year if that will point us in that direction?

Mr. Stephen Mulvany

We will have to come back. Another Deputy had a similar question in terms of the use of private ambulances. We will get the actual figure, as we have just gone to contract on that.

An Cathaoirleach

What percentage of the service is provided by private providers?

Mr. Stephen Mulvany

None of the emergency service uses private providers.

An Cathaoirleach

I know that.

Mr. Stephen Mulvany

None of the critical care service or the retrieval of small babies service use private providers to supplement-----

An Cathaoirleach

Are we talking about 2% or 20%?

Mr. Stephen Mulvany

I would say it is less than 10% but I would have to come back. We use it for the intermediate care part of the business, as in transporting patients to or from hospital post-treatment.

An Cathaoirleach

Will Mr. Mulvany come back with a figure for last year on the costs of private ambulances, and the expected cost for this year?

Mr. Stephen Mulvany

Absolutely.

Mr. Bernard Gloster

I have a note from the National Ambulance Service, NAS. To continue the utilisation of private ambulance companies to support the NAS inter-facility services, and indirect support for the performance would require a budget allocation of approximately €5.5 million from 1 July to 31 December 2023.

An Cathaoirleach

That is for half a year. We are looking at approximately €11 million for one year.

Mr. Bernard Gloster

It is variable because we use private ambulances for inter-hospital transfer and inter-care facility transfer. We would use them more in the winter than in the summer and so on.

An Cathaoirleach

I understand.

Mr. Stephen Mulvany

That is out of a budget of approximately €220 million. It is less than 5%.

An Cathaoirleach

I know there is a challenge with staff and recruitment of staff. We have had discussions about it at this committee before. In some areas there might be 60% of the staff that are needed. This question is to Ms Hoey. Briefly, what is the current position? What is the shortfall in terms of staff required in the ambulance services?

Ms Anne Marie Hoey

I do not have the vacancies. I can come back to the committee with those. I do have the employment levels, if the Cathaoirleach can bear with me a moment.

An Cathaoirleach

Have we an estimate for how many are-----

Mr. Bernard Gloster

I have the leavers and joiners statistics for the National Ambulance Service for the period 2019 to the first half of this year. The total who joined the National Ambulance Service was 1,010, and the total who left was 479. That is net growth.

An Cathaoirleach

How many staff are there at the moment?

Ms Anne Marie Hoey

There were 2,201 staff in the ambulance service at the end of August. That had increased by 14% compared with the beginning of 2020.

Mr. Bernard Gloster

We are also increasing the training college places in the National Ambulance Service. I visited their training centre in Tallaght, recently. We are increasing training provision in Tullamore and in County Cork as well.

An Cathaoirleach

Have the numbers going into training increased?

Mr. Bernard Gloster

Yes, that is what is leading to the increased workforce you see there.

An Cathaoirleach

What figure needs to be hit?

Mr. Bernard Gloster

I do not know. I will have to come back. to the Cathaoirleach

Mr. Stephen Mulvany

As part of the strategy over the next seven to ten years, the target is to more or less double the workforce from approximately 2,000 to close to 4,000.

An Cathaoirleach

On a related question, are ambulances lying idle because of that shortage?

Mr. Stephen Mulvany

I do not believe so.

An Cathaoirleach

If the workforce is being doubled, there is a shortage of ambulances and staff according to that. That would indicate we have just over half of the workforce we need. Either ambulances are lying idle or we do not have the number of ambulances we need.

Mr. Stephen Mulvany

We would not buy them if we could not staff them.

An Cathaoirleach

I understand that.

Mr. Stephen Mulvany

The strategy is to take account of demographics and any current deficit.

An Cathaoirleach

But the population might be double.

Mr. Bernard Gloster

The other point in the strategy to double the workforce over the next seven years is that you double the fleet with it. To be fair, the ambulance service would articulate this very well. There was a time when the ambulance service was simply seen as a transport service. You went out, you picked up a person and you brought them to hospital. They are now caring for people at home with Pathfinder. They are the emergency department in the home. They do an amazing amount of clinical and allied health professional-type work. All of that is built into that projection. It is not that there is a fleet of ambulances lying idle waiting for staff.

An Cathaoirleach

I am just asking. I am trying to get a handle on whether we have a situation where we have vehicles but no staff.

Mr. Bernard Gloster

I am sure we have a couple here and there, but I have not heard of it as a big problem.

An Cathaoirleach

That is fine, but we need to double the number of staff.

Mr. Bernard Gloster

Over the next seven years.

An Cathaoirleach

Mr. Gloster might come back with a note on the primary care centre for Portlaoise. It has been long talked about. It is a capital town heading for a population of 30,000, which is a bigger population than Kilkenny City. It is one of the biggest county towns in the country and we have no primary care centre. I know there are challenges but where are we with that?

Mr. Bernard Gloster

After visiting the hospital in Abbeyleix, I told the Cathaoirleach that I am due to visit the hospital in Portlaoise and meet the health community there.

An Cathaoirleach

That is good.

Mr. Bernard Gloster

I am sure I will hear about it there and I will certainly talk to them about. I am spending a lot of time in County Laois.

An Cathaoirleach

I know. The population is expanding rapidly down there. According to the census, it is the fastest expansion outside of Dublin. I know and appreciate that. However, we do not seem to be able to get a primary care centre in place. It has been talked about.

Mr. Bernard Gloster

I will come back to the Cathaoirleach on that.

An Cathaoirleach

I do not expect an answer on it today. There is also the Mountrath health centre. It has been recognised as constrained. The current site is not big enough. It cannot be reconfigured on that site. That is all being looked at, but where is that at the moment? What are the timelines for progress with that? Again, it is a town with an expanding population. I do not expect Mr. Gloster to have the answers to either on the tip of his tongue.

Mr. Bernard Gloster

I will come back to the Cathaoirleach about them.

An Cathaoirleach

I do not want to lose the opportunity to raise it with Mr. Gloster.

Mr. Bernard Gloster

As I said, I intend to address the health community in Laois when I am in Portlaoise hospital.

An Cathaoirleach

Yes. A lot of progress has been made, but there is a lot more to do. I thank Mr. Gloster for that.

That concludes this session. I want to thank the witnesses, as well as the staff at the HSE and the Department, who prepared for today's meeting. I also want to thank the Comptroller and Auditor General and his staff for their assistance. Is it agreed that the clerk to the committee will seek any follow-up information and carry out any agreed actions? Agreed. Is it also agreed that we note and publish the opening statements and the briefing materials provide for today's meeting? Agreed. I thank the representatives, because I know a lot of work goes into the preparation for coming before the committee. There are some things they are to come back to us with. If they can come back with it in a timely manner, it would be much appreciated.

I probably should have also asked if there is a timeline for getting to Sláintecare.

Mr. Bernard Gloster

Yes, so Sláintecare-----

An Cathaoirleach

I do not mean to go back over the whole thing again.

Mr. Bernard Gloster

-----is a policy framework.

An Cathaoirleach

I understand that.

Mr. Bernard Gloster

One could pick loads of different strands of it. We have a dedicated health committee on Sláintecare, which we updated two weeks ago. We have made enormous progress on it on a number of fronts, including on public-only consultant contracts, affordability of care and accessibility of care. We are making better strides on delivering access for people, but we are being overtaken by the level of demand and it is as simple as that.

An Cathaoirleach

Is there alignment with the regional health areas?

Mr. Bernard Gloster

We advertised for six regional health area leaders, the closing date for which is Friday week.

An Cathaoirleach

When are we likely to have them?

Mr. Bernard Gloster

Certainly, it will be in my interests for this to happen as quickly as possible.

An Cathaoirleach

What does that mean?

Mr. Bernard Gloster

Subject to the contractual position of the people who will be selected, I am aiming to have them in their posts for around February.

An Cathaoirleach

Okay, because as Mr. Gloster knows, community care and hospital regions do not align at the moment.

Mr. Bernard Gloster

This is all designed to do that. However, we can put in a structure, but we have to change the behaviour and the culture as well.

An Cathaoirleach

Okay. Is it the case that we could see the shape of them within a year or so?

Mr. Bernard Gloster

The introduction of the regional health areas with the six leaders is in place. They will superimpose that on top of the existing system and they will try to integrate that between February and September. Then, we will populate an integrated structure by September of next year.

An Cathaoirleach

I thank Mr. Gloster for that clarification.

The meeting is suspended until 1.45 p.m., when it will resume in private session to address correspondence and other business of the committee. Go raibh míle maith agaibh.

The witnesses withdrew.

Sitting suspended at 12.52 p.m. and resumed in private session at 1.45 p.m.